The impact of the COVID-19 pandemic on a sample of US young adults who smoke cigarettes: A qualitative analysis

Abstract

Introduction

The ongoing COVID-19 pandemic has been associated with increased negative mood in youth, and a few reports of changes in tobacco use. We sought to increase the depth of knowledge on the effects of the pandemic on early young adult mood states, access to tobacco products and tobacco use behaviors, and knowledge of risks associated with tobacco use and COVID-19 by learning more about the lived experience of the pandemic among young adults early in their smoking trajectories.

Methods

Semi-structured qualitative interviews were conducted with 25 young adults ages 18–20 (M = 19) who smoked cigarettes daily or nearly every day and had used electronic cigarettes (ECs) on ≥ 2 occasions in their lifetime.

Results

Our results uncovered several themes: 1) The majority of teens experienced mental health disturbances as a result of the pandemic, which manifested as depression, anxiety, and/or acute loneliness due to social isolation; 2) tobacco purchasing behaviors sometimes changed, with both greater and less access reported among participants; 3) changes in tobacco use were also reported, with some reporting increases in use, others reporting decreases, and a few reporting quitting; and 4) while some youth reported that tobacco use could increase their risk related to COVID-19, the majority reported confusion and uncertainty about how tobacco use impacted their risk.

Conclusions

The themes identified specific factors that may account for the heterogeneity of impacts of the pandemic on tobacco use, and highlight the value of qualitative work for centering the lived experience of youth for understanding larger trends in substance use.

1. Introduction

Smoking combustible cigarettes remains the leading cause of death, disability, and disease in the United States (USDHHS, 2014), and young adulthood is now the highest risk period for both initiation and progression to established smoking (Barrington-Trimis et al., 2020, Hair et al., 2017, Thompson et al., 2018). Thus, early young adults who smoke are likely to be early in their smoking careers, and perhaps more likely to experience shifts in their use as a function of disruptions. In addition, polytobacco use is increasingly common in young adults, particularly the use of e-cigarettes with other tobacco products (Merianos et al., 2022, Sutfin et al., 2022). Young adulthood is a crucial time for intervening on tobacco use, as quitting smoking before age 30 reduces almost all of the mortality associated with ever smoking (Jha, 2020). As such, understanding what motivates changes in tobacco use may have important implications for understanding tobacco use in this period. The recent pandemic and the associated disruptions to daily life presented an opportune moment to assess potential changes in tobacco use.

The emergence of the novel coronavirus SARS-CoV-2, also known as COVID-19, in December 2019 and the resulting stay-at-home orders, economic recession, and over 1 million deaths in the U.S. to date (CDC, 2022) have led to substantial increases in stress, anxiety, depression, insomnia, and substance use among U.S. adolescent and young adult populations over the past two years (Jones et al., 2022, Samji et al., 2022). Even before the pandemic, suicide rates were rising at an alarming rate among US youth, becoming the second most common cause of death among 10–24-year olds (Curtin & Heron, 2019). Against this troubling backdrop, youth have also experienced a large number of pandemic-related consequences (e.g., school closures, loss of caregiver income from increased unemployment, social isolation), leading to increased rates of stress, anxiety, and depression among youths (FAIR Health, 2021, Abramson, 2022). In 2021, an estimated 37% of high school students reported experiencing poorer mental health during the pandemic relative to 26% in 2009, and 19% (vs. 14% in 2009) endorsed serious contemplations of suicide (Jones et al., 2022). In addition to worsening mood, 24.7% of young adults reported initiating or increasing their substance use during the pandemic relative to 13% of adults (Czeisler et al., 2020).

The majority of studies exploring changes in patterns of e-cigarette, cigarette, and other tobacco product use in the U.S. during the pandemic were conducted primarily among young adult and adult populations, and found varied patterns of use across different types of tobacco products. Several cross-sectional and qualitative interview studies of young adults and older adults indicated that factors associated with more frequent cigarette and/or e-cigarette use during the pandemic included COVID-19-related stress and anxiety, loneliness/isolation, time at home and irregular routines, and boredom (Bennett et al., 2022, Giovenco et al., 2021, Kleinet al., 2021, Popova et al., 2021, Sharma et al., 2020). Factors associated with reductions in tobacco product use during the pandemic included increasing health concerns and perceptions of risks associated with smoking and/or vaping with COVID-19, having to take off their masks to smoke, increased product costs and job loss, decreased interpersonal interactions and fear of sharing products, and moving back home after university closures for college-age young adults (Giovenco et al., 2021, Kleinet al., 2021, Popova et al., 2021, Sokolovsky et al., 2021).

Similarly, a study conducted in 2020 among 4,351 adolescents and young adults ages 13 to 24 years who used e-cigarettes in their lifetime, found that approximately half of the sample changed their use, with some increasing and others decreasing. Factors involved in decreased usage of e-cigarettes included difficulty with access to vape shops and products after the pandemic began, which resulted in purchasing from alternative retail stores and online, whereas factors involved in increased e-cigarette use included concern about potential lung damage and not wanting parents to find out (Gaiha et al., 2020). A 2022 study assessing changes in smoking and vaping behaviors during COVID-19 stay-at-home policies in 1,727 young adults found similar results to the previous study, such that young adults reported reductions in e-cigarette and cigarette use during stay-at-home orders (Denlinger-Apte et al., 2022).

Only one qualitative study to our knowledge has investigated youth tobacco use and/or knowledge of tobacco-related risks in youth during the COVID-19 pandemic. The study interviewed adolescents from Hong Kong who smoked, purposively selecting equal numbers of those who had increased, decreased, or had not changed their smoking. The authors found that tobacco use behaviors patterns decreased as a result of spending more time at home, having fewer social gatherings, concern over finances, and decreases in access, while family tensions and lack of social interaction led to increases in smoking for others (Lam et al., 2022). The authors also found that participants were aware that smoking could increase risks of COVID. To our knowledge, there have been no qualitative studies of the impact of the pandemic on tobacco and e-cigarette use among US youth or young adults. The current study aims to examine the effects of COVID-19 pandemic on mood states, access to tobacco products, effects on tobacco purchasing and use behaviors, and knowledge of risks associated with tobacco product use and COVID-19 among a sample of 25 U.S. youth in early young adulthood (ages 18–20) who currently smoke and use e-cigarettes. Our sample is unique because the young adults we interviewed smoked daily or near-daily, and all of them had a lifetime history of using e-cigarettes, making them a high-risk sample for continued tobacco use. Understanding the lived experience of these youth can help identify reasons for changes in tobacco purchasing and use, as well as a more nuanced understanding of tobacco use and COVID risk, that may not be captured in larger quantitative studies.

2. Methods

2.1. Participants

Young adults recruited from the Providence, RI metropolitan area who had completed a laboratory study examining the impact of various flavor and nicotine combinations on choices for research cigarette and/or e-cigarette puffs (U54DA031659) were invited to take part in interviews about their experiences in the study and during the pandemic. A description of the parent study and results of qualitative responses to the study products can be found elsewhere (Denlinger-Apte et al., Under Review). At the time of the parent study, participants were required to: be between 15 and 20 years old, report smoking daily or nearly daily, provide a carbon monoxide (CO) level of > 5 ppm (or urinary cotinine level > 100 ng/ml), have used an e-cigarette at least twice in their lifetime, and be able to speak and read in English. Potential participants were excluded if they reported: a plan to quit smoking within the next month, use of other non-cigarette or e-cigarette tobacco products, binge drinking, other drug use more than 9 times in the past month, unstable medical and/or psychiatric conditions as determined by a brief medical history and discussion with our study clinician, an allergy to e-cigarettes, an unwillingness to use the study products, or had completed a similar study with research cigarettes in the past year. Interviews were conducted one-on-one with a research assistant via Zoom.

2.2. Interview procedures

Interviews were conducted several months after participants completed the parent study (between 5 and 18 months since study completion; we did not reconfirm parent study eligibility at this time). Interviews were conducted between August 2020 and September 2020 via video teleconferencing software. Participants received a $25 Amazon gift card after the interview was completed. The interview guide was developed primarily by author RDA in collaboration with authors RNC, SMC, JG, and JWT.

2.3. Data analysis

The data was transcribed and coded using Atlas.ti Version 9.0 by the Qualitative and Patient Reported Outcomes (Q-PRO) shared resource at Wake Forest School of Medicine/Comprehensive Cancer Center. Q-PRO team members, authors AES and KDW, first developed a number of codes that were based on the semi-structured interviews and initial transcript review. Transcripts were then independently coded in groups of 2–4 by AES and KDW, and consensus was achieved where discrepant codes were identified through iterative meetings following each coding period. The codebook was updated iteratively following independent coding, and themes were identified inductively; all authors were involved in interpretation of the finalized themes. As such, we do not report inter-rater agreement as independent coding occurred during the theme development phase and not during the final coding phase.

3. Results

Interviews were conducted with 25 participants out of 45 who had completed all procedures; the remaining participants were either unable to be re-contacted or declined to participate. The participants who responded did not differ significantly from those who did not respond on age, sex at birth, gender, cigarettes smoked per day, percent of days on which they vaped out of the last 30, race, ethnicity, or menthol status. n average, interviewed participants were 19 (SD = 0.62, range 18–20) years old, smoked 5 (SD = 3.07) cigarettes per day, and had been smoking daily (at least 28 out of the last 30 days) for 1 (SD = 1.71) year. Roughly half of the interviewed participants identified as female, and 20.8% identified as Non-White. The majority (80%) of the participants were in college, vocational or technical school; the rest were not enrolled in school. The audio-recorded interviews averaged 21:19 min in length. Themes and illustrative quotes are presented in Table 1, Table 2, Table 3 .

Table 1.

Effects of the COVID-19 pandemic on access to tobacco products and purchasing behavior.

Theme	Illustrative Quotes
Decreased Access
Limiting time/trips away from home due to safety concerns and/or stay-at-home orders	“…there was like nowhere to go, everyone was supposed to just stay home and so I wasn't really going out or anything. I wasn't really…driving around, couldn't really get cigarettes. So, it's probably because of the stay at home order.” “I was scared to go to convenience stores because you get those weirdos inside convenience stores who don't wear masks. And then you don't know if they have [COVID-19] or what they're coughing from, or if they have it but they're not affected by it. So it definitely made me more scared to go out to any store, to get cigarettes, or even to be out in public.”
Store closures or changes in opening hours	“…there were tobacco shops that closed during quarantine, so I actually had to change the store where I bought the cigarettes.” “Just in the very beginning, a bunch of convenience stores would close at night or just have different hours and that's often when I'd go to get cigarettes.”
Increased Access
Ease of avoiding minimum age laws	“[Access] increased…by a lot…’cause I left the country when COVID started and in the US it was super hard to get [cigarettes] cause I'm under 21 and here you can buy it pretty much any age.”
Changes in Purchasing Patterns
Bought tobacco products in bulk	“I try to buy my vape stuff in bulk. Whenever I go, I only go once now…so I don't have to go out to the store as much, or I don't have to take the drive out.” “Everybody's been buying a lot more, whether it's weed or tobacco, they are just buying a lot more of it and in bulk.”
Buying more frequently	“I've definitely bought more packs, more frequently.”
Buying different tobacco products	“…because I wanted to smoke more, I would get tobacco pouches so I could roll my own cigarettes, which meant that I was not aware of how many cigarettes I was actually smoking a day cause I was rolling.” “I switched from tobacco, from cigarettes to vape.”
Buying tobacco products online	“I was ordering vapes online rather than getting them from the shop.” “For a while I had to get it mailed to me, which meant that I was smoking less because I was having to wait for it to come…then I started purchasing [more], because I realized it was taking so long and I was getting agitated…”

Table 2.

Reasons for changes in tobacco use during the COVID-19 pandemic.

Theme	Illustrative Quotes
Decreased Use
Family member disapproval	“I’m with my family right now. They don't know I smoke.” “My parents know, but don't approve too much…to be smoking in the house is quite disrespectful for my family. So it just meant that I'd have to go outside for long walks to [smoke]. So it meant that I was limiting [smoking] cause I couldn't, didn't have access to just do it all the time whenever I wanted.”
Increased awareness of the health risks of smoking	“… when COVID started, I totally quit. I think maybe it was just COVID was like, ‘oh, people are actually dying.’ And then I was like, wait, I can actually die because of smoking down the line. I think it was just a reality check and I quit.” “…I saw a lot of studies come out where people who were smoking tobacco and cigarettes were at a higher risk of a more serious Coronavirus case, I guess. So that definitely kept me away. I was like, ‘I do not want to be the 20 year old who dies from Corona.’”
Change in priorities/daily activities	“I got a job recently and started dedicating myself to different hobbies. So just spending my time with things to do…I just forgot about [smoking].” “…at first I was [smoking] more because I was still working during the lockdown and…I was a little bit stressed…And then as time went on, I just kind of got used to it. And then I made more time to work out at home. So that's why I was able to cut down.”
Smoking as a social behavior	“…most of them have quit because the reason is they don't have any friends to smoke with. If you don't have anybody to smoke with, and you're just smoking a cigarette by yourself, that's just not a good look. It was mainly a social thing. It wasn't really a, ‘Oh, I have troubles and I need a smoke to calm my nerves.’ It was mainly, ‘Hey, do you guys want to go smoke?’”
Cost of cigarettes	“I know some people have thought about stopping because of money and not having a job during COVID.” “I don't want to spend money in the middle of what's about to be a recession.”
Increased Use
Coping with boredom/ social isolation	“I was like craving…socializing. It kinda drew me to more substances to try to gain pleasure as the restriction orders did not allow me to go outside or do any activities I normally do.” “I definitely use [tobacco] more during COVID just because I'm bored and don't have a lot to do.”
Coping with stress/anxiety	“A lot of friends have said they're smoking more because they're stressed out. And so they've leaned on that to help with the stress.” “I very quickly felt the need for, or the hunger for…I could really go for a cigarette right now because in the past it's helped me at least calm myself down a bit. So I feel like with all the stress going on, it kind of pushed me back towards cigarettes just because I have that kind of dependency and seeing it as a little escape.”

Table 3.

Knowledge of risks related to tobacco use and COVID-19.

Theme	Illustrative Quotes
COVID-19 risk for people who smoke cigarettes
Increased Risk	“…it's an illness that damages the lungs and people who smoke cigarettes have damaged lungs. So the illness can manifest in a lot worse ways in people with lungs that aren't as healthy.” “I'm going to assume that the risk would be a little higher. Because it is a respiratory virus, and smoking does weaken your respiratory system.“
Uncertain	“I think they have less chances of getting it, but then once if they do get it, they will probably have a more severe form of COVID-19…in France we have…statistics based on patients admitted to the hospitals and they said that almost none of them were smokers…scientifically speaking, the parts in your body where the virus attaches itself…is the same place where nicotine attaches itself. So if the place where nicotine is, is already taken by nicotine, then the COVID virus will have more difficulty getting into you.” “…at the beginning at least, they thought that nicotine could actually…decrease your chances of getting [COVID-19]. I heard that doctors in Italy…had nicotine patches on them, because they thought that that could help them not get COVID. But then I heard if you're smoking, it might be a little bit harder for you to get COVID, but once you get it, it's much, much worse.”
COVID-19 risk for people who use e-cigarettes
Increased Risk	“Compared to the general population, I would say that they have a little bit more of a risk, ‘cause vaping still affects your lungs and your body in many ways.” “I would assume they're also at an increased risk, ‘cause I know that [vaping] affects their lung health.”
Decreased Risk	“I would say decreased just because I got really educated on vaping actually by a person who is the owner of a vape shop. And I don't know how accurate her information was, but she really sold the product, so I just take it that what she had said would help decrease [COVID-19 risk] somehow.” “…if there is something to do with nicotine, then probably it's also less likely for [e-cigarette users] to get COVID, a little bit more resistance to get COVID.”
Uncertain	“I assume it's the same…it seems like everywhere says that vaping is not as bad for you as cigarette smoking in the long term. But I don't know about the short-term cause it seems like young people with vapes consume that a lot more than the occasional cigarette a few times a day.” “I guess it's almost relatively the same, that it'd be harder to breathe and whatnot. Cause either way, you're still smoking, you're still affecting your lungs, and for COVID-19 being a respiratory problem, it'd still affect them. I don't think as much as smokers, cause I don't know what vaping does to your lungs yet, but I'd still say it affects you. I just don't think it'd affect you as badly as smoking a cigarette.”
Increased Risk relative to Smoking	“I don't know too much, but I imagine [vaping] would be worse…people would get pneumonia from vaping, and I know you can get pneumonia from, from COVID so it's double pneumonia.” “If I were to just go off of how vaping generally makes you feel…extensive vaping versus extensive smoking, I would say it would feel a lot worse. If you were routinely vaping and you already started developing the symptoms and your body's telling you, ‘Hey, easy there, maybe you should lay off for a couple of days,’…your lungs are already hurting so much from vaping and then you add COVID to it. It's, can't be pleasant. It's probably going to be worse.”
Decreased Risk Relative to Smoking	“Probably worse cause of your lungs, but they checked my lungs and my lungs were pretty good. I don't think vapes are bad for your lungs, really. Maybe over a long, long term but way less bad than cigs.”

3.1. Effects of the COVID-19 pandemic on mood states

Participants were asked about how the pandemic had affected their mood, and they overwhelmingly reported that they had felt increased stress, anxiety, boredom, and depression. Stress and anxiety increased for some participants due to financial concerns:

“…it's just definitely increased a lot of anxiety, a lot of financial anxiety due to the lockdown in the beginning. I think now that…everything's opened up a little and there's a little less of that, I've been feeling better. But for a few months there, money was an issue and the stress was really, really high.”

The lack of interpersonal interactions and school closures also led to boredom and depressed mood for many participants: “Made me more stressed out 'cause I'm always home and I can never really go out. I get scared about going out and I'm bored.” Many participants also noted the negative effect of missing important milestone events, such as first jobs:

“…not anxious but depressed because of not much going on. I had a lot of things lined up for me leading up to this. I had internships. I was supposed to go work as a ranger for three months in the summer. I was supposed to do a lot of things. So definitely that aspect of a social isolation has definitely taken a toll.”

While most participants reported negative mood, a few participants noted improvements in mood as a result of the stay-at-home orders: “I'm pretty happy. I like staying inside, it's nice. I like to be alone…I've been feeling better actually.”.

3.2. Effects of the COVID-19 pandemic on access to tobacco products and purchasing behavior

In terms of how the COVID-19 pandemic changed participants’ access to tobacco products, experiences varied. About half of participants reported that their access had changed, and the other half said that it had not changed. Of those who reported a change, most said their access had decreased, and a few said that it had increased. About a quarter of the total number of participants reported that their access was decreased due to to a general decline in shopping at brick-and-mortar stores due to safety concerns or changes in store hours (Table 1). This also led to some participants shifting to buying tobacco products online. To reduce shopping trips (i.e., to limit going out in public places during the pandemic), some participants also reported shifting their purchases towards buying in bulk. Others reported that the pandemic led them to switch to different tobacco products such as loose tobacco, whether to reduce cost associated with increased smoking or for other reasons. A few reported that they bought cigarettes more frequently, due to an overall increase in smoking. Concerningly, a few participants also reported an increase in ability to purchase tobacco products due to mask wearing, which they perceived as allowing them to evade age limit restrictions: “…honestly, it might be easier cause most people can't even tell my [age], look at my face…’cause I'm wearing a mask, and a lot of places aren't carding these days.”.

3.3. Reasons for changes in tobacco use during the COVID-19 pandemic

Participants also asked about whether and why their tobacco use behavior had changed during the pandemic (Table 2). Several participants reported that living with their family during lockdown reduced their smoking due to parental or family disapproval and lack of privacy to engage in tobacco use. Many participants also reported that the respiratory nature of COVD-19 caused them to think about their lung health and to decrease their smoking in order to reduce their risk of contracting and/or exacerbating COVID-19. The change in young adults’ routines due to the pandemic meant that many participants had less unsupervised time to use tobacco, that their new routines did not include as many situatons that previously included tobacco use (e.g., socializing with friends), or that this routine disruption led to less smoking because these were not activities that had been previously associated with smoking: I was also busy with transitioning from in-person school to online school. So that mainly took up my time. I really didn't reach out to smoking for that.”.

The cost of tobacco products was also noted, highlighting the overall financial precarity faced by many families as a result of the pandemic. However, negative mood, including stress and anxiety, were associated with increased tobacco use to cope with these feelings or decrease boredom. One participant noted: “I feel like I smoke a lot more, because there's just a lot more time that I have in the day…when I stay at home, I smoke a lot more.” Another participant stated: “I just feel a lot more stress at times…I think it's work, in tandem with a lot that's going on these days, not just COVID, but…I noticed a lot more stuff getting to me and that's what usually drives me towards smoking.”.

3.4. Knowledge of risks related to tobacco use and COVID-19

As the parent study included participants who both smoked cigarettes and had ever used e-cigarettes, we asked participants about their perceptions of how both cigarette smoking and e-cigarette use may affect risks related to COVID-19 (i.e., specifically, “What do you know about the health risks of COVID-19 for cigarette/e-cigarette smokers? Do you think smokers/vapers have an increased or decreased risk of developing severe COVID-19 symptoms?). Illustrative quotes are shown in Table 3. Most participants were aware that cigarette smoking increased the risk of exacerbating the health effects of COVID-19 infection since smoking damages lung capacity and COVID-19 is a respiratory illness: “…if a smoker gets COVID, it could affect them more because…their lungs [are] already affected by smoking.” Others were uncertain, mainly due to news articles reporting that nicotine exposure could reduce the chances of COVID-19 infection: “I've heard mixed things, even that smoking reduces the risk of getting COVID. I've read about nicotine patches being delivered to healthcare workers in France. I'm not sure how that works exactly.” In terms of risk for people who use e-cigarettes, there was more variety in responding. Most believed that vaping could increase risk due to the potential damaging effects of vaping on the lungs, while a few thought that it would be protective due to media accounts of the potential for nicotine to ward agasint COVID infection. However, some were uncertain whether the risk would be different than that related to smoking cigarettes but posited that it was likely a similar risk profile. A few participants thought that vaping would pose a greater risk than smoking due to negative coverage of vaping in the news or the perception that heavy vaping “feel[s] a lot worse” than heavy smoking, while one participant reported that vaping in general is less harmful to the lungs than smoking and therefore may be less of a risk factor than smoking.

4. Discussion

This study explored the impact of the COVID-19 pandemic on mood states, tobacco purchasing and use, and knowledge about the effects of tobacco use on the risk of contracting and/or developing serious COVID-19. This study is the first, to our knowledge, to use qualitative analyses to understand youth tobacco use during the pandemic in a U.S. sample of high-risk, daily-smoking early young adults who had used e-cigarettes. In summary, we found that: 1) as has been widely reported, the majority of teens had experienced mental health disturbances as a result of the pandemic, which manifested as symptoms of depression, anxiety, and/or acute loneliness due to social isolation; 2) both greater and less access to tobacco were reported; 3) changes in tobacco use were also reported, again with some reporting increases in use (mainly attributed to coping with negative mood and/or boredom) and others reporting decreases or quitting altogether (mainly attributed to reduced opportunities to use and health concerns); and 4) while some participants reported that tobacco use could increase their risk related to COVID-19, many reported confusion and uncertainty about how tobacco use could impact their risk. The heterogeneity of the responses is consistent with other cross-sectional U.S. data on youth tobacco use during the pandemic (e.g., Gaiha et al., 2020) as well as qualitative data from a sample of youth from Hong Kong who smoke cigarettes (Lam et al., 2022) and highlights the value of qualitative work for uncovering specific factors that may be related to differential outcomes and similar experiences of youth in different global contexts.

The participants in our study overwhelmingly reported that their mood was negatively affected by the pandemic and related stay-at-home orders and school closures. As other studies have noted (Czeisler et al., 2020, Jones et al., 2022, Leeb, 2020, Millner et al., 2022, Vahratian et al., 2021), depression, anxiety, and stress were reported, and attributed to social isolation, restlessness from being “always home,” and the cancellation or postponement of important milestone events like first jobs. Given that young adults are highly vulnerable to the development of mental health disorders as a result of transitions from adolescence to emerging adulthood (Kessler et al., 2007), the overwhelming signal that young peoples’ mental health was negatively impacted by the pandemic points to the need for more comprehensive solutions to the crisis of youth and young adult mental health (Abrahamson, 2022).

The pandemic also resulted in changes in tobacco purchasing among youth. One theme reported was the rise in online purchasing of tobacco products. This is concerning, as internet sales of tobacco products are less likely to be age-verified, meaning that youth under 21 can use these channels to evade age-restriction laws. In a recent experimental study, 97.8% of attempts to purchase little cigars and cigarillos online by teens under 18 were successful and resulted in product delivery and a similar study reported that 76.5% of such attempts to buy e-cigarettes online were successful (Williams et al., 2015, Williams et al., 2020). Furthermore, some participants reported that mask requirements made evading age law requirements easier for in-person purchasing. As the FDA continues to evolve and update its regulation of these products, online sales remain an important area of regulatory scrutiny for reducing access to tobacco products by minors, as well as more widespread enforcement of Tobacco 21 laws.

Reports of changes in tobacco use patterns also varied. As reported in other studies, both increases and decreases in use were reported (Denlinger-Apte et al., 2022, Gaiha et al., 2020). Consistent with another study that reported that moving home with parents was associated with reducing tobacco use in college students (Sokolovsky et al., 2021), several of our participants reported that being home with family led to a reduction in use, generally as a result of parental disapproval. However, negative mood and boredom were also reported as triggers for increased use. This is not surprising as depression frequently co-occurs with tobacco use in teens (Audrain-McGovern et al., 2015, Gorfinkel et al., 2022, Lechner et al., 2017, Sumbe et al., 2022), who report tobacco use as a way to cope with symptoms (Audrain-McGovern et al., 2009), and teens report negative mood as a barrier to sustained quitting (Myers et al., 2011). Future interventions should focus on emerging adults experiencing depression, as the transition away from the protective influence of parents may be a particularly vulnerable period for tobacco use escalation (Cadigan et al., 2019, O’Brien et al., 2018).

Participants in our study also reported significant confusion about how tobacco use affected their risk for contracting COVID-19 and/or how tobacco use may exacerbate the effects of COVID-19 on the lungs. This may reflect the legitimate murkiness in the literature about the role of nicotine in protecting people from COVID-19. Early in the pandemic, there were reports that doctors in Italy were using nicotine patches to reduce their risk of contracting the disease, and overall the literature suggests that current tobacco use may be protective against infection (Duszynski et al., 2021, Korzeniowska et al., 2021, Simons et al., 2021). These reports draw from the lower-than-expected COVID-19 hospitalization rates of people who currently smoked cigarettes, and the hypothesized mechanism by the SARS-CoV-2 proteins may interact with specific subunits of nicotinic acetylcholine receptors (Lagoumintzis et al., 2021). However, as correctly noted by several participants, if a person who smokes does contract COVID-19, their health outcomes are generally worse than those of people who do not smoke (Baker et al., 2022, Alqahtani et al., 2020, Mahamat-Saleh et al., 2021, Paleiron et al., 2021, Reddy et al., 2021). The data on e-cigarette use and COVID-19 infection and progression are still emerging, but a recent study indicated that e-cigarette use was related to more severe COVID-19 outcomes (Burnett-Hartman et al., 2022). The persistent confusion about the role of tobacco use in increasing risk for COVID-19 underscores the need for the public health community to work toward consistent messaging about how tobacco use can accelerate risk for severe outcomes from COVID-19.

Limitations of our study include the focus on young adults who smoke cigarettes most days, as frequent cigarette use among youth is becoming rarer (Meza et al., 2020). Though this makes our population less representative of all tobacco-using youth, this population is also at high-risk of continuing to smoke, and therefore we felt it was worth investigating this high-risk population of youth in depth. Our study is also limited in that we did not compare quantitative aspects of immediate pre-pandemic tobacco use with tobacco use during the pandemic, and we were therefore unable to characterize precise changes in use. As this study was conceived to understand the lived experiences of young people undergoing an unprecedented disruption to their lives and how this may affect their tobacco use behaviors and risk perceptions, we do not have specific data to compare to; nor did we ask about use in quantitative terms during the interviews, thus we cannot compare quantitative use rates pre- and post-COVID. However, as noted earlier, other larger studies have done this; our sample size is adequate for this type of qualitative work as we reached saturation on themes of interest. The value of our paper lies in adding to literature on the effects of the pandemic on tobacco use and mood in youth by highlighting qualitative experiences such as the interplay between negative mood, parental influence, and tobacco availability. While the specific conditions of the early pandemic (lockdowns, stay-at-home orders, etc.) are no longer in effect, our work sheds light on how abrupt changes in specific contextual and emotional factors can lead to similarly abrupt changes in tobacco use. Such insights can point to avenues for future research on reducing tobacco use through improved mental health, greater parental monitoring, and reduced tobacco availability.

CRediT authorship contribution statement

Rachel N. Cassidy: Conceptualization, Funding acquisition, Investigation, Methodology, Supervision, Visualization, Writing – original draft, Writing – review & editing. Mariel S. Bello: Writing – original draft, Writing – review & editing. Rachel Denlinger-Apte: Conceptualization, Methodology, Writing – review & editing. Christine Goodwin: Data curation, Formal analysis, Validation, Writing – review & editing. Julissa Godin: Data curation, Validation, Writing – review & editing. Ashley E. Strahley: Data curation, Formal analysis, Resources, Software, Validation, Writing – review & editing. Kimberly D. Wiseman: Data curation, Formal analysis, Resources, Software, Validation, Visualization, Writing – review & editing. Dorothy Hatsukami: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Writing – review & editing. Eric Donny: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources. Jennifer W. Tidey: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing – review & editing. Suzanne M. Colby: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing – review & editing.

Funding

This research and the preparation of this manuscript were supported by grants U54DA031659 and U54DA036114 from the National Institute on Drug Abuse and the Food and Drug Administration Center for Tobacco Products. This research was also supported by the Qualitative and Patient-Reported Outcomes Developing Shared Resource of the Wake Forest Baptist Comprehensive Cancer Center’s NCI Cancer Center Support Grant P30CA012197 and the Wake Forest Clinical and Translational Science Institute’s NCATS Grant UL1TR001420. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Food and Drug Administration.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.