key: cord-0744609-sl4gg7ab authors: Chertok, Ilana R. Azulay title: Perceived risk of infection and smoking behavior change during COVID‐19 in Ohio date: 2020-09-27 journal: Public Health Nurs DOI: 10.1111/phn.12814 sha: 5780aec301bdfb557a07c0bece377eaec2ec3294 doc_id: 744609 cord_uid: sl4gg7ab OBJECTIVE: The recent COVID‐19 pandemic may catalyze smoking behavior modification. The purpose of the study was to examine factors associated with reducing smoking exposure during the COVID‐19 outbreak. DESIGN: Cross‐sectional design using the Health Belief Model to develop an online survey distributed throughout Ohio early during the outbreak. SAMPLE: 810 adults in Ohio (77.9% non‐smokers, 22.1% current smokers). MEASUREMENTS: Sociodemographic factors, smoking and behavior changes since the COVID‐19 outbreak, and perceived risk of infection were collected. Logistic regression analyses were conducted to determine factors associated with indoor smoking bans and factors associated with desire to quit smoking since the outbreak. RESULTS: For the overall sample, the odds of indoor smoking bans were significantly associated with never smoked, college education, single‐family residence, not living with smokers, and perceived importance of avoiding public places. For smokers, the desire to quit smoking since the COVID‐19 outbreak was associated with diabetes and perceived risk of severe infection. CONCLUSIONS: Identified factors inform residential smoking exposure reduction through indoor smoking bans. Having an increased perceived risk of severe infection among smokers may motivate cessation. Public health nurses can provide accurate and accessible resources for smoking cessation during the COVID‐19 pandemic to promote healthy lifestyle modification. the virus can enter the body. Asymptomatic viral transmission has been noted which increases the risk of unknowingly spreading the virus. Additionally, susceptible populations have been identified as those who have preexisting conditions including immunosuppression, respiratory problems, cardiovascular disease, older adults, and health workers (Driggin et al., 2020; Rothan & Byrareddy, 2020) . By minimizing close human contact as through "social distancing" (also known as "social isolation" and "physical distancing") along with other measures such as handwashing, cleaning surfaces, and wearing personal protective equipment, viral transmission may be minimized. On community levels, the most common strategy for containment has been quarantine and isolation, with countries recommending and enforcing containment and mitigation strategies in different ways. While recommendations such as the extent of quarantine and wearing masks on community levels vary, individuals maintain their own beliefs and practices regarding prevention of infection. Smoking is a modifiable behavior that has been associated with poor respiratory outcomes and higher risk of severe influenza (Vardavas & Nikitara, 2020) . To date, there have been limited large population-based research studies published since the outbreak regarding the association of smoking on the infection risk and severity of COVID-19. A meta-analysis of 19 studies with a pooled total of 11,590 COVID-19 infected patients, found a significantly higher risk of disease progression among smokers compared to never smokers (Patanavanich & Glantz, 2020) . Considering the upregulation of angiotensin-converting enzyme-2 (ACE2) receptors with smoking and the role that ACE2 plays in severe respiratory syndromes, researchers have recently suggested that smoking potentially increases the risk of developing severe COVID-19 (Brake et al., 2020; Leung et al., 2020) . As such, the increased risk of COVID-19 infection and severe infection among people with risk factors, may motivate smoking cessation among those who smoke. Additionally, households where indoor smoking bans were previously lacking may adopt such restrictions during the global outbreak of COVID-19 as reduction of secondhand smoke exposure through the restriction of indoor smoking has been found to decrease breathing problems (Young et al., 2016) . The Health Belief Model explains health behavior change such as smoking modification in relation to the perceived susceptibility, benefits, barriers, and self-efficacy of health behavior modification, along with personal modifying factors (Rosenstock et al., 1988) . In the current context, the pandemic outbreak of COVID-19 and recommendations of social isolation can serve as cues to action to engage in positive behavior modification along with the global transformation in routine daily activities and socialization such as home quarantine and modified, and for many curtailed, employment. In England, concern was expressed that a consequence of social isolation and possible stress is increased smoking among smokers and relapsed smoking among former smokers (Patwardhan, 2020 (Hlavaty, 2020) . A cross-sectional study was conducted using an anonymous online survey. The survey was developed using the Health Belief Model as the theoretical framework (Rosenstock et al., 1988) . A set of eight questions were developed based on the model's constructs about perceived risk of COVID-19 infection (measured on a scale of 1 = lowest and 10 = highest) (Table 1) , for which an overall Cronbach's alpha was calculated. The outbreak of COVID-19 and recommendations of social isolation to reduce the risk of infection can serve as an external cue, prompting behavior modification, specifically reducing smoking exposure in the home in general, and smoking cessation among smokers. Following survey development, the online survey was piloted to obtain feedback from 10 colleagues (whose data were excluded from the survey results), after which minor adjustments were made. Institutional review board approval was granted by the author's academic institution prior to initiation of the study. Adult residents of Ohio who were at least 18 years of age were eligible to participate in the online survey. The survey was distributed TA B L E 1 Questions on perceived risk of COVID-19 infection Using the scale of 1 = none and 10 = extremely high, rate your perception of risks associated with COVID−19… How much do you think that you are personally at risk of getting infected? How much do you think that you are personally at risk of severe infection? How much do you think that members of your home are at risk of getting infected? How serious is the overall risk in your community of the spread of infection? How serious is the overall risk in your country of the spread of infection? How easily does coronavirus spread? How important is it for you to avoid crowds or groups of people? How important is it for you to avoid public places? through listservs and social media outlets with specific boosts targeting adults residing in the state of Ohio. Social media outlets have been found to be an effective method of recruitment (Khatri et al., 2015) , especially during the pandemic outbreak and the need to maintain social distancing. Upon reading the online informed consent, the participant could decide whether to proceed with the survey. At the time of the initiation of the survey on April 7, 2020, there were 4,782 confirmed cases in the state and 167 fatalities (Hlavaty, 2020) . The governor of Ohio signed an Execute Order Declaring a State of Emergency on March 9, 2020 after three adults in the state tested positive for COVID-19 (DeWine, 2020), making Ohio one of the early states to actively join the global effort in mitigating the outbreak. The primary independent variable of interest was cigarette smoking status with options of currently smokes, formerly smoked, and never smoked. The primary dependent variable of indoor smoking ban was dichotomized: not permitted to smoke in the house (which included permitted to smoke on the porch/outside and no smoking in the house), and permitted to smoke in the house (permitted to smoke anywhere in the house, permitted to smoke in specific rooms, and permitted to smoke in only one specific room). Participants were also asked to report on changes in health behaviors since COVID- for purposes of analysis, the classification of cigarette smokers was comprised of cigarettes only and both cigarettes and e-cigarettes. There were also two dichotomous questions regarding the perceived association of smoking and COVID-19 infection. Frequencies and proportions were used to describe participant characteristics. Chi-square tests were used to examine the proportional differences of characteristics and health behaviors between current smokers and non-smokers with Friedman's exact tests used when the sample was small for a given category. Independent sample t tests were used to calculate the mean differences in the continuous variable of age between smokers and non-smokers. To examine differences based on smoking status in perceived risk of COVID-19 infection scale questions, nonparametric Mann-Whitney U tests were conducted. Significance was set at p ≤ .05. Significant variables from the bivariate analyses were used in logistic regression models to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) to determine factors associated with indoor smoking bans since COVID-19 among all participants, and to identify factors associated with desire to quit among current smokers and those who quit since the outbreak. Data analyses were conducted using SPSS 25 (NY, IBM Corporation) and post hoc power analysis was conducted using G*Power 3 (Faul et al., 2007) . There were reported smoking behavior changes among current smokers and those who quit since COVID-19 (Table 3) , with 36.7% (n = 66) having attempted to quit since the outbreak. Among those who attempted to quit, six used a quit-line or application, eight received support from a health care provider, 12 used prescription medication, 10 used over the counter medication, and 12 used other resources. There were significant differences in perceived risk between people who reported no desire to quit smoking and those who reported a desire to quit smoking among current smokers and those who quit since COVID-19, notably that those who desired to quit perceived a higher risk of infection (Table 4 ). In the final logistic regression model of having indoor smoking bans (n = 810, x 2 = 164.49, p < .001), the statistically significant vari- (Table 6 ). to women, which may be associated with higher rates of smoking among men (Cai, 2020) . A systematic review of five studies conducted in China and published in English on COVID-19 and smoking found that smoking was likely associated with adverse outcomes of the infection (Vardavas & Nikitara, 2020). We expected that perceived risk of COVID-19 would influence indoor smoking bans, based on the Health Belief Model. We found that among the total sample, only perceived importance of avoiding public places was significantly associated with having indoor bans, along with personal and household characteristics of never smoking, higher level of education, single-family home, and not living with smokers. In our study, the overall rate of indoor smoking bans was 87.0%, higher than the national average rate of 79% in the United States (United States Department of Health & Human Services, 2014) and only minimally changed from before COVID-19 to following the outbreak. It is noteworthy that 49.6% of the study participants had a bachelor's degree or higher which is greater than the state average of 27.8% and the national average of 31.5% (American Community Survey, 2018) indicating a relatively highly educated sample which may be a contributing factor to the high rates of smoking bans among the participants. Higher education is also associated with increased likelihood of owning a home, which may explain the higher smoking bans among adults living in single-family homes (Malito, 2017) . People living in multifamily buildings may experience a lack of compliance with and enforcement of smoke-free policies among residents (Rokicki et al., 2016) which may increase their risk of second-hand smoke exposure. Among study participants, current smokers and those who quit since the outbreak had a significantly lower rate of indoor smoking bans than nonsmokers. It is possible that there is a lack of awareness of the detrimental effects of secondhand smoke among adults who smoke thereby contributing to the lower rate of indoor smoking bans among smokers, as was found in a national survey study (Kruger et al., 2016) . This finding is further supported by the lower proportion of current smokers compared to nonsmokers who responded that smoking in- ing. It is important to consider the potential for increased stress with social distancing and precarious employment, which can consequently negatively impact smokers and former smokers, raising concern regarding an increased risk for smoking and smoking relapse (Patwardhan, 2020 (Geldsetzer, 2020) , public health nurses and other members of the health care team are critical in providing accurate and accessible information such as through phone and Internet-based resources, thereby facilitating smoking exposure reduction through online communication and resources. The recent outbreak of COVID-19 has led to changes in people's typical routines, social contexts, and health behaviors. Using the Health Belief Model, the current study found that perceived risks of infection were associated with desire to quit smoking among current smokers and those who quit since the outbreak in Ohio. Public health nurses should utilize Internet-based resources to distribute accurate messages and facilitate access to resources to promote healthy lifestyle modification including smoking cessation and smoking exposure reduction during the current pandemic outbreak. The author acknowledges Dr. Yael Bar-Zeev for her feedback on the design and analysis and Dr. Zelalem Haile for his guidance on the data analysis. Ilana R. 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Increase the proportion of smokefree homes. Healthy People 2020. : United States Department of Health and Human Services Health, secondhand smoke exposure, and smoking behavior impacts of no-smoking policies in public health housing How to cite this article: Chertok IRA. Perceived risk of infection and smoking behavior change during COVID-19 in