Traditional smoking associated with alcohol and psychotropic substance use in post-lockdown in a representative sample of the Italian population| Tabaccologia

Abstract

Introduction: Vulnerable population subgroups, such as drug users or alcoholics, have been most impacted by the pandemic. The objective of the present work is to assess which variables are associated with the concomitant consumption of smoking, alcohol and psychotropic substances after the lockdown in Italy and to estimate a possible association between the consumption of these substances and the level of mental health.

Methods: The data used come from the Lost in Tuscany 2023 survey, a project carried out with the aim of assessing the impact of the COVID-19 pandemic on the lifestyles and mental health of the Italian population aged 18 to 74.

Results: The concomitance of smoking, alcohol use and psychotropic substances appears to be especially prevalent among younger people. College graduates accompany traditional smoking more with both risk behaviors; those with low degrees, on the other hand, make greater use of exclusive smoking. Regarding the psychological component: the concomitant use of alcohol and psychotropic substances is higher among the most frail individuals, who present symptoms of anxiety and depression; in addition, the proportion of smokers who accompany smoking with both risk behaviors is higher among those who use psychoactive drugs.

Conclusion: Even before the lockdown anxiety and depression were known risk factors for smoking, alcohol and psychotropic substance use. The restrictive measures implemented following the pandemic worsened the mental health of citizens, increasing the use of these substances. After the lockdown in Italy, younger individuals and those with worse mental health are at greater risk for consuming smoking, alcohol and other psychotropic substances.

Introduction

During the COVID-19 pandemic, given the imposition of a nationwide lockdown, about 60 million Italians were confined to their homes for several weeks. The restrictive measures applied, incentivized marginalization and worsened the mental health of citizens, leading to increased symptoms of anxiety, depression and insomnia [1,2].

Vulnerable population subgroups, such as drug users or alcoholics, suffered most from the impact of the pandemic. In fact, increased use of alcohol, drugs, and other forms of addiction, often in association with mental disorders, was noted during the lockdown [3-7]. Indeed, stress, anxiety, depression and isolation are known risk factors for the onset of addiction and substance abuse [8-12]. In addition, the interruption of treatment and recovery programs due to work lockdown and the difficulty in accessing health services during lockdown have increased the likelihood of substance abuse and relapse by users [13,14].

In Italy, specifically, there are few studies regarding the use of drugs and other forms of addiction during lockdown. From a representative study of the Italian adult population [15], it appears that cannabis use among occasional users decreased during lockdown but remained stable among regular users. In 2022, compared with the pre-pandemic phase, the percentage of Italian adults aged 55-74 years who used cannabis decreased while there was a sharp increase among younger individuals (18-34 years). Men, individuals with low or high levels of education, and those with above-average economic status used cannabis more frequently during 2022. In addition, in 2022, cannabis use was more frequently reported in association with smoking (both traditional cigarettes and new tobacco products), alcohol, gambling, and in those who reported worse mental health during lockdown. A second study that investigated alcohol use in young Italians (18-26 years old) found that participants with low socioeconomic status and inactive from a work perspective during lockdown were more at risk for alcohol use than those who enjoyed opposite situations [16]. Regarding smokers, increased consumption of both traditional cigarettes and new tobacco products (e-cigarettes and heated tobacco products) was reported during the lockdown. Individuals who started smoking during the lockdown were more frequently men and individuals with addictions, such as cannabis users and gamblers [17]. Again, the close relationship between smoking, alcohol and other addictions is confirmed.

To date, however, there are still few studies regarding substance abuse after the pandemic, following the resumption of all work and social activities. The aim of the present work is to study which variables are associated with concomitant smoking, alcohol and psychotropic substance use after lockdown and to secondarily estimate a possible association between smoking habit, alcohol use and other substance use with the level of mental health.

Materials and methods

The Lost in Tuscany (LOckdown and LifeSTyles in Tuscany) project represents the continuation of what was achieved through the Lost in Italy (LOckdown and LifeSTyles in Italy) survey, a project conducted in 2021 with the aim of assessing the impact of the COVID-19 pandemic on the lifestyles and mental health of the Italian population aged 18-74. Lost in Tuscany collected, through two additional surveys conducted in March 2022 and April 2023, respectively, data comparable with the national data collected in the first study, while maintaining the representativeness of the Italian adult population [1].

The data used in this research refer to the latest Lost in Tuscany survey (April 2023). The sample includes 6,600 individuals interviewed through a self-administered online questionnaire lasting about 20 minutes. In addition to socio-demographic information (gender, age, marital status, employment and economic status), the questionnaire also collects anthropometric characteristics (height, weight) and regarding lifestyle habits (hours of physical activity and hours outdoors, smoking habits, use of heated tobacco products and e-cigarettes, exposure to secondhand smoke, alcohol consumption, use of cannabis or other drugs, gambling or video game habits, social/app dating). Information is also collected regarding social habits (physical contact with other people and sexual activity), pandemic-related information (vaccinations, use of masks), and detailed information on mental health status, in terms of presence of symptoms of anxiety and depression, quality and quantity of sleep, quality of life, and use of psychoactive medications (antidepressants, anxiolytics, hypnotics, antipsychotics, mood stabilizers).

The main variables of interest considered in this paper concern the use of traditional smoking and the concomitant use of alcohol and/or other substances. With reference to the latter category, users of other substances are defined as those who have used cannabis/cannabis light or other psychotropic substances such as cocaine, heroin, crack cocaine, opiates, opioids, synthetic psychostimulant substances, hallucinogens, smart drugs, and psychotropic drugs without prescription in the four weeks prior to the interview.

Regarding traditional smoking, participants were classified as current smokers if they had smoked at least 100 cigarettes in their lifetime and were smoking at the time of the interview, ex-smokers if they had smoked 100 cigarettes in their lifetime but were not smoking at the time of the interview, and non-smokers if they had never smoked more than 100 cigarettes in their lifetime.

Regarding the consumption of alcoholic beverages, subjects were classified as being at risk through the definition provided by a variant of the audit C test (Alcohol Use Disorders Identification Test), a questionnaire consisting of three questions that allows the amount and frequency of alcohol consumption to be identified in order to define the degree of risk and dependence to which the subject is exposed [18].

STATA 17.0 was used to conduct the sample analyses. Statistical weights were used to ensure the representativeness of the sample for the total Italian adult population aged 18-74 years in terms of age, sex, and geographic area. Univariate and multivariate analyses were performed; differences between the variables of interest were investigated with chi-square tests.

Results

A description of the sample with reference to sociodemographic and psychological characteristics is given in Table 1. The 6,600 subjects are distributed almost equally with respect to gender: 50.3% male and 49.7% of the female counterpart. With reference to age, a slight imbalance in favor of the older ages is reported: 36.7% of the sample in the 55-74 age group, 39.4% in the 35-54 age group, while the proportion of young people is lower (23.9% in the 18-34 age group). About half of the sample (50.7%) has a high school diploma, 34.7% have a college degree, and 14.6% have a low educational qualification (middle school diploma or below); with reference to working status, more are employed (65.1%) than inactive and retired, 15.6% and 19.3%, respectively. 74.6% of the sample say they have an average quality of life, compared with 17.7% and 7.7% who report a low and high quality of life, respectively. In reference to sleep, 72.1% of the sample say they have adequate sleep quality, but 78.4% report insufficient amount of sleep. Low levels of anxiety and depression appear to be dominant in the sample: 75.3% of the sample reports a low level of anxiety versus 24.7% high and 82.7% report a low level of depression versus 17.3%. In addition, 92.3% of the sample report that they have not used psychoactive medications in the four weeks prior to the interview, while the remaining 7.7% have used them. Putting the focus on risk behaviors, about half of the sample is composed of nonsmokers (49.8%), while the remaining portion is distributed almost equally between current smokers (23.3%) and former smokers (26.9%). One-third of the total sample consumes alcohol (30.2%), while the use of other substances is not particularly prevalent (7.7%).

Table 2 shows the population distribution for sociodemographic and mental health status variables with respect to smoking habit and concomitant use with other risk behaviors. Specifically, exclusive smoking, smoking in association with another risk behavior (whether alcohol consumption or use of other substances), and finally, concomitant use of smoking and both of the two risk behaviors considered are considered.

Approximately half of the total 1,583 smokers in the sample (53.7%) use cigarettes exclusively; 35% accompany smoking with another risk behavior, whether alcohol or other substance use; and finally, 11.3% of smokers accompany smoking with both risk behaviors. No particular differences by gender emerge, however, the prevalences of risk behaviors with reference to other demographic variables are significant: among the total number of individuals included in the 55-74 age group, 63.3% use smoking exclusively, while among the youngest (18-34 age group) only 40% use smoking exclusively. With reference to risk behaviors, 25.8% of the youngest individuals accompany smoking with two risk behaviors compared to 3.9% of participants with 55-74 years. Regarding working status, retirees are the main users of exclusive smoking (65.9%) compared to employed and inactive. With reference to the concomitance of smoking and two risk behaviors, it is pensioners who are the least users (2.9% of total pensioners) compared to the other two classes. With reference to the exclusive use of smoking by educational qualification, no particular differences emerge between low and medium degree holders, around 56% for both, while 48% of college graduates use cigarettes exclusively; however, with regard to the concurrence of smoking and two risk behaviors, college graduates use more (15.6%) than low (11.6%) and medium (8.5%) degree holders.

With reference to sleep, there were no significant differences in both the quantity and quality of sleep in the three risk behavior groups. The distributions regarding symptoms of anxiety and depression in relation to risk behaviors appear to be similar to each other. Referring to exclusive smoking, those with low levels of anxiety use it more (57.2% of the sample) than those who reported high levels of anxiety (45% of the sample). The prevalence of those who accompany smoking with another risk behavior, however, is higher among those with high levels of anxiety (37.4%) than among those with low levels of anxiety (34%). This imbalance becomes even more pronounced in reference to smoking and two concomitant risk behaviors, with 8.8% of the sample reporting low levels of anxiety and concomitant use of smoking and two other substances versus 17.6% of the sample who reported high levels of anxiety. Similarly, for symptoms of depression we note a higher proportion among those who have low levels of depression and use smoking exclusively (57.1%) compared to those who reported high levels (40.2%); the proportions are similar with regard to those who also have another risk behavior, and are reversed for individuals who smoke and have two concomitant risk behaviors: 25% of the total smokers with high levels of depression accompany smoking with two other risk behaviors, compared to 7.9% of those who have few symptoms. In reference to psychoactive medication use, the distribution also follows the trends observed for anxiety and depression. If, among exclusive smokers, it is those who do not use drugs who make up the largest proportion (56.7% of the total of those who do not use drugs, compared to 35.7% of the total of those who do), the situation is reversed for those who accompany smoking with two risk behaviors: they turn out to be 38.8% of drug users compared to 6.8% of those who do not use drugs.

Discussion

Of the total 6,600 subjects in the sample, 1,583 (23.3%) are smokers and of these, 53.7% are exclusive smokers, that is, they do not accompany this habit with the consumption of alcohol or other substances such as cannabis, cannabis light, psychotropic substances. The remaining portion of smokers is divided between those, 35%, who accompany smoking with a risk behavior (alcohol or other substances) and those, 11.3%, with both behaviors considered.

However, the concomitance of smoking and such risk behaviors appears to be widespread, especially among younger people (18-34 years old). This finding reflects what has been reported in the literature: the population group most at risk of addictive behaviors (smoking, alcohol or other substances) are young people [15]. This can be explained by the fact that, among young people, it is common to resort to the consumption of such substances when in company, as a means of socialization.

College graduates accompany smoking more with both risk behaviors considered, those with low degrees, on the other hand, make greater use of exclusive smoking [15,16].

With reference to the psychological component, we can observe a clear difference regarding the presence of symptoms of anxiety, depression, and the concomitance of smoking and other risk behaviors: 17.6% of smokers with high anxiety and 25% of smokers with high depression accompany smoking with both risk behaviors, compared with 8.8% of smokers with low anxiety symptoms and 7.9% of smokers with low depression symptoms. These findings are in agreement with what is known in the literature: concomitant consumption of alcohol and psychotropic substances is higher among the most psychologically fragile individuals who present with symptoms of anxiety and depression, which are known risk factors for abuse and the onset of addiction to these substances [8-12]. To complete the picture of those who are frail and therefore most at risk, we can also consider those who use psychoactive medications such as antidepressants, anxiolytics, hypnotics, antipsychotics, and mood stabilizers. The proportion of smokers who accompany smoking with both risk behaviors considered is higher among those who use drugs: 38.8% of smokers who use such types of drugs accompany smoking with the other two risk behaviors, while 6.8% of smokers who do not use such drugs also consume alcohol and psychotropic substances. Again, the use of drugs may be associated with greater psychological fragility and thus a greater risk of developing forms of addiction.

Even before the lockdown, stress, anxiety, depression and isolation were known risk factors for smoking, alcohol and psychotropic substance use. The restrictive measures implemented in the aftermath of the pandemic have worsened the mental health of citizens, increasing the use of these substances. Although there are still not many publications in the post lockdown in Italy investigating the concomitant use of traditional smoking and alcohol and/or psychotropic substances, it has emerged from this analysis younger individuals tend to associate smoking use with alcohol and psychotropic substances more than older people. In addition, it is the more frail individuals with high levels of anxiety, depression, and who use psychoactive medications who make greater concomitant use of smoking and other substances.

Conclusion

After the lockdown in Italy, younger individuals and those with worse mental health are at higher risk of consuming smoking, alcohol and other psychotropic substances. Therefore, it would be appropriate to support these subgroups through dedicated interventions, so as to prevent and reduce the occurrence of risk behaviors in the Italian population.

Figures and tables

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