Effects of lockdown on tobacco products and electronic cigarette| Tabaccologia

Between April 2020 and May 2021, the Istituto Superiore di Sanità (ISS), in collaboration with the Istituto di Ricerche Farmacologiche “Mario Negri”, the Università Vita-Salute S. Raffaele (UniSR) and the Istituto per lo studio, la prevenzione e la rete oncologica (ISPRO), conducted a longitudinal study to aimed at analyzing the smoking habits during the pandemic period in a representative sample of the Italian population (18-74 years), according to the main socio-demographic characteristics. In particular, three surveys were carried out: the first in April 2020, the period of strictest lockdown, where respondents’ smoking habits were investigated both during the lockdown and in the period immediately before (January 2020); the second in November 2020 during a partial lockdown; the third in May 2021 (partial re-openings).

The interviews were conducted using an anonymous online questionnaire, collected through a CAWI method (computer assisted web interviewing).

The first survey, conducted at the end of the first lockdown in April 2020, showed that smokers in Italy before the lockdown were 10.1 million (23.3% of the population), 5.2 million men (24.4%) and 4.9 million women (22.2%) and about 630 thousand people (334,500 men and 295,500 women) had quit smoking during their confinement at home. They were mainly young (18-34 years) subjects, single and living with other people. These subjects have had probably more difficulties in smoking at home (e.g. children in the presence of their parents).

However, the decrease in the percentage of smokers observed in April 2020 compared to January 2020 (21.9% vs 23.3%) was not confirmed in subsequent surveys: the percentage of smokers increased to 24% in November and to 26.2% in the survey conducted in May 2021. The same trend was observed stratifying the sample by gender (men: 24.4% Jan 2020, 22.9% Apr 2020, 24.6% Nov 2020, 25.7% May 2021, and women: 22.2% in Jan 2020, 20.9% in Apr 2020, 24.5% in Nov 2020, 26.7% in May 2021). In particular, the survey carried out in May 2021 showed an increase of about 1 million of smokers compared to the period immediately preceding the first lockdown.

In May 2021, the number of cigarettes smoked per day, that had experienced an increase in the period of strictest lockdown (the average number of cigarettes per day was 10.9 before the lockdown and 12.7 during the lockdown) returned to the levels of before the pandemic (10.8 cigarettes per day, 11.4 males, 10.1 females). Regarding the use of novel tobacco products (electronic cigarettes and heated tobacco products), the study noted that their consumption has also been affected by the pandemic period.

The survey conducted in May 2021 found that 9.0 % of the Italian population currently (regularly + occasionally) uses electronic cigarette (e-cig), with on average 30 puffs per day. Overall, 65% of consumers use rechargeable devices, 22% with large tanks and 13% “disposable”. The presence of nicotine in refill liquids seems to be a particularly important for electronic cigarette users: 67% of them, in fact, uses mainly or exclusively liquids containing nicotine. The percentage of e-cig users increased by about one percentage point during the pandemic period: before the lockdown it was 8.1%, it rose to 9.1% in April 2020 and remained similar both in November 2020 and May 2021.

Regarding the Heated Tobacco Products (HTP), the survey conducted in May 2021 found that 7% of the population uses them currently (regularly or occasionally). The proportion of HTP users increased significantly during the pandemic period from 4.1% in January 2020 to 4.4% in April 2020 to 7% in November 2020 and May 2021. Also, for these products, as it has been found for electronic cigarettes, we confirm an increasing trend in the number of consumers during the pandemic period.

The role of Heated Tobacco Products (HTP) and Electronic Cigarettes in initiating, relapsing and smoking cessation

An interesting aspect related to the use of these products concerns their role on the initiation, relapse and smoking cessation. The longitudinal study conducted during the pandemic period assessed the relationship between the changes in the Italians’ smoking habits and the use of electronic cigarettes and HTP.

Regarding smoking initiation, the study shows that in November 2020, 4.7% of those who reported to have never used traditional cigarettes in April, became smokers. In this population of “new smokers”, the consumption of e-cig and HTP seems to have strongly favored the smoking initiation: in fact, only 2.1% of those who had never used e-cig started smoking traditional cigarettes in the considered period, whereas 19,6% of those who already used electronic cigarettes became dual users. Comparable results have been obtained for HTP users: only 3.2% of those who reported to have never used heated tobacco products became smoker, whereas 19.3% of those who already used heated tobacco products became also smoker of traditional cigarettes.

Concerning the relapses, the longitudinal study shows that 17.2% of those who had declared to be a former smoker of traditional cigarettes in April (period of the first lockdown), relapsed in November. Again, the use of e-cig and HTP seems to have played an important role as a risk factor for relapse. In fact, while 7.7% of ex-smokers who had never used e-cig returned to smoking in the considered period, 39.1% of electronic cigarette users started smoking again in November. Similarly, while 11.2% of former smokers who had never used HTP returned to smoking, 58.3% of those who used HTP returned to smoking also traditional cigarettes.

Considering the role of e-cig and HTP in facilitating the smoking cessation, the longitudinal study shows that in the survey conducted in November 2020, 14.6% of those reporting to be traditional cigarette smokers in April, managed to quit and become ex-smokers. In this population of former smokers, the use of electronic cigarettes and heated tobacco cigarettes played a negative role: in fact, 15.4% of those who had never used e-cig managed to quit smoking, while only 6.7% of those using e-cig succeeded in this intent. Similarly, 15.5% of those who had never used HTP managed to quit, while none of those who used HTP succeeded in smoking cessation.

In conclusion, the results of the study show that the use of e-cig and HTP in Italy during the pandemic period contributed both to the initiation and relapse of traditional cigarettes and hindered their cessation, and thus fuelling the tobacco epidemic.

Figures and tables

Figura 1.Stime di prevalenza dei fumatori in Italia nel periodo immediatamente antecedente il primo lockdown e durante il periodo pandemico.