INTRODUCTION

Studies on how the COVID-19 pandemic has affected the smoking behaviors of tobacco users yield varying results based on the sociocultural background of the sample populations. Some studies found an increase in smoking habits¹, while others found an increased willingness to stop smoking among the public². In addition, there have been changes to the access and purchase of tobacco products due to lockdown measures, travel restrictions and border closures. Moreover, studies on the effects of the pandemic period on tobacco in Turkey do not exist. In a survey study from China that evaluated the tobacco use behavior of smokers conducted on 1595 adults between February and April 2020, it was noted that 65.3% of the sample reported no change in overall tobacco use, 23.1% used less, and 11.6% used more tobacco. Additionally, the decrease was prevalent for cigarettes compared to heated tobacco products and e-cigarettes³. Another study determined that smokers increasingly want to quit smoking as COVID-19 is associated with an increased risk of adverse outcomes⁴. A study examining the quitting rates of smokers who applied to the smoking cessation outpatient clinic in Turkey before and during the pandemic found that the smoking cessation rate was 23.7% before and 31.1% during the pandemic⁵. Furthermore, it is known in Turkey that lower priced tobacco products can be obtained in border regions. One of these regions is the Hopa district of Artvin, which is known for its access to low-priced cigarettes from duty-free shops and for cross-border purchases, as Georgia, the neighboring country, had cheaper cigarettes before the pandemic period.

With borders closed during the pandemic, access to this low-priced cigarette source was also closed. Hence, we aimed to investigate how both the effect of the pandemic and the closure of access to low-priced cigarettes may have affected the smoking behavior of individuals. In this study, we aim to assess the smoking behaviors of smokers living in the border region of Turkey, where access to low-priced tobacco products is easy, and to compare their smoking patterns and behaviors during the pandemic period in the pre-pandemic period.

METHODS

RESULTS

A total of 204 responses were collected. The average age was 38.6 ± 11.6 years, 75% were male, 61.3% were married, 37.7% were high school graduates, and 45.6% were university graduates. The monthly income of the household was three times the minimum wage in 63.2% of the participants. The average age of starting smoking was 19.7 ± 5.2 years, and the average duration of being a smoker was 18.8 ± 11.6 years (Table 1). A comparison of the characteristics of smokers according to their tobacco product use is presented in Table 2.

The number of cigarettes smoked per day was 18.9 ± 9.7 before the pandemic; this figure increased to 19.2 ± 9.6, but the difference was not statistically significant (p=0.407). The percentage of smokers using non-cigarette tobacco products increased from 3.9% to 6.4% during the pandemic. The pre-pandemic rates of roll-your-own tobacco use, duty-free tobacco, and the use of cross-country domestic cigarettes were 2.5%, 10.2%, and 3.0%, respectively, while these rates were determined to be 6.8%, 2.5%, and 0%, respectively, during the pandemic (p<0.05) (Table 3).

Regarding the amount of tobacco used, 65.2% of the participants reported no change, 21.1% reported increased use, and 13.7% reported a decrease in tobacco use. The financial status of 69.1% of the participants was adversely affected due to the pandemic; among all participants, the budget allocated for cigarettes during the pandemic remained unchanged at 61.8%, while it increased by 22.6% and decreased by 15.7% for the participants. Of the participants with a change in their smoking behaviors, 24.6% switched to cheaper tobacco products, 35.0% tried to quit smoking, and 40.4% reduced the number of cigarettes smoked daily (Table 3). No significant difference was found between the amount of tobacco use during the pandemic and changes in financial status during the pandemic (Table 4); however, as noted in Table 5, those who stated that their financial status had changed adversely during the pandemic preferred cheaper cigarettes (p<0.05).

DISCUSSION

During the pandemic period, for nearly two-thirds of the participants the smoking stayed the same, and those that changed more their behavior increased rather than reduced smoking, in this region of Turkey. Of the participants with a change in their smoking behaviors, one in four switched to cheaper tobacco products, one in three tried to give up smoking, and 40.4% reduced the number of cigarettes smoked daily. During the pandemic, access to cheaper tobacco products via border checkpoints decreased due to the pandemic restrictions, and the rate of roll-your-own cigarettes increased, according to our findings. Despite the changes in the economic conditions, no significant relationship was found between the amount of tobacco consumption before and after such changes.

Other studies have also indicated changes in tobacco product use during the pandemic. Gold et al.⁶, in their study dated May 2020 in the US, found that the majority (68.9%) of smokers consumed fewer cigarettes than their normal amounts in the last one month and that the increasing fear of COVID-19 motivated people to quit or reduce smoking. A study conducted in Turkey found that short-term smoking cessation of patients with COVID-19 diagnosis who were active smokers was 78.9%. This rate was maintained at 57.8% in the long-term, a teachable moment for smoking cessation⁷. A study by Yingst et al.⁸ in the US, assessed the changes in tobacco use of active smokers during the COVID-19 pandemic, and found that 28% increased their tobacco use, 15% reduced their tobacco use, while 24.5% tried to quit smoking. In a study in Korea, the rates of those who increased their tobacco use and those who decreased their tobacco use were found to be comparable, 20.2% and 19.5%, respectively⁹. While research in England revealed that the first COVID-19 lockdown was associated with increased smoking prevalence among younger adults. More smokers made quit attempts during the lockdown and more smokers quit successfully¹⁰.

In our study, while 21.1% of the smokers increased their tobacco use, 13.7% reduced their tobacco use. While the rate of those who increased tobacco use is close to the literature data, this rate is low for those who reduce it. This may be potentially due to the smokers’ tendency to purchase cheaper tobacco products. Another important finding of our study is that the places where smokers obtain tobacco products have changed significantly during the pandemic. While 84% of the participants bought cigarettes from TEKEL dealers (cigarettes with taxation) before the pandemic, this rate increased to 90.7% during the pandemic period. The rate of untaxed foreign cigarette smokers decreased from 3% to 0% during the pandemic. While the rate of purchase from duty-free shops was 10.2%, it decreased to 2.5% during the pandemic; in contrast, the rate of roll-your-own cigarettes increased to 6.8% during the pandemic period from the pre-pandemic rate of 2.5% (p<0.05). The cigarettes bought from TEKEL stores are more expensive compared to the other sources due to the taxes imposed. While the alternative purchase options to the TEKEL dealers were, in descending order, duty-free shops, untaxed foreign cigarettes, and roll-your-own cigarettes, this situation changed to roll-your-own cigarettes and purchases from duty-free shops because borders were closed during the pandemic period due to COVID-19 restrictive measures. During the pandemic period, the majority of our study population faced economic difficulties; however, the budget allocated for smoking did not change in 61% of the participants. Therefore, there was no clear difference in terms of worsening economic conditions and smoking, which is another finding of our study; smokers who purchased cigarettes from duty-free shops or untaxed foreign cigarettes opted for cheaper tobacco products (such as roll-your-own cigarettes). Of the participants with a change in their smoking behaviors due to increased prices, 24.6% switched to cheaper tobacco products, 35.0% tried to give up smoking, and 40.4% reduced the number of cigarettes smoked per day. During the pandemic, smoking cessation assistance services remained in the background, and smokers who wished to quit smoking could not access evidence-based smoking cessation methods. Smoking cessation support should be enhanced during the pandemic as a high COVID-19 risk perception has been found to be correlated with the desire to stop smoking¹¹ and smoking cessation attempts in the pandemic lockdown period¹⁰.

We found out that the people who stated their economic conditions worsened opted more for cheaper cigarettes, and those who were adversely affected by the pandemic in terms of financial condition constituted the entire population of those who opted for more affordable tobacco products. It has been reported that price hikes, increase in taxes on cigarettes, and minimum tax limit regulations, are significantly effective policies for smoking cessation and preventing smoking. However, the effect of these measures was limited in cases where access to cheaper tobacco products was available¹², while it has been reported that the practice of minimum base price law on tobacco control would be a practice that would reduce socio-economic inequalities in smoking prevalence¹³. In the Philippines, smoking prevalence decreased from 28.3% to 23.8% after a price increase in 2012¹⁴. In a study conducted to evaluate the effects of the tobacco prices on starting smoking and smoking cessation in China, the rates for initiating smoking decreased with higher prices; however, smoking cessation behavior patterns showed a lower result stemming from price increases, as access to cheaper tobacco products is relatively high¹⁵. South Korea increased the taxes on cigarettes in 2015 and after the tax hike in tobacco prices, 60.9% of smokers tried to quit smoking and 34.7% managed to achieve smoking cessation. Those who continued smoking showed a decrease in smoking frequency; however, no such effect was observed among light smokers, young smokers, and those in the higher income brackets¹⁶. Tobacco prices are related to smoking cessation and lead to a reduction in the number of cigarettes smoked. Research has indicated that in low-income smokers, the price correlation is stronger; however, in high-income smokers, the relation between smoking cessation and price was stronger. In light of these findings, it was reported that higher cigarette prices may trigger smoking cessation in the short-term among smokers of all income levels; however, low-income smokers might require additional factors to continue their smoking cessation¹⁷. In systematic reviews that evaluate the effectiveness of price/tax policies, low socioeconomical smokers are noted to be more responsive to price/tax increases compared to high socioeconomical smokers. However, some underestimated effects that can be considered as ‘bias’ are: only capturing short-term effects which do not translate into sustained quitting, and not accounting cross-border sales or smuggling¹⁸. In line with the above literature, we note that smokers’ access to untaxed tobacco products (smuggled cigarettes, roll-your-own tobacco, duty-free tobacco, etc.) should be prevented to achieve the goals envisaged by taxation policies. Our findings are parallel with these results.

CONCLUSIONS

There was no change in smoking status in the majority of smokers during the pandemic period, with an increase observed in 21.1% and a decrease in 13.7% of the participants. During the pandemic period, changes were observed in tobacco product supply points and tobacco product preferences for reasons such as closed border gates and being affected by the economic conditions. People who turned to lower priced tobacco products such as roll-your-own tobacco comprised those who experienced a negative effect in their economic situation due to the pandemic. These findings are in line with studies examining the effectiveness of tobacco taxation policies. Our findings support the view that societies where tobacco users with low socioeconomic status prefer cheap tobacco products when prices increase and have access to low-priced tobacco products, taxation policies may not be effective in supporting quitting smoking.