Study design

This was a cross-sectional, descriptive and analytical study. Cigarette smokers aged >18 years were included in the study. The sampling method was non-probability, convenience sampling.

Data were collected using an anonymous questionnaire developed by the authors. This tool consisted of 52 questions, most of which were closed-ended. It included: 1) sociodemographic and economic data on participants, 2) smoking profile, and 3) two psychometric tests, the Fagerström test for nicotine dependence (FTND)⁹ and the Quit Motivation Questionnaire (Q-MAT)¹⁰. The items on these scales were completed by the participants during the confinement. For the period before the confinement, the measurement was retrospective.

The questionnaire also included an introductory section explaining the purpose of the current research, the rights of participants, anonymity, and voluntary informed consent. Validating the consent allowed participants to access the questionnaire.

The data collection tool was distributed via e-mail and social networks such as Facebook, WhatsApp and Messenger, during a containment period from 9 May to 11 June 2020. Before being distributed, the questionnaire was checked and validated by five resource persons from different fields. It was also pre-tested with 10 smokers excluded from the study.

Measurements

Nicotine dependence

The FTND is the most commonly used tool for assessing the degree of nicotine dependence in smokers. It consists of six questions about the individual’s smoking habits. The score obtained from this test varies from 0 to 10. Different categories of dependence are assigned according to the scores obtained: 0–2 no dependence, 3–4 low dependence, 5–6 medium dependence, and 7–10 strong to very strong dependence. During confinement, this measurement scale is completed by the participant in a single operation for the two periods before and during confinement.

Motivation to stop smoking

The Quit Smoking Motivation Questionnaire (Q-MAT)¹⁰ was used to assess the degree of motivation to quit smoking by means of four questions. The test score ranges 0 to 20. A score <6 indicates insufficient motivation, 7–12 average motivation, and >12 indicates high motivation. During confinement, this motivation scale is completed by the participant in one go for the two periods before and during confinement.

Statistical analysis

Data entry and management were conducted using the Jamovi software. The distribution of quantitative variables (dependence and motivation scores) was assessed using the Shapiro-Wilk test, in addition to graphical representation of values (Q-Q-Plot, Histogram). Non-normally distributed quantitative variables were described in terms of median and interquartile range, and then compared using the Wilcoxon test. However, qualitative variables (degree of dependence and degree of motivation) were described in terms of frequencies and percentages, and compared using the McNemar test.

Sociodemographic and economic characteristics of participants

This study involved 478 Moroccan smokers. The participants were predominantly male (95%) and more than half were married (54%) and aged 26–45 years (54%). The results also showed that 75% of those surveyed had a university education, 74% declared an income of over 2800 Moroccan Dirhams and 73% of participants had social security cover. Urban smokers accounted for 82% (Table 1).

Smoking profile of the participants

A study of the smoking profile (Table 2) revealed that 81% of the participants had attempted to quit, 77.5% of them without any help. In addition, alcohol (28%) and cannabis (20%) use were found among the study population. The first cigarette was smoked from the age of 10 years. Moreover, 72% of participants started smoking their first cigarette before the age of 20 years. Similarly, 80% of respondents indicated that they started smoking daily before reaching the age of 25 years. As regards spending on tobacco, 65% of participants said they spent more than 100 Dirhams a week. In addition, a fifth of participants spent more than 200 Dirhams a week on their tobacco consumption.

As for the state of knowledge of the population studied, 61.3% were aware of the negative effects of tobacco on health. On the other hand, 21.5% of participants felt that smoking is a risk factor for contracting COVID-19, while 50.4% had no knowledge of this. Furthermore, 47.5% of the population thought that smoking could aggravate the complications associated with COVID-19.

Nicotine dependence

The results showed a significant variation (p<0.001) in dependence scores before and during confinement, with a mean decreasing from 3.82 to 2.95. The median also decreased from 4.00 to 2.00. However, the standard deviation remained unchanged at 2.29, indicating stability in the dispersion of scores. In terms of percentiles, the 25th percentile decreased from 2.00 to 1.00, and the 75th percentile from 6.00 to 4.00, reinforcing the idea of a reduction in dependence (Table 3).

During confinement, there was a significant increase in the percentage of people with no dependence on tobacco (50.6% compared with 32.2% before confinement) (Table 4).

These results highlight a downward trend in all levels of tobacco dependence during confinement. The percentages of low, medium and high dependence all decreased.

Motivation to quit smoking

Table 5 presents the results for the motivation score, comparing the results before and during confinement. The main descriptive statistics are provided for these two periods, as well as a p-value to assess the significance of the difference between the two periods. Motivation increased during confinement, with higher median, lower quartile and upper quartile values. This increase was statistically significant (p<0.001).

In addition, Table 5 presents the results concerning the participants’ degree of motivation to stop smoking before and during the confinement period. The data were divided into three levels of motivation, and a p-value was provided to assess the significance of differences between the two periods.

This table shows that during the confinement period, there were significant changes in people’s motivation to stop smoking. The ‘good motivation’ category increased, while the ‘insufficient motivation’ and ‘average motivation’ categories decreased.

Dependence

A study of the smoking profile before and during confinement revealed a reduction in consumption. This finding is consistent with the results of several studies. The study carried out in Spain by Rebollar Álvarez et al.¹¹ confirmed the reduction in tobacco consumption. Another recent study supported this result¹².This reduction in tobacco consumption was linked, on the one hand, to restrictions on movement and financial constraints^13,14. On the other hand, researchers have correlated this reduction with smokers’ fear of contracting a serious form of COVID-19¹⁵.

These results can be interpreted in different ways. It is possible that some people took advantage of the confinement to reduce their smoking, perhaps because of limited opportunities to smoke or increased health awareness during the pandemic. However, it is important to note that other factors may also have contributed to these changes, and further studies may be needed to fully understand the motivations and implications of these variations.

However, some studies have contradicted these results. According to Yan et al.³ and Sidor and Rzymski¹⁶, more than 45% and 74.1% of smokers, respectively, saw their frequency of consumption increase during confinement. Similarly, Klemperer et al.¹⁷ and Chagué et al.¹⁸ reported that 30% of respondents increased their consumption. The study carried out by the French public health authorities¹⁹ on smoking behavior and trends, found that around 25% of smokers said they had increased their tobacco consumption; the same figure was reported by Cransac-Miet et al.²⁰.

In addition, the Chinese survey by Sun et al.²¹ showed that 20% of regular smokers had increased their cigarette consumption and 25.3% of ex-smokers had relapsed. Several studies have supported this increase in consumption^22-32. Numerous studies have linked this increase in consumption to various factors, including stress, anxiety, boredom, working at home, lack of social contact, and negative feelings engendered by confinement^25,29,33-35.

As for inferential analysis, our result relating to dependence was statistically significant (p<0.001). In the same sense, and according to Dogas et al.³⁶, participants reported smoking a significantly higher number of cigarettes (from 11.8 ± 7.4 cigarettes/day before confinement to 13.9 ± 9.8 cigarettes/day during confinement, p<0.001). In addition, Hanafi et al.³⁷ recorded a significant increase in cigarette consumption. The significance was also confirmed by the work of Souza et al.³¹. However, according to Cicero et al.²⁸ and Abouzid et al.³⁸ confinement did not significantly modify smoking habits.

Motivation to quit smoking

The participants’ assessment of their motivation to stop smoking increased during confinement, with higher median, lower quartile and upper quartile values. This increase in motivation was statistically significant (p<0.001).

The work of Klemperer et al.¹⁷ specified that motivation to stop was increased in 35.6% of cigarette smokers. Moreover, according to Shimpo et al.³⁹, 6.4% stopped smoking during confinement (p<0.001). Similarly, COVID-19 was significantly associated with an increase in quit attempts, successful cessation among smokers¹⁵. In addition, a study⁴⁰ comparing smoking cessation success before and after the pandemic, found a 31.1% cessation rate during the pandemic with a statistically significant difference (p<0.001). Moreover, intentions to quit smoking increased from 26% to 40% according to the results of Zubović et al.²⁴. Furthermore, several studies have supported these results in relation to the increase in motivation to quit smoking during confinement^13,34,41-44. However, according to Freire et al.²² most smokers did not report any change in their motivation to stop smoking. Another study found that participants were not more motivated to quit smoking during the COVID-19 pandemic⁴⁵. Overall, these studies show that the period of confinement due to COVID-19 led to a significant increase in motivation to stop smoking. The results suggested that the exceptional circumstances associated with the pandemic had a positive impact on smokers’ motivation to quit.

Strengths and limitations

To our knowledge, this study was the first in Morocco to assess tobacco dependence and motivation to quit before and during the confinement imposed by COVID-19. In addition, the 478 participants represented 12 regions of Morocco. The present work has, however, some limitations. First, the cross-sectional study does not allow for temporal evaluation. Second, the sampling technique does not allow for generalization of the results. Third, the participants’ responses could be subjective, despite the use of validated psychometric scales.