Tobacco smoking changes during the first pre-vaccination phases of the COVID-19 pandemic: A systematic review and meta-analysis

Background Globally, tobacco smoking remains the largest preventable cause of premature death. The COVID-19 pandemic has forced nations to take unprecedented measures, including 'lockdowns' that might impact tobacco smoking behaviour. We performed a systematic review and meta-analyses to assess smoking behaviour changes during the early pre-vaccination phases of the COVID-19 pandemic in 2020. Methods We searched Medline/Embase/PsycINFO/BioRxiv/MedRxiv/SSRN databases (January- November 2020) for published and pre-print articles that reported specific smoking behaviour changes or intentions after the onset of the COVID-19 pandemic. We used random-effects models to pool prevalence ratios comparing the prevalence of smoking during and before the pandemic, and the prevalence of smoking behaviour changes during the pandemic. The PROSPERO registration number for this systematic review was CRD42020206383. Findings 31 studies were included in meta-analyses, with smoking data for 269,164 participants across 24 countries. The proportion of people smoking during the pandemic was lower than that before, with a pooled prevalence ratio of 0.87 (95%CI:0.79-0.97). Among people who smoke, 21% (95%CI:14-30%) smoked less, 27% (95%CI:22-32%) smoked more, 50% (95%CI:41%-58%) had unchanged smoking and 4% (95%CI:1-9%) reported quitting smoking. Among people who did not smoke, 2% (95%CI:1-3%) started smoking during the pandemic. Heterogeneity was high in all meta-analyses and so the pooled estimates should be interpreted with caution (I-2>91% and p-heterogeneity<0.001). Almost all studies were at high risk of bias due to use of non-representative samples, non-response bias, and utilisation of non-validated questions. Interpretation Smoking behaviour changes during the first phases of the COVID-19 pandemic in 2020 were highly mixed. Meta-analyses indicated that there was a relative reduction in overall smoking prevalence during the pandemic, while similar proportions of people who smoke smoked more or smoked less, although heterogeneity was high. Implementation of evidence-based tobacco control policies and programs, including tobacco cessation services, have an important role in ensuring that the COVID-19 pandemic does not exacerbate the smoking pandemic and associated adverse health outcomes.

Automated summary

This study conducted a systematic review and meta-analyses to assess smoking behavior changes during the early stages of the COVID-19 pandemic. The findings indicate that smoking prevalence decreased during the pandemic, but there were similar proportions of smokers who increased or decreased their smoking. Implementing evidence-based tobacco control policies and programs is crucial in preventing the exacerbation of smoking issues and associated adverse health outcomes during the COVID-19 pandemic.