The Effect of COVID-19 on Smoking and Vaping Rates.

To the Editor:

It was recently brought to light that a more abrupt reduction in smoking prevalence occurred in 2020 after the start of the coronavirus disease (COVID-19) pandemic when compared with prior trends (1). Although this is a perceived positive of the pandemic, there is more to this story than meets the eye. Starting in March 2020, estimated national e-cigarette sales trended upward fairly steadily, increasing in more than three-quarters of the subsequent months, until reaching an all-time high in August 2021 (2). The reason behind how these trends are related is at least twofold.

First, there were many missed opportunities to provide treatment to those with some interest in smoking cessation, likely leading many to seek “treatment” with e-cigarettes, a method that, at present, lacks proven efficacy (3). Outpatient appointments were frequently canceled or rescheduled at that time, and many patients did not seek to schedule follow-up or to reschedule. Outpatient visits were reduced by greater than 20% for the first 11 weeks of the pandemic in the United States and sustained a 50% reduction during 5 of those weeks. Visits did not stabilize to baseline numbers until October 2020. Pulmonology and cardiology, two specialties most inclined to provide treatment for nicotine dependence, had, respectively, 25% and 20% overall reductions in visits from March 2020 to the end of that year. Primary care visits were 10% lower overall (4). In addition, quit line utilization took a big hit, in part because of the lack of healthcare interaction, given that 26.8% of national quit line users in the calendar year before the pandemic were referred by health professionals (5). Nationally, quit line use rates reduced substantially, by nearly 40%, during the 3 months immediately after the start of the pandemic. This was a time when concerns for the interplay between smoking and COVID-19 were at their peak and receiving coverage in mainstream media. Overall, the quit line saw a 27% reduction in calls in 2020 (6).

There were vital opportunities to initiate appropriate treatment for tobacco and nicotine use, but many users were instead left empty handed or instead maybe with an e-cigarette in one hand. Although calls to focus on implementing tobacco treatment campaigns were made early in the pandemic (7), this chronic disease state was again left undertreated.

Smokers who generally used outdoors, especially those living in apartment buildings or complexes without easy outdoor access in urban environments, may have switched to e-cigarettes to allow indoor use while mitigating odor and potentially the effects on household members. Results support this hypothesis, as smoking rates in urban areas declined, while rural rates did not (1).

Although the COVID-19 pandemic may have hastened a reduction in smoking rates, e-cigarettes have been making substantial headway as the products of the future for some time now. Treatment of tobacco and nicotine dependence, regardless of the tobacco or nicotine product used, must have a more consistent and urgent presence in all healthcare settings, pandemic or not.