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COVID-19 Restrictions and Adolescent Cigarette and E-cigarette Use in California

Published:October 16, 2022DOI:https://doi.org/10.1016/j.amepre.2022.09.014

      Introduction

      Shelter-in-place orders altered facilitators and barriers to tobacco use (e.g., outlet closures, restricted social gatherings). This study examined whether the duration of time in shelter in place and compliance with different shelter-in-place orders influenced adolescent cigarette and E-cigarette use and how the use may differ by demographic characteristics.

      Methods

      Shelter-in-place policy data obtained from government websites were merged with cross-sectional 2020 survey data on adolescents in California. Treatment variables included the proportion of time in shelter in place and self-reported compliance with shelter-in-place orders (for essential businesses and retail spaces and social and outdoor contexts). Multilevel logit models for dichotomous past 6-month cigarette and E-cigarette use and multilevel negative binomial regression models for past 6-month frequency of use were used. Moderation analyses were conducted on demographic measures. The sample included 1,196 adolescents (mean age=15.8 years, age range=13–19 years, 49.2% female, 50.0% White). Analyses were conducted in 2022.

      Results

      No associations were found between the proportion of time in shelter in place and outcomes. Shelter-in-place compliance with essential business and retail space orders was associated with lower odds of using cigarettes and E-cigarettes in the past 6 months. Compliance with social and outdoor context-related orders were associated with lower odds of using E-cigarettes and fewer days using cigarettes and E-cigarettes. Being aged ≥18 years moderated the associations between essential business/retail space and social/outdoor context-related shelter-in-place compliance orders and past 6-month frequency of cigarette smoking.

      Conclusions

      Findings support tailored interventions for less compliant and older adolescents for future pandemic mitigation measures.

      INTRODUCTION

      In the early stages of the coronavirus disease 2019 (COVID-19) pandemic, shelter-in-place (SIP) orders were adopted by state and local governments to mitigate the spread of the virus. SIP orders included stay-at-home mandates and other restrictions that drastically changed adolescents’ environments.
      • Czeisler MÉ
      • Howard ME
      • Robbins R
      • et al.
      Early public adherence with and support for stay-at-home COVID-19 mitigation strategies despite adverse life impact: a transnational cross-sectional survey study in the United States and Australia.
      ,
      • Gao S
      • Rao J
      • Kang Y
      • et al.
      Association of mobile phone location data indications of travel and stay-at-home mandates with COVID-19 infection rates in the US.
      Such changes likely altered facilitators and barriers to tobacco use (e.g., closures of tobacco stores, restricted social gatherings),
      • Gaiha SM
      • Lempert LK
      • Halpern-Felsher B.
      Underage youth and young adult e-cigarette use and access before and during the coronavirus disease 2019 pandemic.
      yet little is known about the influence of these shifting environments on adolescent tobacco use behaviors. This study examined whether the duration of SIP orders and individual compliance with various SIP orders influenced adolescent cigarette and E-cigarette use and how the use may differ by age, gender, racial/ethnic identity, and SES. Evaluating the impacts of duration in and compliance with SIP orders on adolescent tobacco use may contribute to the understanding of longer-term effects and unintended consequences of SIP policies.
      Adolescent cigarette and E-cigarette use are highly prevalent, with 3.1% of U.S. middle and high-school–aged youth reporting cigarette use and 12.7% reporting E-cigarette use in 2020.
      • Gentzke AS
      • Wang TW
      • Jamal A
      • et al.
      Tobacco product use among middle and high school students–United States, 2020.
      Tobacco and nicotine use is also highly varied depending on demographic characteristics, with higher rates of past 30-day cigarette and E-cigarette use among adolescents who identified as male (5.4% cigarettes and 20.4% E-cigarettes), are non-Hispanic White (5.3% and 23.2%), and are in high school versus in middle school (4.6% and 19.6%).
      • Gentzke AS
      • Wang TW
      • Jamal A
      • et al.
      Tobacco product use among middle and high school students–United States, 2020.
      Health risks associated with smoking and vaping are well established. Both cigarette and E-cigarette use can damage the respiratory and immune system,
      • McConnell R
      • Barrington-Trimis JL
      • Wang K
      • et al.
      Electronic cigarette use and respiratory symptoms in adolescents.
      ,
      • Wills TA
      • Pagano I
      • Williams RJ
      • Tam EK.
      E-cigarette use and respiratory disorder in an adult sample.
      increasing the risks and complications associated with COVID-19.
      • Gaiha SM
      • Lempert LK
      • Halpern-Felsher B.
      Underage youth and young adult e-cigarette use and access before and during the coronavirus disease 2019 pandemic.
      ,
      • Gaiha SM
      • Cheng J
      • Halpern-Felsher B.
      Association between youth smoking, electronic cigarette use, and COVID-19.
      • Javelle E.
      Electronic cigarette and vaping should be discouraged during the new coronavirus SARS-CoV-2 pandemic.
      • Meyers MJ
      • Delucchi K
      • Halpern-Felsher B.
      Access to tobacco among California high school students: the role of family members, peers, and retail venues.
      COVID-19 and consequent restrictions, such as SIP orders, significantly impacted daily activity and life in the U.S.,
      • Czeisler MÉ
      • Howard ME
      • Robbins R
      • et al.
      Early public adherence with and support for stay-at-home COVID-19 mitigation strategies despite adverse life impact: a transnational cross-sectional survey study in the United States and Australia.
      ,
      • Gao S
      • Rao J
      • Kang Y
      • et al.
      Association of mobile phone location data indications of travel and stay-at-home mandates with COVID-19 infection rates in the US.
      causing rapid changes to adolescents’ social and physical environments. These drastic environmental changes may have altered how adolescents accessed tobacco products, which types of products they used, where and with whom they used them, and their motivations for use (e.g., coping with stress).
      • Czeisler MÉ
      • Howard ME
      • Robbins R
      • et al.
      Early public adherence with and support for stay-at-home COVID-19 mitigation strategies despite adverse life impact: a transnational cross-sectional survey study in the United States and Australia.
      ,
      • Gao S
      • Rao J
      • Kang Y
      • et al.
      Association of mobile phone location data indications of travel and stay-at-home mandates with COVID-19 infection rates in the US.
      For example, most adolescents reported that they accessed cigarettes and E-cigarettes from friends and tobacco outlets before the COVID-19 pandemic, whereas during and after, they purchased these products online.
      • Gaiha SM
      • Lempert LK
      • Halpern-Felsher B.
      Underage youth and young adult e-cigarette use and access before and during the coronavirus disease 2019 pandemic.
      ,
      • Meyers MJ
      • Delucchi K
      • Halpern-Felsher B.
      Access to tobacco among California high school students: the role of family members, peers, and retail venues.
      Another study found E-cigarette outlets or vape shops to be noncompliant with essential business regulations and more likely to remain open and accessible early in the pandemic.
      • Berg CJ
      • Callanan R
      • Johnson TO
      • et al.
      Vape shop and consumer activity during COVID-19 non-essential business closures in the USA.
      In addition, COVID-19 influenced adolescent social use and access to cigarettes and E-cigarettes.
      • Nagata JM
      • Abdel Magid HS
      • Pettee Gabriel K
      Screen time for children and adolescents during the coronavirus disease 2019 pandemic.
      ,
      • Unni Z
      • Weinstein E.
      Shelter in place, connect online: trending TikTok content during the early days of the U.S. COVID-19 pandemic.
      How, with whom, and in what spaces adolescents socialized changed during COVID-19 SIP, particularly in-person school closures, which may be associated with social isolation.
      • Liu JJ
      • Bao Y
      • Huang X
      • Shi J
      • Lu L.
      Mental health considerations for children quarantined because of COVID-19.
      • Pierce M
      • Hope H
      • Ford T
      • et al.
      Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population.
      • Singh S
      • Roy D
      • Sinha K
      • Parveen S
      • Sharma G
      • Joshi G.
      Impact of COVID-19 and lockdown on mental health of children and adolescents: a narrative review with recommendations.
      Other research has suggested that adolescents’ social landscapes included more remote, digital, and social media‒based social interaction during the pancdemic,
      • Nagata JM
      • Abdel Magid HS
      • Pettee Gabriel K
      Screen time for children and adolescents during the coronavirus disease 2019 pandemic.
      ,
      • Unni Z
      • Weinstein E.
      Shelter in place, connect online: trending TikTok content during the early days of the U.S. COVID-19 pandemic.
      which may have additional implications for social access to tobacco products during SIP. Changes in adolescents’ access to tobacco products may have influenced adolescents’ tobacco use behavior, including which products were used and how often.
      This research is framed by the Social Cognitive Theory, which postulates a multifaceted causal structure wherein beliefs, personal characteristics, and experiences operate conjointly with outcome expectations and environmental facilitators and barriers to produce an individual's motivation and behavior.
      • Bandura A.
      Health promotion by social cognitive means.
      • Bussey K
      • Bandura A.
      Social cognitive theory of gender development and differentiation.
      • Creamer MR
      • Delk J
      • Case K
      • Perry CL
      • Harrell MB.
      Positive outcome expectations and tobacco product use behaviors in youth.
      On the basis of recent findings from the literature, SIP-related changes in adolescent environments (e.g., school closures, social restrictions, stay-at-home mandates) may have created competing influences on adolescents’ tobacco and nicotine use.
      • Vogel EA
      • Henriksen L
      • Schleicher NC
      • Prochaska JJ.
      Perceived susceptibility to and seriousness of COVID-19: associations of risk perceptions with changes in smoking behavior.
      Furthermore, the types of products used may be affected by changing environments, such that increases in E-cigarette use during the pandemic may be due to the need to conceal tobacco use around parents or caregivers.
      • Gaiha SM
      • Lempert LK
      • Halpern-Felsher B.
      Underage youth and young adult e-cigarette use and access before and during the coronavirus disease 2019 pandemic.
      ,
      • Gaiha SM
      • Cheng J
      • Halpern-Felsher B.
      Association between youth smoking, electronic cigarette use, and COVID-19.
      ,
      • Kreslake JM
      • Simard BJ
      • O'Connor KM
      • Patel M
      • Vallone DM
      • Hair EC
      E-cigarette use among youths and young adults during the COVID-19 pandemic: United States, 2020.
      ,
      • Ramamurthi D
      • Chau C
      • Jackler RK.
      JUUL and other stealth vaporisers: hiding the habit from parents and teachers.
      Finally, there is evidence suggesting that behavior under COVID-19 SIP orders and other restrictions may differ by demographic characteristics, with younger and female-identified adolescents being more compliant with safety precautions such as SIP, social distancing, masking, and handwashing.
      • Dardas LA
      • Khalaf I
      • Nabolsi M
      • Nassar O
      • Halasa S.
      Developing an understanding of adolescents’ knowledge, attitudes, and practices toward COVID-19.
      • Oosterhoff B
      • Palmer CA
      • Wilson J
      • Shook N.
      Adolescents’ motivations to engage in social distancing during the COVID-19 pandemic: associations with mental and social health.
      • Riiser K
      • Helseth S
      • Haraldstad K
      • Torbjørnsen A
      • Richardsen KR.
      Adolescents’ health literacy, health protective measures, and health-related quality of life during the Covid-19 pandemic.
      • Rodríguez-Ruiz J
      • Zych I
      • Llorent VJ.
      Adolescent compliance with anti-COVID measures. Is it related to substance use?.
      This study aimed to assess how the proportion of time in SIP orders and individual's self-reported compliance with SIP, by orders impacting essential businesses and retail spaces and orders aimed at social and outdoor contexts, are associated with adolescent self-reported past 6-month cigarette or E-cigarette use (yes/no) and past 6-month frequency (number of days) of cigarette or E-cigarette use. In addition, this study assessed how these associations may differ for adolescents by age, gender, racial or ethnic identities, and SES. Given the limited research in this area, directional relationships are not predicted for time in SIP or SIP compliance and cigarette or E-cigarette use. Results may have implications for policy considerations with future COVID-19 variants or other viruses.

      METHODS

      Multilevel, cross-sectional analyses were conducted on the third, web-based follow-up survey from an existing longitudinal study on substance use among adolescents in California. The third follow-up survey was administered from April 1, 2020 through December 3, 2020 and was the first in the series to include COVID-19–related questions, which is why it was selected for analysis. The response rate for the third follow-up was 91.4% from baseline (n=1,229). The sample was recruited from commercially available listings of California households and through social media, with additional recruitment details referenced by Kaner et al.
      • Kaner E
      • Islam S
      • Lipperman-Kreda S.
      Adolescent alcohol initiation: context of close friendships and the role of trust.
      Parental and guardian consent and adolescents’ assent were obtained, and participant privacy was ensured throughout all data collection processes. The study was reviewed and approved by the IRB of the Pacific Institute for Research and Evaluation.

      Study Sample

      Overall, 1,229 adolescents participated in the third follow-up survey from 51 California counties, with 33 participants excluded on the basis of self-reported age for the survey not being accurate (e.g., the participant had aged negative years since baseline) and no other missing data, yielding a sample of 1,196 participants from 49 counties (Table 1). Of study participants, 50.6% identified as male (n=605), 50.0% identified as White (n=598), 29.18% identified as >1 race or other race (n=349), 7.78% identified as African American/Black (n=73), and 35.03% identified their ethnicity as Hispanic/Latino (n=419). The mean age was 15.82 years (SD=1.54, range=13–19 years). Of all study participants, 78.26% (n=936) reported subjective SES as about or above average. For cigarette use, 6.1% of participants (n=73) reported past 6-month use, with a mean number of days of use of 9.4 days (SD=32.7). For E-cigarette use, 19.8% of participants (n=237) reported past 6-month use, with a mean number of days using E-cigarettes of 23.8 days (SD=50.1).
      Table 1Demographic Characteristics of Adolescents in the Analytic Sample
      CharacteristicsAll surveys,
      frequency (%)
      Total surveys by completion date1,196 (100.0)
      Cigarettes
       Past 6-month use (yes)73 (6.1)
      E-cigarettes
       Past 6-month use (yes)237 (19.8)
      Cigarettes, mean (SD)/range
       Past 6-month number of days used9.39 (32.69)/0–180 days
      E-cigarettes, mean (SD)/range
       Past 6-month number of days used23.80 (50.11)/0–180 days
      Age (at survey response date), mean (SD)/range15.82 (1.54)/13–19 years
      Sex
       Male605 (50.6)
       Female589 (49.2)
       Gender not reported2 (0.2)
      Race
      American Indian Alaska Native20 (1.7)
       Asian49 (4.1)
       African American/Black93 (7.8)
      Native Hawaiian/Pacific Islander12 (1.0)
       White598 (50.0)
       Other189 (15.8)
       More than 1 race160 (13.4)
      Ethnicity
       Non-Hispanic/Latino755 (63.1)
       Hispanic/Latino419 (35.0)
       Ethnicity not reported22 (1.8)
      Subjective SES
       Well below average12 (1.0)
       Below average61 (5.1)
       A little below average180 (15.1)
       About average493 (41.2)
       A little above average278 (23.2)
       Above average125 (10.5)
       Well above average40 (3.3)
       Subjective SES not reported7 (0.6)

      Measures

      Participants self-reported their gender, age, race, ethnicity, and subjective SES (Table 1). Participants who did not respond to a demographic characteristic question were coded as missing for that characteristic. Previous studies among young people have used measures of perceived or subjective SES. Studies have found that subjective SES is associated with health behaviors and health outcomes,
      • Quon EC
      • McGrath JJ.
      Subjective socioeconomic status and adolescent health: a meta-analysis.
      ,
      • Goodman E
      • Huang B
      • Schafer-Kalkhoff T
      • Adler NE.
      Perceived socioeconomic status: A new type of identity that influences adolescents’ self-rated health.
      rationalizing its use for this study.
      Participants were asked, In the past 6 months, on how many days, if any, did you smoke cigarettes? (Number of days from 0 to 180/Refused), and the same question for use of an E-cigarette or vape device to get nicotine? E-cigarette or vape device was defined in a previous survey question as a JUUL, e-pen, vape pen, cigalike, e-hookah, personal vaporizer, or mod to get nicotine. A variable was generated to reflect dichotomous past 6-month use from the question mentioned earlier (Yes ≥1 day of E-cigarette use, No=0 days of use). Past 6-month frequency of cigarette and E-cigarette use was reported as a number (0–180 days).
      SIP compliance was obtained by the following survey question: During the COVID-19 Shelter-in-Place order in your area, how often have (did) you go out to a (variety of contexts, e.g., grocery store, friend's `house). The full question and responses are found in Appendix Table 1 (available online). The possible responses were (1) Never (most compliant with SIP in original survey question), (2) Rarely, (3) Sometimes, (4) Often, and (5) Very often (least compliant with SIP in survey question). This SIP compliance variable was inverted such that a higher SIP compliance score (5) indicates greater compliance with state and county SIP orders. Overall reliability was assessed (Cronbach's α=0.86).
      A factor analysis was conducted using principal component factor methods on the 10 SIP compliance items. Results indicated a pattern of factor loadings in which essential business and retail space-related SIP compliance survey items were loaded onto 1 factor (Items 1–4, listed in Appendix Table 1, available online) and social and outdoor context-related SIP compliance items loaded onto the second factor (Items 5–10 listed in Appendix Table 1, available online). Because this distinction in the factor loadings was conceptually supported,
      • Bandura A.
      Health promotion by social cognitive means.
      • Bussey K
      • Bandura A.
      Social cognitive theory of gender development and differentiation.
      • Creamer MR
      • Delk J
      • Case K
      • Perry CL
      • Harrell MB.
      Positive outcome expectations and tobacco product use behaviors in youth.
      2 SIP compliance measures were constructed taking the mean score for all items for the 2 types of compliance: (1) essential business and retail space (business/retail orders) and (2) social and outdoor contexts (social/outdoor orders). Reliability was assessed on business/retail SIP compliance (Cronbach's α=0.75) and social/outdoor SIP compliance (Cronbach's α=0.81).
      County-level dates of the first SIP orders were obtained through California state and county government websites. SIP was characterized as the implementation date of a SIP order by county or the start of Governor Gavin Newsom's order on March 19, 2020 and the county attestation for Phase 2 reopening, which denoted a formal end to SIP. Using these data, the proportion of days each participant spent in an SIP order in the past 6-month period was calculated from the date on which they completed their survey. This treatment variable was created to align with cigarette and E-cigarette use outcomes measured in the 6-month period.

      Statistical Analysis

      Adolescent survey data were merged with COVID-19 SIP order start and end dates to derive the proportion of time in SIP for participant's past 6 months by county. Descriptive statistics were included (Table 1). Mixed effects logit models were used to analyze the associations of the proportion of time in SIP orders and order compliance with past 6-month cigarette and E-cigarette use (yes/no). Results were reported as ORs for ease of interpretation. Multilevel negative binomial regression models were used to assess associations with past 6-month cigarette and E-cigarette consumption frequency with results reported as incident rate ratios (IRRs). Moderation analyses were used to assess whether race/ethnicity, gender, age, and subjective SES moderated the associations between the proportion of time in SIP orders and SIP order compliance with past 6-month use and consumption frequency of cigarettes and E-cigarettes. All models included control variables for race, ethnicity, gender, age, and subjective SES and took the nesting of individuals within counties into account. Analyses were conducted using Stata, Version 16.

      RESULTS

      For main effects models (Table 2), results indicate that no significant associations were found between the proportion of time in SIP orders and participant self-reported past 6-month use (yes/no) and past 6-month frequency (number of days) of cigarette or E-cigarette use. However, results also show that greater compliance with SIP orders was associated with lower odds of past 6-month cigarette and E-cigarette use and lower frequency of use. Specifically, for business/retail orders, with each 1-point increase in the 5-point Likert-type scale SIP compliance score (where 5 indicates greater compliance with orders), there were 43% lower odds that the participant would report past 6-month cigarette use (OR=0.57; p<0.05) and 22% lower odds that participants would report past 6-month E-cigarette use (OR=0.78; p<0.05). For social/outdoor orders, with each 1-point increase in the compliance score, there were 40% lower odds that the participant would report past 6-month cigarette use (OR=0.60; p<0.001). For past 6-month frequency of use outcomes, for each 1-point increase in the social/outdoor SIP compliance score, participants reported fewer days of cigarette use by 69% (IRR=0.31; p<0.01) and 43% fewer days using E-cigarettes (IRR=0.57; p<0.05) in the past 6 months. For moderation analyses (Appendix Table 2, available online), results suggest that being aged ≥18 years and more compliant was associated with a greater number of days cigarettes were used (business/retail orders: IRR=6.06; p<0.01; social/outdoor order compliance: IRR=10.02; p<0.01). In addition, being non-Hispanic White and more compliant with SIP orders was associated with a greater number of days cigarettes were used (business/retail orders: IRR=4.67; p<0.05).
      Table 2COVID-19 Orders and Order Compliance and Past 6-Month Adolescent Cigarette and E-Cigarette Use
      VariablesProportion of past 6 months in SIP orderCompliance by context and place (scales 1–5, 5 is the most compliant)
      Past 6-month use: yes/noPast 6-month use: number of daysPast 6-month use: yes/noPast 6-month use: number of days
      Cigarettes,E-cigarettes,Cigarettes,E-cigarettes,Cigarettes,E-cigarettes,Cigarettes,E-cigarettes,
      OR (95% CI)OR (95% CI)IRR (95% CI)IRR (95% CI)OR (95% CI)OR (95% CI)IRR (95% CI)IRR (95% CI)
      Time in SIP: past 6 months0.512 (0.06, 4.698)0.445 (0.107, 1.858)1.603 (0.0366, 70.22)0.195 (0.0172, 2.202)
      Average compliance: essential businesses and retail spaces0.565* (0.345, 0.926)0.783* (0.621, 0.988)1.038 (0.504, 2.139)0.799 (0.523, 1.22)
      Average compliance: social and outdoor contexts0.786 (0.570, 1.084)0.595*** (0.463, 0.764)0.306** (0.140, 0.671)0.568* (0.341, 0.945)
      Non-Hispanic White0.965 (0.568, 1.64)0.927 (0.698, 1.23)0.399 (0.136, 1.174)1.001 (0.67, 1.496)1.048 (0.651, 1.687)0.898 (0.656, 1.230)0.448 (0.152, 1.315)0.981 (0.548, 1.757)
      Age1.248** (1.09, 1.43)1.251*** (1.137, 1.376)2.070*** (1.531, 2.80)1.847*** (1.587, 2.149)1.134 (0.936, 1.374)1.185*** (1.082, 1.30)2.023*** (1.516, 2.699)1.929*** (1.704, 2.182)
      Gender1.642* (1.103, 2.44)1.395* (1.042, 1.87)1.319 (0.493, 3.52)1.757** (1.20, 2.57)1.752* (1.08, 2.84)1.451* (1.052, 2.001)1.497 (0.547, 4.099)1.570* (1.069, 2.307)
      Subjective SES1.092 (0.83, 1.445)0.895 (0.795, 1.01)1.261 (0.929, 1.710)0.964 (0.802, 1.160)1.133 (0.866, 1.482)0.918 (0.808, 1.043)1.263 (0.950, 1.678)1.019 (0.857, 1.212)
      N1,1871,1871,1871,1871,0751,0751,0751,075
      Note: Boldface indicates statistical significance (*p<0.05, **p<0.01, ***p<0.001).
      IRR, incidence rate ratio; SIP, shelter in place.

      DISCUSSION

      Results did not indicate significant relationships between the proportion of time in a SIP order and adolescent past 6-month cigarette or E-cigarette use and past 6-month frequency of use. This finding is substantiated by a recent large-sample analysis assessing pre‒ and post‒COVID-19 trends for adolescents who were either under SIP orders or not at a follow-up survey, finding no significant impact of being in SIP on cigarette and E-cigarette use outcomes.
      • Chaffee BW
      • Cheng J
      • Couch ET
      • Hoeft KS
      Halpern-Felsher B. Adolescents’ substance use and physical activity before and during the COVID-19 pandemic.
      However, SIP order compliance and tobacco and nicotine use are less studied. Results show compliance with business/retail SIP orders to be significantly associated with lower odds of past 6-month cigarette and E-cigarette use among participants. Greater social/outdoor SIP order compliance was associated with lower odds of past 6-month E-cigarette use and fewer days of cigarette and E-cigarette use in the past 6 months. Results supported findings from a recent study among adolescents showing that less compliance with COVID-19 measures was associated with increased tobacco use.
      • Rodríguez-Ruiz J
      • Zych I
      • Llorent VJ.
      Adolescent compliance with anti-COVID measures. Is it related to substance use?.
      A multitude of factors may contribute to the mechanisms behind this study's results suggesting that compliance with SIP orders influences adolescent tobacco and nicotine use more than the orders themselves. For one, compliance and COVID-19 precautions could suggest that increased attention to health risks from the pandemic also influenced adolescent tobacco and nicotine use by limiting opportunities to use with more time spent at home and indoors.
      • Czeisler MÉ
      • Howard ME
      • Robbins R
      • et al.
      Early public adherence with and support for stay-at-home COVID-19 mitigation strategies despite adverse life impact: a transnational cross-sectional survey study in the United States and Australia.
      Fewer social use opportunities and obtaining cigarettes and E-cigarettes from peers may also have contributed to lower odds of use when participants were more compliant with social/outdoor SIP orders.
      • Nagata JM
      • Abdel Magid HS
      • Pettee Gabriel K
      Screen time for children and adolescents during the coronavirus disease 2019 pandemic.
      ,
      • Unni Z
      • Weinstein E.
      Shelter in place, connect online: trending TikTok content during the early days of the U.S. COVID-19 pandemic.
      In addition, for adolescents who were more compliant with business/retail SIP orders, this may have diminished opportunities to purchase and procure tobacco and nicotine products.
      Additional considerations include that other individual characteristics that were not available in these data may relate to SIP compliance. For example, participants who were more compliant with SIP orders may have also had greater concern for COVID-19–related health risks, especially considering that tobacco use is a known risk factor for respiratory conditions and more severe COVID-19–related outcomes.
      • Gaiha SM
      • Lempert LK
      • Halpern-Felsher B.
      Underage youth and young adult e-cigarette use and access before and during the coronavirus disease 2019 pandemic.
      ,
      • Gaiha SM
      • Cheng J
      • Halpern-Felsher B.
      Association between youth smoking, electronic cigarette use, and COVID-19.
      • Javelle E.
      Electronic cigarette and vaping should be discouraged during the new coronavirus SARS-CoV-2 pandemic.
      • Meyers MJ
      • Delucchi K
      • Halpern-Felsher B.
      Access to tobacco among California high school students: the role of family members, peers, and retail venues.
      More generally, there may be an underlying unobserved characteristic and endogenous variable factoring into the relationship between SIP compliance and tobacco and nicotine use, which is overall health conscientiousness. The literature suggests that individual personality attributes, including increased health conscientiousness, are associated with less tobacco use in U.S. and Canadian adults
      • Malouff JM
      • Thorsteinsson EB
      • Schutte NS.
      The five-factor model of personality and smoking: a meta-analysis.
      and that childhood health conscientiousness is a predictor of lifetime smoking.
      • Pluess M
      • Bartley M.
      Childhood conscientiousness predicts the social gradient of smoking in adulthood: a life course analysis.
      Given that the results of this study did not yield significant associations between participant time in SIP orders but did find that greater SIP compliance was associated with lower odds of tobacco and nicotine use, this may highlight the role of individual characteristics in tobacco and nicotine use in the context of greater environmental influences.
      Although the scope of this study was to explore and establish the associations between SIP and compliance with tobacco and nicotine use, another important consideration for future research is the role of adolescent mental health during SIP. One study found that adolescents’ compliance with SIP and social distancing orders, potentially increasing isolation, was related to symptoms of anxiety, depression, and feelings of burdensomeness.
      • Oosterhoff B
      • Palmer CA
      • Wilson J
      • Shook N.
      Adolescents’ motivations to engage in social distancing during the COVID-19 pandemic: associations with mental and social health.
      A cross-sectional study conducted with Canadian adolescents 3 weeks after SIP found that most adolescents using substances, including tobacco, did so in solitary settings (49%) and that depression and fear of COVID-19 predicted this solitary substance use.
      • Dumas TM
      • Ellis W
      • Litt DM.
      What does adolescent substance use look like during the COVID-19 pandemic? Examining changes in frequency, social contexts, and pandemic-related predictors.
      Future research is needed to establish the relationships between potentially protective factors (health conscientiousness and SIP compliance as a possible proxy for this individual attribute) and risk factors (depression, anxiety, isolation, and other mental health concerns during the pandemic).
      Although majority of the findings showed that compliance with SIP was associated with lower odds of cigarette and E-cigarette use and fewer number of days of use, there were 2 notable exceptions found in the moderation analyses. Respondents who were aged ≥18 years and more compliant with essential business/retail space and social/outdoor context SIP orders reported a greater number of days where cigarettes were used in the past 6 months than participants aged <18 years. A potential explanation for this finding is that the group aged ≥18 years may have used tobacco longer and more frequently and potentially developed more reliance or dependence on use than those aged <18 year. Older adolescents may be less likely to live with and be monitored by parents or guardians and have greater independence, which may lead to increased tobacco and nicotine use opportunities.
      • Mills R
      • Mann MJ
      • Smith ML
      • Kristjansson AL.
      Parental support and monitoring as associated with adolescent alcohol and tobacco use by gender and age.
      The young adults aged ≥18 years may also experience more stressors related to work, school, and other responsibilities contributing to increased tobacco use.
      • Vanderbruggen N
      • Matthys F
      • Van Laere S
      • et al.
      Self-reported alcohol, tobacco, and cannabis use during COVID-19 lockdown measures: results from a web-based survey.
      In addition, being non-Hispanic and White and more compliant with business/retail SIP orders was associated with more days of cigarette use. This may reflect the relatively greater prevalence of cigarette use among non-Hispanic White middle and high-school students in a national sample (5.3% reporting past 30-day use) than among adolescents identifying as Hispanic (4.6%) or non-Hispanic and Black (2.8%).
      • Gentzke AS
      • Wang TW
      • Jamal A
      • et al.
      Tobacco product use among middle and high school students–United States, 2020.

      Limitations

      There are several limitations to note. Other tobacco-related policies, specifically the law about persons aged 21 year to purchase tobacco enacted in California in 2016
      • Schiff S
      • Liu F
      • Cruz TB
      • et al.
      E-cigarette and cigarette purchasing among young adults before and after implementation of California's tobacco 21 policy.
      and tobacco product flavor ban restrictions,
      • Feld AL
      • Rogers T
      • Gaber J
      • et al.
      Impact of local flavored tobacco sales restrictions on policy-related attitudes and tobacco product access.
      may have contributed to lower odds and fewer days of cigarette and E-cigarette use. Cigarette and E-cigarette use outcomes were of relatively low prevalence within the sample (6.1% cigarette use, 19.8% E-cigarette use in the past 6 months). Small sample sizes when conducting subgroup moderation analyses potentially limit the ability to detect significant relationships in the interaction models. In addition, measures of nicotine concentration in products and participant nicotine dependence were not included in the survey and are a limitation of the data. In addition, outcomes are self-reported and are thereby affected by social desirability bias; however, the survey data collection process ensured privacy from parents or others to limit this bias. However, additional future research should investigate the long-term impacts of the pandemic on adolescents’ tobacco and nicotine use behaviors.

      CONCLUSIONS

      Tailoring interventions to adolescents who may exhibit less compliance with SIP orders and who are possibly less health conscientious generally may be advantageous in reaching more at-risk groups. In addition, targeting adolescents who are aged ≥18 years may also be beneficial. Such interventions may be warranted if future restrictive measures are reinstated in response to the COVID-19 pandemic or for future viruses.

      ACKNOWLEDGMENTS

      The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Alcohol Abuse and Alcoholism or NIH.
      This research was supported by Grants P60-AA006282 and T32-AA014125 from the National Institute on Alcohol Abuse and Alcoholism of NIH. The study was reviewed and approved by the IRB of the Pacific Institute for Research and Evaluation (FWA00003078).
      This study was presented at the Society for Nicotine and Tobacco Research 28th Annual Meeting on March 16, 2022.
      No financial disclosures were reported by the authors of this paper.

      CRediT AUTHOR STATEMENT

      M. Kristina Wharton: Conceptualization, Formal analysis, Methodology, Software, Writing – original draft. Sabrina Islam: Conceptualization, Writing – review and editing. Melissa Abadi: Writing – review and editing. Pallav Pokhrel: Writing – review and editing. Sharon Lipperman-Kreda: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Resources, Software, Supervision, Validation, Writing – review and editing.

      Appendix. SUPPLEMENTAL MATERIAL

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