key: cord-0712249-dnxur57e authors: Ayran, Gülsün; Köse, Semra; Küçükoğlu, Sibel; Aytekin Özdemir, Aynur title: The effect of anxiety on nicotine dependence among university students during the COVID‐19 pandemic date: 2021-05-03 journal: Perspect Psychiatr Care DOI: 10.1111/ppc.12825 sha: 3fd673c89806de3b88542e8fb9ba6b00854d5e17 doc_id: 712249 cord_uid: dnxur57e PURPOSE: This study investigated the effect of anxiety on nicotine dependence among university students during the COVID‐19 pandemic. DESIGN AND METHODS: This was a descriptive and correlational study. The sample consisted of 503 university students in Turkey. Data were collected online using a demographic characteristics form, the State‐Trait Anxiety Inventory (STAI), and the Fagerström Test for Nicotine Dependence (FTND). FINDINGS: FTND scores differed by gender, family type, and grade level, while STAI scores differed by gender, income, and region of residence (p < 0.05). Fifty‐one percent of the participants had moderate anxiety, while 65.2% had low nicotine dependence. FTND and STAI mean scores were strongly correlated (p < 0.05). PRACTICAL IMPLICATIONS: The higher the anxiety, the higher the nicotine dependence among university students during the COVID‐19 pandemic. mental disorders and nicotine dependence among young people. However, there is no sufficient empirical evidence to support the correlation between anxiety and nicotine dependence. Therefore, the aim of this study is to examine the effect of anxiety on nicotine dependence among university students during the COVID-19 pandemic. • What characteristics of university students affect their anxiety levels? • What characteristics of university students affect their nicotine addiction levels? • Does the level of anxiety experienced during the pandemic process affect the nicotine addiction rate of university students? 2 | METHODS This was a descriptive and correlational study. The study was conducted between May and June 2020. The study population consisted of all private and public university students (seven regions of Turkey) who had been smoking for at least 6 months. The inclusion criteria were (1) having been receiving online education during the study, (2) having Internet access, and (3) agreeing to participate. The exclusion criteria were (1) withdrawal from courses due to the COVID-19 pandemic, (2) having received treatment for nicotine dependence before, and (3) having a mental disorder. A power analysis was performed using GPower (version 3.1.9.2) to determine the appropriate sample size for significant differences. Both male and female participants' mean State-Trait Anxiety Inventory (STAI) scores were used for the analysis. The post hoc power analysis revealed a power of 95% with an effect size of 0.33 (α = 0.05), indicating that the sample (n = 501) was large enough to detect significant differences ( Figure 1 ). Since the study was collected online, only the participants who completely filled out the questionnaires were included in the study. The study was terminated when a sufficient sample size was reached (n = 503). Data were collected online using a demographic characteristics form (DCF), the STAI, and the Fagerström Test for Nicotine Dependence (FTND). The DCF was based on a literature review conducted by the researcher. [14] [15] [16] The form consisted of 26 items and three sections. The first section consisted of items on participants' demographic characteristics and health status (gender, family type, perceived income, place of residence, region of residence, housing type, grade level, and chronic disease in themselves and/or in family members). The second section consisted of items on participants' experiences with the COVID-19 pandemic (having tested or having any family members tested positive for COVID-19, adaptation to social isolation, and home activities during the pandemic). The third section consisted of items on nicotine dependence and changes in it during the pandemic. Data were collected online (5 min for each participant). Three experts were consulted for the items of the second and third sections. The STAI was developed by Spielberger et al. 17 to evaluate how one feels at a particular moment and situation. The STAI was adapted to Turkish by Öner and Le Comte. 18 The STAI consists of 20 items scored on a 4-point Likert-type scale of 1 (almost never) to 4 (almost always). The total score ranges from 20 to 80. Higher scores indicate greater anxiety. Ten items (1, 2, 5, 8, 10, 11, 15, 16, 19, and 20) After the researchers obtained the necessary permission, they created online versions of the DCF, STAI, and FTND and shared the link to the questionnaires on WhatsApp groups. They asked participants to complete the questionnaires accurately and send the link to other university students (snowballing sampling). Data collection lasted 10-15 min ( Figure 2 ). Data were analyzed using the Statistical Package for Social Sciences (SPSS; version 22.0) at a significance level of 0.05. Percentages, means, the independent-samples t-test, analysis of variance test, and Pearson correlation coefficient were used for analysis. The Bonferroni test was used for post hoc comparisons. The study had two limitations. First, the survey relied on participants' self-reports, and therefore, data accuracy was not verified. Second, levels of anxiety and nicotine dependence were measured only using the STAI and FTND. The mean age of participants was 21.57 ± 2.46. The mean number of people they had lived with during the pandemic was 4.88 ± 1.81. Of participants, 53.5% were men, 78.5% had a nuclear family, 45.3% had a neutral income, 58.4% were living in the city center, 28.4% were from Eastern Anatolia, 62.4% were living in apartments, and 33% were freshmen. Participants' FTND scores differed by gender, family type, and grade level, while their STAI scores differed by gender, income, and region of residence (p < 0.05). The post hoc test result showed that participants from the Marmara region had higher STAI scores than those from the Black Sea region (Table 1) . Of participants, 12.1% had a chronic disease, 44.5% had a family member with a chronic disease, 1.8% had tested positive for COVID-19, 2% had a family member who had tested positive for COVID-19, and 76.9% was able to adapt to social isolation. Participants' mean FTND and STAI scores were compared by chronic disease, having been tested positive for COVID-19, and adaptation to social isolation. Chronic disease and adaptation to social isolation affected their mean FTND scores (p < 0.05, Table 2 ). During social isolation, participants mostly spent time on social media (77.1%), followed by sleeping (71.4%), watching TV (64.2), and listening to music (65.6%). Participants who did nothing during social isolation had a significantly higher mean STAI score than those who read books during social isolation ( (Table 3) . Participants' mean FTND and STAI scores differed by "other smokers in the family," "perceived relationship with family members," "increased smoking during social isolation," "stockpiling cigarettes during curfews," and "anxiety and stress caused by not being able to buy cigarettes during social isolation" (p < 0.05, Table 3 ). Participants had a mean STAI of 43.42 ± 12.06. Slightly more than half of the participants (51%) had moderate anxiety. Participants had a mean FTND score of 2.7 ± 2.5. More than half of them (65.2%) had low nicotine dependence (Table 4 ). In Table 5 , whether there is a relationship between the nicotine addiction and state level of the students was examined; a statistically positive and very strong significant correlation was found between FNBT and DAÖ mean scores (r = 0.106, p = 0.017). University students are a group at high risk for symptoms of depression and anxiety. 7 The mental health of university students is adversely affected due to the spread of the epidemic throughout the country, strict isolation measures and the closure of schools, colleges and universities, decrease in students' motivation to study, increasing pressures for independent learning, and abandonment of daily routines. 5 Increasing anxiety at unexpected and unusual times can be an important risk factor for smoking. 9 For this reason, in this study, the effect of anxiety experienced by university students during the COVID-19 process on nicotine addiction was discussed, and the findings were discussed in line with the literature. Most of our participants had been smoking during the COVID-19 pandemic. Male participants had significantly higher nicotine dependence than females (Table 1) . Research on Turkish university students shows in general that male students have significantly higher nicotine dependence than females. [21] [22] [23] Provenzano et al. 16 reported that male nursing students had significantly higher nicotine dependence than females. Mallet and Dubertret 24 found that men had significantly higher nicotine dependence than women during the COVID-19 pandemic. Male and female behaviors are shaped according to certain stereotypes within the structure of the society they are in. For this reason, men more independent. Starting from a young age, raising men in a more liberal nature, putting a cigarette in the mouth of a boy gives rise to the idea of "I am strong, I am free" in boys and triggers nicotine addiction in men. 25 As a result of the regression analysis performed in our study, it was found that our variable, which was significant in the model in which nicotine addiction was moderate and high, was the gender of the person ( Table 6 ). The probability of nicotine addiction was found to be higher in men than in women, and this finding is consistent with the literature and analysis. Our female participants experienced more anxiety than males (Table 1) , which was consistent with the literature. Yakar et al. 14 reported that female medical students suffered from anxiety more than males during the COVID-19 pandemic. Wu et al. 26 and Zhao et al. 27 also found that Chinese female university students experienced more anxiety than males during the COVID-19 pandemic. Women are more emotional than men due to physiological differences between men and women, such as genetic sensitivity, hormone, and cortisol levels. Because of these differences, women were more vulnerable to stress and pain than men, so they may experience more sadness and anxiety. 28 Participants from broken families had higher nicotine dependence than those from nuclear families (Table 1) . Research, in general, shows that people from broken families have higher nicotine dependence than others. 21, 29 A study from Italy has found a correlation between nicotine dependence and nonconventional family types (single-parent, broken families, etc.). 30 Young people from broken families are more likely to develop nicotine dependence and criminal behavior due to socioeconomic problems and limited parental control. 31 As a result of the regression analysis performed in our study, our variable, which was significant in the model with moderate nicotine addiction, was found to be the family type of the person ( Table 6 ). The probability of nicotine addiction was found to be higher in the fragmented family-type compared to other family types, and this finding is consistent with the literature and analysis. It is noteworthy that participants from broken families had higher nicotine dependence during the pandemic. Therefore, more research is warranted on factors affecting nicotine dependence in people from broken families. Participants with a negative income had higher anxiety than those with a positive income (Table 1) . Low socioeconomic status is associated with both increased nicotine dependence and anxiety. 32 The loss of job and income makes the COVID-19 curfews more challenging and stressful for all family members. 33 The pandemic has adverse financial impacts on thousands of people. 32 Negative income may have put the participants in a vicious cycle; not being able to afford to buy cigarettes caused more anxiety, which resulted in increased nicotine dependence. Participants from the Marmara region experienced higher levels of anxiety than those from the other regions (Table 1 ). The World Health Organization (WHO) 34 conducted an epidemiological study involving people of all age groups from Turkey and found that respondents from Eastern Anatolia (50%), Aegean (49%), and Marmara regions had the highest pandemic-related anxiety. 34 Participants from the Marmara region reported the highest levels of anxiety, probably because it is the region with the highest number of COVID-19 cases. It is also because Marmara has coastal cities with good climatic conditions, social opportunities, and a large young university-educated population, which we believe has been severely affected by social isolation during the pandemic. Participants with chronic diseases had higher nicotine dependence than others (Table 2) . WHO states that people with chronic diseases are more likely to develop severe or critical COVID-19. 35 Those participants may have developed more nicotine dependence because they were unable to access health services, buy their prescription drugs, and socialize due to quarantine constraints during the COVID-19 pandemic while at the same time having to cope with their chronic diseases. Participants who had difficulty adapting to social isolation had higher FTND scores ( social media (44%), with the highest increases observed in Generation Z. 39 Loss of interest in activities is a sign of anxiety among adolescents. Therefore, it is not surprising that participants who did nothing at home during the pandemic had significantly high anxiety. Participants who had other smokers in the family had higher nicotine dependence and anxiety (Table 3) , which is consistent with the literature. Having family members who smoke affects nicotine dependence among students. 40 Oğuz et al. 41 found that students with smoking mothers and sisters had higher nicotine dependence. Birinci and Bulut 33 also reported that students with smoking parents or siblings had higher nicotine dependence. Elbi et al. 42 detected a positive correlation between the nicotine dependence rates of students and their family members. Participants with conflicting relationships with family members had higher nicotine dependence and anxiety (Table 3 ). Many people were in constant contact with family members during the quarantine. Having to spend more time at home with family during the COVID-19 pandemic is frustrating and inhibiting for young people who are used to socializing and connecting with their friends, which inevitably resulted in increased anger and anxiety. 37, 43, 44 Therefore, young people with conflicting relationships with family members may turn to smoke, which is frowned upon by parents. Participants who smoked more cigarettes, stockpiled packs of cigarettes, and were worried about the possibility of not being able to go out and get cigarettes during the COVID-19 pandemic had higher nicotine dependence and anxiety (Table 3) . Social isolation is as serious a risk factor as nicotine dependence, obesity, and a sedentary lifestyle. 45 Social isolation, voluntary social distancing, and lockdowns make smoking and exposure to secondhand smoke more likely. 46 Health and social measures for COVID-19 may have caused participants to experience more anxiety, making them smoke more and stockpile more packs of cigarettes to cope with stress and anxiety. Participants had a mean STAI of 43.42 ± 12.06. Slightly more than half of the participants (51%) had moderate anxiety (Table 4 ). Söğüt et al. 46 investigated midwifery students' pandemic-related knowledge and anxiety and found that most students experienced mild anxiety. 46 Yakar et al. 14 Table 5 ). The possibility of nicotine addiction was found to be higher in those with high anxiety levels than those with low levels, and this finding is consistent with the literature and analysis. Many adolescents smoke less than adults. However, adolescents who smoke, especially those who regularly smoke, experience nicotine dependence and withdrawal. 47 Participants had a mean FTND score of 2.7. More than half of them (65.2%) had low nicotine dependence (Table 4 ). Elbi et al. 42 and Provenzano et al. 16 also reported low nicotine dependence among more than half of university students. Chinwong et al. 47 looked into the prevalence of nicotine dependence in Thai university students and found that 71.7% of the male students (mean FTND = 2.3) and 88.4% of the female students (mean FTND = 1.8) had low nicotine dependence. 48 There is a correlation between anxiety and nicotine dependence. 46, 49 In this study, it was found that as the anxiety levels of the students increased, the rate of nicotine addiction also increased (Table 5 ). Izadpanah et al. 49 found that young people with nicotine dependence had high anxiety. Zvolensky et al. 50 reported a moderate correlation between anxiety sensitivity and nicotine dependence among Latin smokers. Many smokers argue that smoking helps them cope with stress. Therefore, people who wanted to cope with stress during the pandemic turned to smoking. 10 The results showed that the participants were trapped in a vicious circle. On the one hand, they smoked more to reduce anxiety, but on the other hand, they experienced more anxiety as they feared that they would not be able to find or afford to buy cigarettes during the pandemic. Therefore, students should be informed about strategies to cope with stress and anxiety during pandemics. There was a positive correlation between anxiety and nicotine dependence among smoking participants. The severity of nicotine dependence depended on the gender, family type, chronic disease, adaptation to social isolation, other smokers in the family, quality of relationship with family members, stockpiling packs of cigarettes, and anxiety about not being able to find or afford to buy cigarettes during the pandemic. The severity of anxiety depended on the gender, income, region of residence, activities at home during social isolation, other smokers in the family, quality of relationship with family members, increase in nicotine dependence, stockpiling packs of cigarettes, and anxiety about not being able to find or afford to buy cigarettes during the pandemic. Experts and parents should pay attention to young people concerning pandemic-related physical and mental issues. Young people going through difficult times are more prone to substance and tobacco use. Therefore, online courses should address not only the subjects in the curriculum but also physical and mental issues and provide content to raise students' awareness of the dangers of substance and tobacco use. Telehealth services should be provided to university students. COVID-19 pandemic has taken hold of the whole world rapidly and continues to change our lives drastically. Therefore, we need more studies with larger samples to examine its effects on substance and tobacco use among adolescents. 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Acad Elegance Anksiyete Sensitivitesinin Nikotin Bağımlılığı Ve Sigara Bırakma Başarısına Etkileri The relationship between COVID-19 knowledge levels and anxiety states of midwifery students during the outbreak: a cross-sectional web-based survey A comparison of gender differences in smoking behaviors, intention to quit, and nicotine dependence among Thai university students Sigara bağımlılarında depresyon, anksiyete, uykululuk ve uyku kalitesi düzeyleri arasındaki ilişkinin belirlenmesi. Acibadem Universitesi Saglik Bilimleri Dergisi Anxiety in social interactions and nicotine dependence in nicotine-dependent men: the role of metacognitions about smoking Anxiety sensitivity and smoking among Spanish-speaking Latinx smokers The effect of anxiety on nicotine dependence among university students during the COVID-19 pandemic The authors would like to thank the university students who participated in the study. The authors declare that there are no conflict of interests. The data that support the findings of this study are available from the corresponding author upon reasonable request.