key: cord-0734763-dzk66p7x
authors: Oh, Hans; Leventhal, Adam M.; Tam, Christina; Rajkumar, Ravi; Zhou, Sasha; Clapp, John D.
title: Stressors experienced during the COVID-19 pandemic and substance use among US college students
date: 2021-11-22
journal: Drug and alcohol dependence reports
DOI: 10.1016/j.dadr.2021.100005
sha: 6542e5668a66873d565233bf76a787a52af335fd
doc_id: 734763
cord_uid: dzk66p7x

Background : The COVID-19 pandemic caused numerous stressors that may have been linked to substance use among college students. Methods : We analyzed data from the Fall 2020 Healthy Minds Study (N=15995), a non-probability sample of students attending one of 28 universities, who completed an online survey during the COVID-19 pandemic (September – December, 2020). Using multivariable logistic regression, we examined the associations between COVID-19 stressors (concern, racial/ethnic discrimination, financial distress, infection, illness of loved one, death of loved one, caregiving) and substance use (alcohol, cigarette, marijuana), adjusting for age, gender, race/ethnicity, and international student status. All COVID-19 stressors were included in the same weighted logistic regression models. Results : About 46.89% of the sample reported drinking any alcohol (in the past 2 weeks), 7.38% used any cigarettes, and 16.87% used any marijuana over the past month. Multivariable logistic regression models showed that infection and caregiving were significantly associated with alcohol use; racial/ethnic discrimination and financial distress were associated with smoking cigarettes; and concern and infection were associated with marijuana use. Conclusions : COVID-19 stressors were related to substance use, though the strength and significance of the associations varied depending on the stressors and the type of substance.

Historically, substance use has increased during infectious disease outbreaks (P. Wu et al., 2008) and natural or man-made disasters (Hirst et al., 2018; Kanehara et al., 2016) , presumably as a means of coping with distress (Rogers et al., 2020) . In the COVID-19 pandemic, reports have been mixed, with some studies showing elevated rates of substance use in the general adult population (Czeisler et al., 2020 )(Pollard et al., 2020 . Prior studies have identified key stressors resulting from the pandemic, such as psychological distress, financial worries, racial tensions, personal or familial difficulties, social isolation and lack of social support (Capasso et al., 2021; Currie, 2021; Lechner et al., 2021; MacMillan et al., 2021; Rolland et al., 2020) . Studies have suggested that people may have used substances to cope with these COVID-19 stressors (Czeisler et al., 2020) and the mental health symptoms resulting from the stressors (Firkey et al., 2020; Horigian et al., 2020; Jones et al., 2021) . However, few studies have crosssectionally examined the wide range of COVID-19 stressors and how they are related to various substances.

Substance use among college students in the United States (U.S.) has been well documented (Schulenberg & Patrick, 2012) , and research has begun to examine how the COVID-19 pandemic has affected this population. The pandemic caused unprecedented changes to the lives of students on college campuses, with major disruptions to social networks, housing and financial instability, and emotional distress (Jones et al., 2021) , which studies have shown were significantly associated with substance use (e.g., alcohol consumption (Busse et al., 2021; Flaudias et al., 2021) . However, studies examining the college population have been conducted on small or region-specific samples from single institutions. Thus, the aim of this study was to examine the associations between various stressors related to the COVID-19 pandemic and substance use in a large U.S. national sample of college students.

We analyzed data from the Fall semester cohort of the 2020 Healthy Minds Study (HMS), a crosssectional, web-based survey examining mental health and related factors in undergraduate and graduate student populations. A total of 28 colleges opted to administer the COVID-19 module (N=15995). The response rate was 14% and sampling weights were used to adjust for non-response. The 

Any alcohol use was measured using the binary (yes/no) item: "Over the past 2 weeks, did you drink any alcohol?". Cigarette use was assessed using the ordinal item: "Over the past 30 days, about how many cigarettes did you smoke per day?" Marijuana use was measured using the item that asked respondents (yes/no) whether they had used marijuana over the past 30 days.

2.2.2. COVID-19 stressors. We examined seven COVID-19 stressors, which were COVID-19 concern (scale between 10-50), Racial/ethnic discrimination (yes/no), Financial distress (ordinal variable, 0-4), Infection (yes/no), Infection of loved one (yes/no), Death of a loved one due to (yes/no) 

We used multivariable logistic regression analyses to test for associations between each COVID-19 stressor and each type of substance [Supplemental Materials]. We then included all seven COVID-19 stressors in the same models. All models were adjusted for sociodemographic characteristics and were run with and without survey weights. We present results as adjusted odds ratios with 95% confidence intervals. Missing data for individual variables was handled using listwise deletion, with <10% of data missing. For the purposes this study, we focus on the weighted models that include all seven stressors simultaneously in the same models. Details about the data collection procedures, survey weighting, variables, descriptive statistics, and all analyses (weighted, unweighted, each stressor in its own model, all stressors included in the same model) can be found in the supplemental materials. All analyses were performed using StataSE 15.

In the analytic sample of 15,995 college students, the median age of the weighted sample was between 24 and 25 years old, with 95% of the sample being 40 years of age or younger. The sample was predominantly White (66.26%), majority women (69.37%), and mostly domestic students (94.96%).

[ Table 1 ]. An estimated 46.89% of the sample had any alcohol over the past two weeks. In a model simultaneously including all COVID-19 stressors and adjusting for sociodemographic characteristics, COVID-19 infection (aOR: 1.42; 95%CI: 1.22-1.66), and caregiving (aOR: 1.51; 95%CI: 1.11-2.05) were associated with significantly greater odds of alcohol use. An estimated 7.38% of the sample had any cigarettes over the past 30 days. Racial/ethnic discrimination (aOR: 2.31; 95%CI: 1.37-3.92) and financial distress (aOR: 1.26; 95%: 1.06-1.49) were associated with significantly greater odds of smoking cigarettes. An estimated 16.87% of the sample used any marijuana over the past 30 days. A one-unit increase on the COVID-19 concern scale was associated with 3% increase in the odds of marijuana use (aOR: 1.03; 95% CI: 1.02-1.04), and COVID-19 infection was associated with significantly greater odds (aOR: 1.34; 95%CI: 1.08-1.66).

In a large sample of students from multiple colleges that specific stressors of the COVID-19 pandemic were related to substance use, with varying associations and significance depending on the stressor and the type of substance use. Explanations for the observed relations are only speculative at this stage.

Notably, substance use (particularly in its most severe form) has been conceptualized as a 'stress surfeit disorder ' (Koob et al., 2014) such that stressors play a key role in the initiation and maintenance of substance use, as well as relapses following a period of abstinence, through multiple mechanisms including dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis and alterations in noradrenaline and γ-amino butyric acid (GABA) neurotransmission (Fronk et al., 2020) . Our current study aligns with this neurobiological evidence, while echoing previous epidemiological findings that stress is related to substance use; specifically, caregiving is associated with greater odds of alcohol use (Rospenda et al., 2010) ; racial/ethnic discrimination and financial distress are linked to cigarette use (Borrell et al., 2010; Slopen et al., 2013) (Slopen et al., 2013) ; and that stress and anxiety are linked to marijuana use (Hyman & Sinha, 2009 ). Data were cross-sectional and did not allow for causal inferences, though it is plausible that the associations were bi-directional. For example, while pandemic-related financial stress may result in cigarette use as a means of coping, it is also possible that using cigarettes (the cost of purchasing cigarettes) can reduce available funds resulting in financial stress (Siahpush et al., 2003) . Still, our overall findings align with prior studies that show that other stressors may have been linked to increased substance use (Gonzalez et al., 2021), but extends this literature by highlighting specific stressors that impact people during the pandemic.

Our findings raise the question of why certain stressors are related to substance use while other stressors are not. For example, a systematic review showed that discrimination was associated with drinking (Gilbert & Zemore, 2016) as well as alcohol use severity (Glass, Williams, & Oh, 2020), but we did not find that COVID-19-related racial/ethnic discrimination was associated with any alcohol use over the past month when accounting for other COVID-19 stressors. We should note that the discrimination item did not specifically refer to Black Americans or Asian American/Pacific Islanders, who were the most likely to experience discrimination during the pandemic (Chen et al., 2020; Ruiz et al., 2020; C. Wu et al., 2021) . We also did not find evidence to suggest that COVID-19 concern was associated with alcohol use net the effects of other stressors, which differs from findings that show virus-related fears were linked to lower rates of risky drinking (Lechner et al., 2021) . While COVID-19 concern has been linked to substance use in other studies (Rogers et al., 2020) , we only found that it was associated with marijuana use over the past 30 days. Also, having a loved one become infected with or die from COVID-19 was also not associated with any substance use, despite being a highly stressful event. Along these lines, caregiving was only associated with alcohol use, but not any other substances. A key area for future research is to ascertain why only certain pandemic stressors are related to specific types of substance use.

Across the U.S., COVID-19 infection surged at different rates depending on the city and state throughout the period of data collection. Our study found that infection was associated with alcohol and marijuana use, net the effects of other stressors. The exact nature of how individuals became infected is unknown; however, there are several possibilities where substance use can lead to infection, and vice versa. For example, it is possible that one may become convivial (Vanderbruggen et al., 2020) while using substances with others (Schmidt et al., 2021) and sharing paraphernalia (noted by (Van Laar et al., 2020) , particularly while indoors in close-quarters. It is also possible that people may have attempted to use substances as pain relief/management from COVID-19 symptoms (see (Khalsa et al., 2021) . Also, it is possible that substance use can reduce immunity and increase vulnerability to viral and bacterial infections (Borgonhi et al., 2021) . More research is needed in this regard, both with respect to acute COVID-19 infection and long-haul syndrome.

There were several limitations to this study. First, data were cross-sectional and did not allow for us to ascertain the temporal order of events or make causal inferences. Second, the data were self-reported, and may have been vulnerable to recall and social desirability biases (e.g., reluctance to disclose COVID-19 infection status or history of substance use). Third, the sample consisted of college students, and it remains to be seen whether findings are generalizable to other populations. Fourth, the response rate was 14%, which raises concerns about sampling bias, though this response rate is comparable to surveys of this nature, and survey weights were used to adjust for non-response. Fifth, we did not have key measures (e.g., compliance with COVID-19 restrictions, measures of substance use prior to COVID, involvement in protesting racial injustice, state/region-level data, locations of college/universities) that could clarify our findings. Thus, our findings may have suffered from omitted variable bias. Sixth, due to small cell counts, we were unable to make meaningful ethno-racial comparisons. Certainly, racial disparities remain a central topic of concern when examining the health impact of COVID-19. Finally, the COVID-19 pandemic was not a static event, and the COVID-19 stressors we examined in the study may have varied over the course of the pandemic.

Despite limitations, the current study provides findings from a large sample of students attending colleges across the U.S. and shows that different stressful aspects of the pandemic are related to certain types of substance use, though the strength and significance of the associations varied. Efforts to address substance use during and after the pandemic may target these specific stressors, such as 

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Oh conceived and designed the analysis and wrote the paper

Sasha Zhou managed the data. Dr. Adam Leventhal's effort was partially supported by DA-K24048160

None.