Study participants' characteristics
In total, 2,505 adult tobacco users from Delhi (n = 1365) and Chennai (n = 1140) were approached to participate in our study. A total of 801 tobacco users participated in the survey out of whom, 444 (55.4%) were from Delhi while 357 (44.6%) were from Chennai. As the survey was conducted telephonically, a disposition table is used to explain the response rates [Tables S2 and S3]. The gross response rate for the study was 48.4%, the basic response rate was 85.3% and the response rate calculated using the CASRO Estimator(23) was 60.9%. Roughly 90% of the adult tobacco users were males, and 87.9% were in the age group of 25–64 years. The majority (81.2%) were employed, and 11.5% had a bachelor's degree and above. The study participants' mean age was 50.5 years, with a range from 25 to 90 years. The majority of tobacco users were smokeless tobacco users (40.5%), followed by cigarette smokers (38.0%) and bidi smokers (24.3%) (Table 1).
Table 1
Socio-demographic characteristics of the study participants (n = 801)
Socio-demographic characteristics | n (%) |
City |
Delhi | 444 (55.4) |
Chennai | 357(44.6) |
Sex |
Males | 722 (90.1) |
Females | 79 (9.9) |
Age (in years) |
25–44 | 253 (31.6) |
45–64 | 451 (56.3) |
65 and above | 97 (12.1) |
Education |
Professional Degree/Post Graduate | 17 (2.1) |
Graduate (B.A/B.Sc./B.Com/Diploma) | 75 (9.4) |
Secondary School /Intermediary | 249 (31.0) |
High school (class V to IX) | 316 (39.5) |
Primary School (up to Class IV) | 64 (8.0) |
No formal education | 80 (10.0) |
Employment Status |
Employed | 650 (81.2) |
Student | 88 (11.0) |
Housewife | 29(3.6) |
Retired | 16(2.0) |
Unemployed | 18(2.2) |
Tobacco use* |
Cigarette smokers | 305 (38.0) |
Cigarette smokers who recently quit | 15(1.9) |
Bidi smokers (n = 798) | 195(24.3) |
Bidi smokers who recently quit (n = 195) | 10(1.2) |
Smokeless tobacco users(n = 800) | 324(40.5) |
Smokeless tobacco users who recently quit (n = 324) | 13 (1.6) |
Dual Users | 30 (3.7) |
*For Cigarette smokers (Out of n = 801, 305 were cigarette smokers; Out of them 15 participants had recently quit cigarette smoking) |
For Bidi smokers (n = 798), three observations were missing; Out of them 195 were bidi smokers; of which 10 participants had recently quit bidi smoking. |
For Smokeless tobacco users (n = 800), one observation was missing; Out of which 324 participants were smokeless tobacco users; of which 13 participants had recently quit smokeless tobacco. |
Recently quit tobacco – Participants who had quit tobacco during past three months (from the onset date of survey). |
Prevalence of depressive symptoms among tobacco users
The mean PHQ-9 score for the study participants was 2.5 ± (3.4). Of the 763 complete responses, 20.6% of tobacco users were found to have depression symptoms (PHQ-9 score > 4). About 16.7% of participants reported mild depression symptoms (PHQ-9 score between 5–9), 2.9% experienced moderate depression (PHQ-9 score between 10–14), 0.7% had moderately severe depression (PHQ-9 score 15–19), and 0.3% had severe depression (PHQ-9 score 20–27) (Fig. 1). The mean depression score for females was 3.2 ± (3.1), which was significantly higher than that for males 2.4± (3.4). (p = 0.02).
Figure 2 represents the distribution of the tobacco users according to the GAD-7 score. The mean GAD-7 score for the study participants was 2.4 (SD ± 3.2). Of the 774 respondents responding to anxiety questions, 20.7% had a GAD score greater than 4. The prevalence of mild anxiety (GAD score 5–9) was 16.9%, 3.1% had moderate anxiety symptoms (GAD score 10–14), and 0.7% had severe anxiety symptoms (GAD score 15–21). When analyzed along gender lines, the mean anxiety score for females was 3 ± (3.2), significantly higher than the mean scores for males at 2.3± (3.20) (p = 0.02).
Table 2 shows the univariate associations of depression and anxiety with the socio-demographic as well as other independent variables. The symptoms of anxiety appeared in 27% and depression in 25% of the study participants, who were employed but currently not working, unemployed, or had uncertain employment status. In contrast, among the individuals who were employed and currently working, 17% experienced depression and 16.9% experienced anxiety.
Table 2
Prevalence of depression and anxiety symptoms among tobacco users
Variables | Depression (≥ 5) (N = 763) n (%) | P value | Anxiety (≥ 5) (N = 774) n (%) | P value |
Sex |
Males (N = 722) | 138 (19.1) | 0.384 | 138 (19.1) | 0.071 |
Females(N = 79) | 18 (22.7) | 22 (27.8) |
Age category (in years) |
25–44 (N = 253) | 51 (20.1) | 0.896 | 57 (22.5) | 0.552 |
45–64 (N = 451) | 86 (19) | 85 (18.8) |
65 years and above (N = 97) | 19 (19.6) | 18 (18.6) |
Education |
Professional degree/post graduate (N = 17) | 1 (5.8) | 0.851 | 1 (5.8) | 0.523 |
Graduate (N = 75) | 15 (20) | 11 (14.6) |
Secondary School /Intermediary(N = 249) | 48 (19.2) | 52 (21.9) |
High school (N = 316) | 64 (20.3) | 66 (20.9) |
Primary School(N = 64) | 12 (18.8) | 12 (18.8) |
Illiterate (N = 80) | 16(20) | 18 (22.5) |
Employment status |
Employed and currently working (N = 551) | 94 (17) | 0.009 | 93 (16.9) | 0.001 |
Employed but currently not working/ unemployed/ uncertain employment (N = 248) | 62 (25) | 67 (27) |
Financial status |
Doing alright (N = 188) | 18 (9.6) | < 0.001 | 15 (8) | < 0.001 |
Just about getting by/ finding it quite difficult (N = 568) | 129 (22.7) | 140 (24.6) |
Lockdown status |
Complete or partial lockdown (N = 481) | 89 (18.5) | 0.609 | 84 (17.5) | 0.706 |
No lockdown (N = 94) | 19 (20.2) | 18 (19.1) |
Food Security (ability to buy food during COVID-19 lockdown) |
Often (N = 598) | 63 (10.5) | < 0.001 | 93 (16) | < 0.001 |
Sometimes/ never(N = 192) | 44 (23) | 66 (34.3) |
House security (worried about paying rent or house loan) |
No (N = 501) | 71 (14.2) | < 0.001 | 61 (12.1) | < 0.001 |
Sometimes (N = 83) | 20 (24) | 20 (24) |
Yes (N = 213) | 65 (30.5) | 79 (37) |
Worried about getting evicted from house |
No (N = 646) | 94 (14.6) | < 0.001 | 86 (13.3) | < 0.001 |
Sometimes (N = 60) | 22 (36.6) | 28 (46.6) |
Yes (N = 91) | 39 (42.8) | 46 (50.5) |
Cigarette use |
Yes (N = 305) | 55 (18) | 0.365 | 57 (18.7) | 0.422 |
No (N = 496) | 101 (20.4) | 103 (20.8) |
Bidi use |
Yes(N = 195) | 32 (16.4) | 0.270 | 30 (15.4) | 0.091 |
No (N = 603) | 122 (20.2) | 128 (21.2) |
Smokeless tobacco use |
Yes (N = 324) | 67 (20.7) | 0.558 | 71 (22) | 0.313 |
No (N = 476) | 89 (18.7) | 89 (18.7) |
*Chi square test and Fisher’s Exact Test; For depression (n = 763)- 38 Observations were missing; For Anxiety (n = 774) – 27 Observations were missing |
Individuals experiencing poor financial status displayed a marked distinction in depression (22.7%) and anxiety symptoms (24.6%) when compared to those who claimed to be financially secure and stable during the pandemic-depression (9.6%) and anxiety (8%). Tobacco users who reported the ability to buy food sometimes or never during COVID-19 lockdown had significantly higher rates of depression (23%) and anxiety symptoms (34.3%) as opposed to (10.5%) and (16%) in people who could often buy food during the pandemic. Of the individuals who were worried about paying house rent or loans, 30.5% claimed to have depression, and 37% reported anxiety symptoms, starkly distinguished from individuals who were not worried (14.2%) had depression and (12.1%) had anxiety respectively. The participants who worried about being evicted from homes were significantly more depressed (42.8%) as compared to those who were not worried (14.6%) and reported anxiety symptoms in 50.5% of participants as compared to those who were not worried (13.3%). We observed that the prevalence of depression and anxiety symptoms did not change with the presence of lockdown restrictions or by type of containment zones (P > 0.05).
We observed that the presence of depression and anxiety symptoms did not change with the type of tobacco use and did not differ significantly between single tobacco product users and dual/multiple tobacco product users. The people who had recently quit tobacco did not display marked distinction in depression and anxiety symptoms than current tobacco users.
Table 3 represents findings from the logistic regression analysis assessing predictors of depression and anxiety in adult tobacco users during COVID-19. In females, the odds of anxiety were twice that in males (OR = 2, 95% CI 1.0-3.8). The risk of depression was 1.8 times and anxiety 2.2 times among participants who were financially just about getting by or finding it quite difficult as compared to those who were financially doing all right (OR = 1.8, 95% CI 1.0 ‒3.1 and OR = 2.2, 95% CI 1.2-4.0, respectively). The risk of being depressed was 2.3 times and being anxious, 1.9 times higher in people who could buy food only sometimes or never than in the people who could buy food often during the lockdown (OR 2.3, 95% CI 1.4 ‒ 3.7 and OR 1.9, 95% CI 1.1 ‒ 3.0), respectively.
Table 3
Predictors of depression and anxiety in adult tobacco users during COVID-19*
Covariates | Depression (n = 715) OR (95% CI) | Anxiety (n = 725) OR (95 % CI) |
City |
Chennai | (Ref) | (Ref) |
Delhi | 1.3 (0.8–2.0) | 1.2 (0.7–1.8) |
Sex | | |
Male | (Ref) | (Ref) |
Female | 1.3 (0.6 ‒ 2.6) | 2 (1.0 ‒ 3.8) |
Age Category |
25–44 | (Ref) | (Ref) |
45–64 | 1.0 (0.7 ‒ 1.6) | 0.8 (0.6 ‒1.3) |
65 years and above | 1.0 (0.5 ‒ 2.1) | 1.0 (0.5 ‒ 2.1) |
Education |
Professional degree/post graduate | (Ref) | (Ref) |
Graduate | 2.6 (0.3 ‒ 21.8) | 1.4 (0.2 ‒12.4) |
Secondary School /Intermediary | 1.9 (0.2 ‒ 15.5) | 1.7 (0.2 ‒ 13.8) |
High school | 1.8(0.2 ‒14.3) | 1.3(0.1 ‒ 10.9) |
Primary School | 1.8(0.2 ‒ 16.1) | 1.2(0.1 ‒ 11.3) |
Illiterate | 1.4(0.2 ‒ 12.6) | 0.9(0.1 ‒ 8.0) |
Employment status |
Employed and currently working | (Ref) | (Ref) |
Employed but currently not working/ unemployed / uncertain employment | 1.0(0.7 ‒ 1.6) | 1.2(0.7 ‒ 1.8) |
Financial status |
Doing alright | (Ref) | (Ref) |
Just about getting by/ finding it quite difficult | 1.8(1.0 ‒3.1) | 2.2(1.2 ‒ 4.0) |
Food Security (ability to buy food during COVID-19 lockdown) |
Often | (Ref) | (Ref) |
Sometimes/ never | 2.3(1.4 ‒ 3.7) | 1.9(1.1 ‒ 3.0) |
House security (worried about paying rent or house loan) |
No | (Ref) | (Ref) |
Sometimes | 0.8(0.4 ‒ 1.8) | 0.8(0.3 ‒1.7) |
Yes | 1.1(0.6 ‒ 2.0) | 1.6(0.9 ‒ 2.7) |
Worried about getting evicted from house |
No | (Ref) | (Ref) |
Sometimes | 3.0 (1.5 ‒ 6.2) | 4.5(2.2 ‒ 9.3) |
Yes | 3.8 (2.0 ‒7.0) | 4.5(2.4 ‒ 8.4) |
*Estimated using logistic regression analyses separately for the outcomes (depression and anxiety) after adjusting for city, sex, age, education, employment status, financial status, food security and house security during the lockdown |
For participants who were only 'sometimes worried about getting evicted', the risk of depression was 3 times and anxiety was 4.5 times more than those who were not worried about getting evicted from the house (OR 3, 95% CI 1.5 ‒ 6.2 and OR 4.5 ,95% CI 2.2 ‒ 9.3). Furthermore, people who were regularly worried about getting evicted had higher odds of depression (3.8 times) and anxiety (4.5 times) than those who did not worry about evictions (OR 3.8, 95%CI 2.0 ‒7.0 and OR 4.5, 95% CI 2.4 ‒ 8.4, respectively).