Full Interview: Tobacco Control, Social Support, and Coping During the Pandemic With Daniel Giovenco
By: Makena Binker Cosen (CC ‘21)
Tell me a little bit about your background as a researcher.
I have been fascinated by public health since I started college. I studied Health Communication at the College of New Jersey, and right after that, I immediately went to graduate school to get my Masters of Public Health Degree at Rutgers University. It was during my master’s program when I really caught the “research bug” and knew that I wanted to be a scientist. I still have a passion for community-based health education, which was the focus of my degree, but during my master’s program, I realized that I also had so many research questions that I wanted to answer. For example, we’ve seen evidence of health disparities for decades, but why do they exist, and what are ways that we can more effectively eliminate them? I knew I needed research training to be able to answer some of those higher-level questions. So, I started a Ph.D. program at Rutgers University and got my Ph.D. in Public Health with a focus on behavioral science. Then, I started working at the Mailman School at Columbia as an assistant professor.
How did you get involved in tobacco control research?
My mentor at Rutgers University was an expert in survey and policy research, and focused most of her work on tobacco control. It was never really my intent to study tobacco use, but as I started learning more about the field, I felt like there was no better health issue to focus on as a public health researcher. Tobacco use is still the leading cause of preventable death and disease in the United States, which is hard to believe after decades of knowing how harmful this behavior is. It’s become so much more complex with the emergence of e-cigarettes and other novel products. As someone who is really passionate about addressing health disparities, I think tobacco use is what I decided I needed to focus on. If you look at the people in the United States who are still smoking at high rates, it’s a lot of populations that have been historically marginalized or disenfranchised — people living in poverty, certain racial and ethnic minority groups, people with mental health disorders, and the list goes on. We have the potential to minimize smoking disparities with tools that we know work. We need to do a better job designing policies, regulating products, and providing quitting support; research can help on that front.
I imagine those disparities have become exacerbated in the pandemic. What do we know about the relationship between tobacco use and a person’s risk of getting COVID-19, as well as the health outcomes related to each of those?
What we know for certain is that the health consequences that smoking causes, like COPD, cancer, other types of lung disease, and heart disease, are documented risk factors for poor COVID-19 outcomes. The data on whether active smoking is a strong risk factor is inconclusive. I don’t think we have a full picture of this relationship yet, partly because data collection is not always high quality. So, when we document COVID cases, we don’t know how people are asking about smoking status or if patient responses are fully accurate.
One can imagine that a behavior that involves inhaling toxic substances probably isn’t protective when it comes to a respiratory illness like COVID-19. Research is still emerging and results have been kind of mixed, actually. There are a lot of studies that show smoking is related to poorer disease outcomes and increased mortality, as we might expect. Interestingly, there are a few studies suggesting that smoking almost seems protective: the rate of smoking among COVID patients is lower than expected. Could nicotine be playing this protective role because of its impact on the body’s inflammatory response? At this point, we don’t know if these findings are just due to poor data or if there truly is enough reason to question the role of smoking.
As soon as the pandemic arrived in the US, I thought to myself, “Well, smoking clearly must be a risk factor, so I wonder what smoking behaviors look like here during this time of high anxiety related to health.” As I continued to think about it, I thought that the precise relationship between smoking and COVID might be less important; the fact is that all of these measures that we put in place to prevent COVID spread — stay at home orders, social distancing, store closures — all of those things are likely going to affect people’s substance use behaviors, including smoking. I got to a point where I almost didn’t care what the relationship was between the two. I just wondered, “What do the behaviors of people who smoke and vape look like during this period of really high stress and anxiety, and how might these persist after we start to control the outbreak?” What’s happened during lockdown periods is an unprecedented shift in how we live and operate. I wanted to better understand that, so we can identify ways to better support the health and well-being of people who use tobacco or vaping products, and who may be addicted to those products.
Could you please describe your current COVID-related research?
My background is in quantitative research, so almost all of my projects involve survey data analysis or using GIS, geographical information systems. I don’t typically do qualitative research studies like interviews or focus groups, but I knew that, for this topic, that was the most appropriate methodology to use. This situation is unprecedented, and the impact that it has on tobacco use behaviors is probably very complex. So we knew that we needed to talk to people through very in-depth interviews to fully understand how people’s demand for their products and their supply sources may have shifted. We decided to do what is called “semi-structured interviews” with people who smoke or vape around the country. The “semi” in “semi-structured” means we have a set of questions that we want to ask, but are flexible as to where the conversation goes. We’re open to uncovering new avenues if they emerge.
We used Facebook and Instagram advertising to recruit participants. We created advertisements that said, “Help Columbia University researchers understand health behaviors during COVID-19.” That advertisement was displayed to thousands of people across the country. If they clicked on it, it took them to a screener survey that assessed their eligibility for participation. To be eligible, they had to be over 18 years old and currently smoke and/or use a vaping product. We got a really diverse set of participants in terms of income level, geography, smoking behaviors, underlying conditions.
We ultimately scheduled interviews with fifty people. They each lasted about an hour - we talked to them about the various ways that the pandemic has impacted their lives in general and altered their substance use behaviors. It has been really fascinating. We finished conducting all the interviews, and are in the process of transcribing the audio and analyzing the data to look for themes that are consistent, or findings we didn’t expect.
What can we expect are ways the pandemic is influencing tobacco use behavior? Is it affecting different groups in different ways?
We thought that, because this is a high stress period, substance use behavior would probably increase among certain people. But for others, acknowledging that smoking can potentially put them at risk for COVID, maybe people would be a little more motivated to quit during this time. Others might not change their behaviors at all. So maybe we’ll find an even split.
What we found is that tobacco use was rarely stable. Almost every person in our sample reported changes in their tobacco use during the lockdown period. Increased use was generally more common than decreases in smoking and vaping. Among those whose use increased, they would frequently say things like, “I’ve never been smoking or vaping more. It’s really ramped up. It’s how I’m coping.” They would even say, “I know that this can put me at risk. I know this can be really bad when this is all over, because I might be even more addicted than I am now. But right now, I need to do this to feel a sense of comfort and for stress relief.”
When we asked about people’s intentions to quit during this time, there was a pretty resounding “No, now is not the time.” We heard that over and over. When we asked people, “Well, if you did decide to quit, hypothetically, what do you think you would need to be successful? What could better support you in that quit attempt?” People commonly mentioned social support, which is very limited right now. It’s like all the worst parts of this pandemic — things like feeling isolated from people, not having access to certain services or treatments — those are all the things that people need to successfully quit using any type of substance and those are all lacking right now. That’s why, generally people were like, “I know there’s probably no better time to quit, it’s just probably not going to happen now.”
Has the pandemic’s stay-at-home measures affected supply of tobacco and vape products?
We actually noticed a really interesting divergence between people who smoke and people who vape. I think one of the most illustrative quotes from this whole project was something like “No toilet paper, but plenty of Camel cigarettes.” A lot of people have said they’re having trouble finding basic necessities, but cigarettes are still everywhere. It’s just as easy to get them as it was before. If you think about essential businesses that have stayed open — places like gas stations, drug stores, grocery stores — most of those places sell cigarettes. So, access for smokers hasn’t been an issue. Some noted that they stockpile, so that they don’t have to go out to the stores as often. Some people that we talked to, if they smoke a pack a day, rather than go to the store every day, they’ll buy multiple packs at the beginning of the week.
But it’s been interesting that a lot of retailers that sell vape products, like vape shops for example, were considered non-essential in many places and shut down. So, a lot of people who vape have said that they have to order their products online now. They have to wait weeks sometimes for them to get to their house. If someone is heavily addicted to something, not knowing when the next supply is going to come can be a real source of stress. So, generally, vapers have found it much harder to find their product, and some even reported that they have gone back to smoking cigarettes because they’re just easier to get, which is really problematic. We know that cigarettes are generally more harmful than vaping is, although vaping certainly isn’t without risk. But we definitely don’t want people who have switched over to vaping to go back to smoking cigarettes, which is what some of our interviewees reported.
Considering younger people are more likely to use Facebook and Instagram, how did you generate a representative sample of participants?
The benefit of using Facebook and Instagram as recruitment methods for this kind of study is, based on the results of our screener survey, we could reach out to individuals to make sure that we had representation from certain priority groups. Although there weren’t a ton people over 70 years old that completed the screener, there were some, and we could reach out to them individually and invite them to an interview, to make sure that their voices were heard. So if I was going to do a quantitative study to make representative estimates of health behaviors, I might not use Facebook and Instagram as my recruitment methodology. For a project like this, however, where we were really most interested in having people share their experiences and describe the complexities of their beliefs and behaviors, I think the strategy was optimal.
Have you heard about or seen any changes in advertising since the pandemic started?
I don’t know the answer to that question. We didn’t hear anything and we didn’t ask about that in this particular study, so I don’t know. We did ask about prices of products changing. Generally, people said “not really” or that changes weren’t noticeable.
I know you’re still in the process of transcribing and analyzing data. Is there anything that gave you a push forward or back? Did you experience any setbacks? We talked about some, but were there any other limitations to the study?
There weren’t any major setbacks. I know this may sound strange, but this was an enjoyable study to be a part of. It felt nice to directly connect with people, especially during a pandemic. The people that we talked to said they really liked having a conversation with someone about the way that COVID-19 has impacted their lives. They appreciated that people were looking into ways to better support the experience of people who do have an addiction to something. That’s one of the great things about qualitative research — you kind of form these relationships with the participants. You’re not just pulling data and spitting it out. You’re talking to people. It was interesting for me, since I’m usually someone who designs a survey, sends it out, and gets the results in. I felt more human than ever, as a researcher, just talking to people. In qualitative research, it’s okay to say things like, “That sounds really tough. I can’t imagine what that’s like. Can you tell me more about this?” You just feel like a human being connecting with another human being, which is something that you don’t always experience in research studies.
I definitely understand that; for me, conducting interviews has been an opportunity to learn more about what is going on and connecting to how people are keeping up with the world today. It’s also just nice to have these conversations, especially to engage with topics that aren’t at the forefront of the headlines of the papers. Are there any online support groups for people trying to control their tobacco use behavior?
I’m sure there are, but generally, if I could pick a central theme from this project so far, it’s that people’s tobacco use behaviors are a lesser priority than some of the other critical issues they’re facing. People are trying to survive. These interviews were sometimes emotionally draining. We talked to people who were in really, really dire circumstances — who have lost their jobs, who are financially struggling, who have family members who are sick or who have died. Just the amount of stress, exhaustion, and sadness that people are feeling — quitting smoking is the least of their priorities right now, from what we’ve gathered. Actually, it’s often what’s helping them to cope with their stressors. That’s not to say that they don’t view it as problematic. Many of them did. Many of them said, “I would love to quit. I know I should. I just can’t even think about that now. Smoking for me just allows me to function, to deal with all of the other stuff that is my priority right now.” That was tough to hear, because as a public health professional and as someone who is interested in helping people access quitting resources, I realized that people generally aren’t receptive to that right now, and for very understandable reasons. It made me wonder, “What are the next steps for us, as public health professionals, when people have so many competing priorities other than the one that you’re trying to intervene on?”
That’s a big take away. I don’t know the answer to that either, but if you find out, let me know! What is your perspective on the future for your research and your work as a public health professional? What about the broader impacts of the pandemic in general?
Yeah, that’s a great question and something that I’ve been thinking about constantly. When you’re working in a particular field, you’re often singularly obsessed with it. You care so deeply about it, that's what you focus all of your efforts on. With tobacco control or any kind of substance use research, we tend to focus on clear, actionable solutions to the problems, such as increasing access to treatment, preventing initiation, and regulating industry manufacturing and marketing. One way this pandemic has affected me very deeply is that it has revealed so clearly that health behaviors and outcomes have very systemic roots and causes. With everything that’s been happening related to COVID, racial injustice, and other social issues, you realize that the reasons why some people use substances can be to cope with and to escape major life stressors driven by these structural inequalities. I’m thinking much more deliberately now about the structural drivers of substance use rather than strategies to solve the problem at a surface level. I think both approaches are important, but we can’t wait around for structural problems to get solved, since they likely will achieve the biggest impact in reducing substance use. In some ways, tobacco use today is just an outward symptom of much larger and deeper underlying problems.
Do you have any recommendations for people using substances to cope or people with loved ones who are?
I have a much better understanding of why people continue to use any of these products and I empathize with that. That said, my “public health answer” is that this is probably the best time to quit considering the risks of COVID, although I acknowledge that it’s probably the most difficult time to quit. But even though the world seems like it has stopped, there are still quitting resources available. State quit lines are still open, so you can call and get access to behavioral support and even free nicotine replacement therapies. There are support groups and a lot of great tools and resources out there. There’s help available.
Do you expect initiation to decrease during the pandemic?
Yes, and it has been slowing, even before the pandemic started. But there will still be remaining smokers who continue to use, so we can’t let up. I think the reason why smoking has lost some attention among the general public is because for some, it’s an “invisible” problem. In a lot of people’s circles, they don’t know anyone who smokes, but smoking has certainly not gone away. The national smoking rate is something like 14% now, but if you look at rates among populations that face social and economic disadvantages, rates are similar to what they were decades ago. For example, among people with mental health disorders, the rate of smoking is around 30-40%. So yes, even though I think less people will start to smoke over time, I think there are people who we need to support in their quit attempts more strongly than ever.