Association of Stress Level with Heavy Drinking and Smoking Depending on Sex and COVID-19 Infection Status: A Cross-sectional Analysis of a Nationally Representative US Adult Survey

Abstract

COVID-19 infection can cause psychological distress and, consequently, lead to an increase in substance use. Studies have also reported distinct sex-specific patterns in COVID-19 infection-related outcomes. This study examined the association of stress with heavy drinking and smoking, depending on sex and COVID-19 infection history. From the 2022 Behavioral Risk Factor Surveillance System, we conducted multiple logistic regression analyses (n = 172,110) to examine the associations of stress level (experienced stress never, rarely/sometimes, or usually/always in the past 30 days) with heavy drinking (> 14 drinks/week for males or 7 drinks/week for females) and heavy smoking (smoked ≥ 100 cigarettes in lifetime and currently smoke > 20 cigarettes/day on average), adjusting for covariates. Regression models were stratified by sex (male or female) and COVID-19 infection history (ever had positive test result or not). Among male adults, heavy drinking did not vary by stress levels, regardless of COVID-19 infection history. Among female adults, those experienced stress usually/always had higher odds of partaking in heavy drinking than those without stress only when they had COVID-19 infection (adjusted odds ratio [AOR] = 1.90, 95% confidence interval [CI] = 1.26, 2.86). Among male adults, those experienced stress usually/always had higher odds of partaking in heavy smoking than those without stress, regardless of COVID-19 infection history, but the same significant association was observed among only female adults who had COVID-19 infection (AOR = 2.60, 95% CI = 1.42, 4.78). Healthy coping mechanisms to manage stress can help prevent excessive drinking and smoking. Targeted substance use prevention efforts are particularly needed for female adults with COVID-19 infection.