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Research Article| Volume 41, P359-367, December 2022

Increased use of psychoactive substances among Brazilian health care professionals during the COVID-19 pandemic

Published:September 10, 2022DOI:https://doi.org/10.1016/j.apnu.2022.09.004
Increased use of psychoactive substances among Brazilian health care professionals during the COVID-19 pandemic
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      Highlights

      • •
        The use of psychoactive substances increased during the COVID-19 pandemic.
      • •
        Tobacco use increased among respondents with no religious preference.
      • •
        Alcohol use increased among higher education respondents.
      • •
        Social isolation was associated with the use of psychoactive substances.
      • •
        Women had higher chances of increasing their use of hypnotics and sedatives.

      Abstract

      This study aimed to estimate the prevalence of increased psychoactive substance use (PSU) and associated factors among health care professionals. A cross-sectional and analytical study with 12,086 Brazilian health professionals was undertaken. An online questionnaire was used to gather data concerning sociodemographic factors, increased consumption of alcoholic beverages, tobacco, and hypnotics or sedatives during the COVID-19 pandemic. The prevalence of tobacco, alcoholic beverages, and hypnotic or sedative consumption were 17.8 %, 69.0 % and 17.1 %, respectively. Regression analyses indicated that having no religion and social isolation were associated with increased PASU during the pandemic. COVID-19 pandemic stressors may increase PASU, and increased PASU may increase the risk of substance use disorders and substance use-related chronic diseases, such as cancer.

      Keywords

      Introduction

      The pandemic caused by the novel coronavirus disease (COVID-19) is a global health crisis that affects the physical and mental health of the general population (
      • Wang C.
      • Pan R.
      • Wan X.
      • Tan Y.
      • Xu L.
      • Ho C.S.
      • Ho R.C.
      Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China.
      International Journal of Environmental Research and Public Health. 2020; 17
      ). In the mental health sphere, the pandemic can cause symptoms such as panic, phobia, stress, anxiety and sleep disturbances, among other symptoms (
      • Banerjee D.
      • Rai M.
      Social isolation in Covid-19: The impact of loneliness.
      International Journal of Social Psychiatry. 2020; 66: 525-527https://doi.org/10.1177/0020764020922269
      ). Specifically, among health care workers (HCW), stress caused by COVID-19 (COVID Stress Scales) can be related to a variety of factors, such as fear of contamination by SARS-COV-2, fear of taking the infection home from work and infecting family members, occupational stress and increased workload during the pandemic (
      • Clay J.M.
      • Parker M.O.
      Alcohol use and misuse during the COVID-19 pandemic: A potential public health crisis?.
      The Lancet Public Health. 2020; 2667: 30088https://doi.org/10.1016/S2468-2667(20)30088-8
      ;
      • McKay D.
      • Asmundson G.
      Substance use and abuse associated with the behavioral immune system during COVID-19: The special case of healthcare workers and essential workers.
      Addictive Behaviors. 2020; 110106522https://doi.org/10.1016/j.addbeh.2020.106522
      ;
      • Tan J.
      • Yoshida Y.
      • Ma K.S.K.
      • Mauvais-Jarvis F.
      Gender differences in health protective behaviors during the COVID-19 pandemic in Taiwan: An empirical study.
      MedRxiv, 2021https://doi.org/10.1101/2021.04.14.21255448
      ;
      • Taylor S.
      • Landry C.A.
      • Paluszek M.M.
      • Fergus T.A.
      • McKay D.
      • Asmundson G.J.G.
      COVID stress syndrome: Concept, structure, and correlates.
      Depression and Anxiety. 2020; 37: 706-714https://doi.org/10.1002/da.23071
      ).
      The co-occurrence of traumatic stress and the use or abuse of psychoactive substances is well known (
      • María-Ríos C.E.
      • Morrow J.D.
      Mechanisms of shared vulnerability to post-traumatic stress disorder and substance use disorders.
      Frontiers in Behavioral Neuroscience. 2020; 31: 14-16https://doi.org/10.3389/fnbeh.2020.00006
      ). According to the World Health Organization (WHO), “Psychoactive drugs are substances that, when taken in or administered into one's system (directly act on and alter the function of the central nervous system) affect mental processes, e.g. perception, consciousness, cognition or mood and emotions. Psychoactive drugs belong to a broader category of psychoactive substances, including alcohol and nicotine. ‘Psychoactive’ does not necessarily imply dependence-producing” (
      World Health Organization (WHO)
      Drugs (psychoactive).
      https://www.who.int/health-topics/drugs-psychoactive#tab=tab_1
      Date: 2020
      ).
      Among HCW, PSU is of significant concern (
      • Merlo L.J.
      • Trejo-Lopez J.
      • Conwell T.
      • Rivenbark J.
      Patterns of substance abuse initiation among healthcare professionals in recovery.
      The American Journal on Addictions. 2013; 22: 605-612https://doi.org/10.1111/j.1521- 0391.2013.12017.x
      ;
      • Ribeiro Í.A.P.
      • Marques L.L.
      • Assis L.R.S.
      • Silveira H.N.
      • Lacerda J.N.
      • Mendes M.R.R.S.
      Substâncias psicoativas no contexto do trabalhador da saúde.
      Revista Enfermagem Atual. 2019; 90: 1https://doi.org/10.31011/reaid-2019-v.90-n.28-art.530
      ;
      • Scholze A.R.
      • Martins J.T.
      • Grandi A.L.
      • Galdino M.J.Q.
      • Robazzi M.L.C.C.
      Uso de substâncias psicoativas entre trabalhadores da enfermagem.
      Revista Portuguesa de Enfermagem de Saúde Mental. 2017; 18: 23-30https://doi.org/10.19131/rpesm.0188
      ) due to impairment in performing work tasks, substance use associated chronic diseases and other negative impacts on well-being and quality of life.
      COVID-19 stress syndrome involves changing emotional reactions (
      • Taylor S.
      • Landry C.A.
      • Paluszek M.M.
      • Fergus T.A.
      • McKay D.
      • Asmundson G.J.G.
      Development and initial validation of the COVID stress scales.
      Journal of Anxiety Disorders. 2020; 72https://doi.org/10.1016/j.janxdis.2020.102232
      ) and other dimensions beyond the individual, such as socioeconomic and labour (job loss or the fear of job loss, for example) factors. In addition, this stress can contribute, through various mechanisms, to the use or abuse of psychoactive substances during the pandemic via activation of the behavioural immune system (BIS) (
      • Schaller M.
      • Park J.H.
      The behavioral immune system (and why it matters).
      Current Directions in Psychological Science. 2011; 20: 99-103https://doi.org/10.1177/0963721411402596
      ).
      Previous studies involving adverse events such as the impacts of disasters, terrorist incidents, natural disasters and the acute respiratory syndrome (SARS) epidemic have reported high rates of substance use, abuse and dependence, including alcohol and tobacco consumption. In this context, it can be inferred that the COVID-19 pandemic increases the risk for psychoactive substance abuse and dependent behaviours (
      • Klimkiewicz A.
      • Schmalenberg A.
      • Klimkiewicz J.
      • Jasińska A.
      • Jasionowska J.
      • Machura W.
      • Wojnar M.
      COVID-19 pandemic influence on healthcare professionals.
      Journal of Clinical Medicine. 2021; 10: 1280https://doi.org/10.3390/jcm10061280
      ), especially across HCW. Additionally, HCW may be in a position of greater vulnerability to the negative impacts of the COVID-19 pandemic, both in the short and long term, with repercussions on their mental health and consequently, on the use or abuse of psychoactive substances. For example,
      • Alonso J.
      • Vilagut G.
      • Mortier P.
      • Ferrer M.
      • Alayo I.
      • Aragón-Peña A.
      • Aragonès E.
      • Campos M.
      • Cura-González I.D.
      • Emparanza J.I.
      • Espuga M.
      • Forjaz M.J.
      • González-Pinto A.
      • Haro J.M.
      • López-Fresneña N.
      • Salázar A.
      • Molina J.D.
      • Ortí-Lucas R.M.
      • Parellada M.
      MINDCOVID Working group
      Mental health impact of the first wave of COVID-19 pandemic on Spanish healthcare workers: A large cross-sectional survey.
      Revista de Psiquiatria y Salud Mental. 2021; 14: 90-105https://doi.org/10.1016/j.rpsm.2020.12.001
      estimated the prevalence of substance use disorders among health professionals in Spain during the first wave of the pandemic at 6.2 %.
      Furthermore, during pandemics in general, consumption of alcohol and other substances has been a relevant issue for this professional category. In a multicentre United States study involving 1132 health professionals, 42.6 % had a probable diagnosis of alcohol use disorder (
      • Hennein R.
      • Lowe S.
      A hybrid inductive-abductive analysis of health workers' experiences and well-being during the COVID-19 pandemic in the United States.
      PLoS ONE. 2020; 15e0240646https://doi.org/10.1371/journal. pone.0240646
      ). During the SARS epidemic in 2003, staff at a hospital in Hong Kong increased their pattern of alcohol consumption compared to the period before the crisis (
      • Lau J.T.F.
      • Yang X.
      • Pang E.
      • Tsui H.Y.
      • Wong E.
      • Wing Y.K.
      SARS-related perceptions in Hong Kong.
      Emerging Infectious Diseases. 2005; 11: 417-424https://doi.org/10.3201/eid1103.040675
      ).
      The increased use of substances may seem like a reflex response from individuals to a new way of life suddenly imposed by the pandemic. Therefore, this study focuses on assessing the prevalence of increased consumption of psychoactive substances and associated factors among HCW who worked in the direct care of patients in various health care scenarios, independent of their COVID-19 diagnosis.

      Methods and procedures

      Study design and sample

      An analytical cross-sectional study using an online survey was conducted in Brazil from October to December 2020 using respondent-driven sampling. Inclusion criteria were health professionals working in the direct care of patients, affected or not by COVID-19, in any health care setting, in public or private services, and working at least in the last six months before data collection.

      Sample calculation

      For the sample calculation, information on the number of professionals per region of Brazil was considered a reference, according to data from the professional councils provided by the Ministry of Health, base year 2010 (
      • Brasil
      Indicadores de recursos. Número de profissionais de saúde por habitante.
      https://tabnet.datasus.gov.br/cgi/deftohtm.exe?idb2012/e01.def
      Date: 2010
      ). A confidence interval (CI) of 95 % was used, with a margin of error equal to 1 % plus or minus, obtaining a minimum sample of 5079 individuals. Following online data collection, 12,086 participants participated in the study. The sample size calculation formula, as described by
      • Valliant R.
      • Dever J.A.
      • Kreuter F.
      Practical tools for designing and weighting survey sample.
      Springer Science – Business Media, New York, Heidelberg2013
      , is as follows:
      n=11n0+1N,


      on what
      n0=z2S2d2


      In the formula presented:
      • •
        z is the value related to the confidence level established for the survey (to 95 % confidence);
      • •
        N is the size of the population;
      • •
        S is the standard deviation;
      • •
        d is the margin of error (pre-established according to the average score to be calculated).

      Data collection procedure

      Researchers from all macro-regions of Brazil were selected to work in the data collection. Firstly, these researchers were trained on how to conduct an online survey. Each researcher then identified health professionals who met the study inclusion criteria. The first eligible professional identified other professionals to follow the recruitment chain. Participants were encouraged, once a week, to recruit other participants (peers) in their category through their social networks to grow the recruitment chain.
      This study followed the Reporting of Observational Studies in Epidemiology STROBE checklist of items that should be included in observational study reports and was guided by the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).

      Study questionnaire and pilot study

      The questionnaire included multiple-choice questions, divided according to sociodemographic information, questions related to professional category, type of care provided, family isolation during the pandemic, and queries related to the use of tobacco and derivatives, alcoholic beverages, and hypnotics or sedatives during the pandemic (in the three last months) according to the Smoking and Substance Involvement Screening Test (ASSIST) (
      • Henrique I.F.S.
      • de Micheli D.
      • de Lacerda R.B.
      • de Lacerda L.A.
      • Formigoni M.L.O.S.
      Validação da versão Brasileira do teste de triagem do envolvimento com álcool, cigarro e outras substâncias (ASSIST).
      Revista da Associação Médica Brasileira. 2004; 50https://doi.org/10.1590/S0104-42302004000200039
      ). The appearance and content of the study's questionnaire were prepared and validated by 15 experts. A pilot study was performed with participants contacted through social media and who were requested to participate in the study through a link. Subsequently, respondents were invited to send feedback and comments on the questionnaire via WhatsApp. In addition to minor adaptations to the terminology, all suggested changes were considered. Data collection took place after the pilot study. The questionnaire was hosted at www.surveymonkey.com, allowing only one submission per Internet protocol (IP) address to protect data integrity.

      Study outcomes

      Three outcomes were considered: use of tobacco and derivatives, alcoholic beverages, and hypnotics or sedatives during the COVID-19 pandemic. In addition, participants were asked, ‘In this pandemic period, has your substance use increased?’ with exclusive dichotomous responses (Yes or No) for each of the substances.

      Data analysis

      The absolute and relative frequency of the outcomes and covariates were calculated in an exploratory analysis. First, chi-square and Fisher's exact tests were used to test associations between each outcome and explanatory variables, with a significance level of 5 % (α = 0.05). Then, separated logistic regression models were performed for each outcome to estimate the adjusted odds ratio (OR) with a respective 95 % confidence level (95 % CI) (
      • Hosmer D.W.
      • Lemeshow S.
      Applied logistic regression.
      (2nd ed). John Wiley & Sons Inc., 2000
      ). In the initial model, the variables that presented a p-value <0.20 (referring to the estimate of their respective coefficients) were selected for a subsequent model. In this new model, the stepwise method was used to select the best set of variables to explain each outcome. Goodness of fit was assessed using the Hosmer–Lemeshow test, with p > 0.05 indicating model adequacy. Data were analysed using the R statistical program, version 4.0.1, available at www.r-project.org

      Ethical considerations

      The project was approved by the Research Ethics Committee of Ribeirão Preto School of Nursing at the University of São Paulo. Participants read and registered an Informed Consent Form before participating in the study.

      Results

      The study reached 12,086 health professionals who worked in direct patient care at various levels of health care in all five Brazilian macro-regions. Respectively, 13, 15 and 35 participants did not answer on the use of tobacco and derivatives, alcoholic beverages, and hypnotics or sedatives. Therefore, for data analysis, 12,073 participants were considered for tobacco and derivatives, 10,071 participants for alcoholic beverages and 12,051 participants for hypnotics or sedatives. As a result, the prevalence of use of tobacco and derivatives, alcoholic beverages, and hypnotics or sedatives was 17.8 % (95 % CI: 17.2–18.48), 69.0 % (95 % CI: 68.18–69.82) and 17.1 % (95 % CI: 16.43–17.77), respectively.
      Female professionals who declared a religious preference and participants with a postgraduate degree predominated for the three outcomes. Nursing professionals who provided care to patients in any clinical area were the most common professional category across all three variables, with or without a diagnosis of COVID-19. Furthermore, professionals who were not diagnosed with COVID-19, did not provide care in a field hospital and were isolated from family members, reported a higher frequency of increased use of tobacco products, alcoholic beverages and hypnotics/sedatives. Data are shown in Table 1.
      Table 1Analysis of factors associated with increased substance use among professionals who worked during the pandemic (N = 12,086). Brazil, 2020.
      VariablesTobacco productsAlcoholic beveragesHypnotics/sedatives
      YesNop
      Chi-square test.
      		YesNop
      Chi-square test.
      		YesNop
      Chi-square test.
      n (%)n (%)n (%)n (%)n (%)n (%)
      Sex<0.010.002<0.01
       Male255 (10.7)2134 (89.3)745 (31.2)1642 (68.8)234 (9.8)2147 (15.7)
       Female635 (6.6)9049 (93.4)2710 (28.0)6974 (72.0)1210 (12.5)8461 (87.5)
      Region<0.01<0.010.025
       Northeast210 (5.8)3423 (94.2)951 (26.2)2683 (73.8)461 (12.7)3169 (87.3)
       North117 (6.6)1660 (93.4)423 (23.8)1354 (76.2)173 (9.7)1603 (90.3)
       Midwest172 (8.1)1955 (91.9)663 (31.2)1462 (68.8)257 (12.1)1865 (87.9)
       Southeast310 (8.9)3179 (91.1)1115 (32.0)2372 (68.0)432 (12.4)3044 (87.6)
       South81 (7.7)966 (92.3)303 (28.9)745 (71.1)121 (11.5)927 (88.5)
      Religion<0.01<0.010.006
       Religious preference (Yes)695 (6.6)9868 (93.4)2880 (27.3)7681 (72.7)1231 (11.7)9313 (88.3)
       Religious preference (No)195 (12.9)1315 (87.1)575 (38.1)935 (61.9)213 (14.1)1295 (85.9)
      Education<0.01<0.010.579
       High school210 (9.7)1960 (90.3)526 (24.2)1646 (75.8)249 (11.5)1921 (88.5)
       College267 (7.9)3109 (92.1)985 (29.2)2388 (70.8)418 (12.4)2954 (87.6)
       Postgraduate studies413 (6.3)6114 (93.7)1944 (29.8)4582 (70.2)777 (11.9)5733 (88.1)
      Type of patients served0.006<0.010.060
       With COVID167 (8.3)1835 (91.7)602 (30.1)1401 (69.9)236 (11.8)1765 (88.2)
       In general307 (6.5)4450 (93.5)1228 (25.8)3525 (74.2)532 (11.2)4215 (88.8)
       Both416 (7.8)4898 (92.2)1625 (30.6)3690 (69.4)676 (12.7)4628 (87.3)
      Professional category0.621<0.01<0.01
       Nursing professional657 (7.3)8370 (92.7)2475 (20.2)6551 (79.8)1051 (11.7)7963 (88.3)
       Physician111 (8.6)1187 (91.4)456 (27.4)841 (72.6)218 (16.8)1078 (83.2)
       Physical therapist43 (6.4)627 (93.6)204 (35.2)466 (64.8)55 (8.2)613 (91.8)
       Psychologist13 (7.0)174 (93.0)59 (30.4)128 (69.6)17 (9.1)169 (90.9)
       Speech therapist4 (6.8)55 (93.2)17 (31.6)41 (68.4)2 (3.4)56 (96.6)
       Occupational therapist4 (10.3)35 (89.7)17 (29.3)22 (70.7)8 (20.5)31 (79.5)
       Odontologist14 (5.8)226 (94.2)65 (43.6)175 (56.4)29 (12.1)210 (87.9)
      Other44 (8.0)509 (92.0)162 (27.1)392 (70.8)64 (11.6)488 (88.4)
      Worked in a field hospital<0.010.1180.072
       Yes315 (8.8)3256 (91.2)1057 (29.6)2512 (70.4)456 (12.8)3106 (87.2)
       No575 (6.8)7927 (93.2)2398 (28.2)6104 (71.8)988 (11.6)7502 (88.4)
      COVID diagnosis0.2820.7940.004
       No620 (7.5)7595 (92.5)2345 (28.5)5869 (71.5)934 (11.4)7261 (88.6)
       Yes270 (7.0)3588 (93.0)1110 (28.8)2747 (71.2)510 (13.2)3347 (86.8)
      Received training on COVID-190.0780.1310.003
       Yes603 (7.1)7890 (92.9)2466 (29.0)6030 (71.0)967 (11.4)7509 (88.6)
       No287 (8.0)3293 (92.0)989 (27.7)2586 (72.3)477 (13.3)3099 (86.7)
      Family isolation<0.01<0.01<0.01
       Yes623 (8.0)7205 (92.0)2422 (30.9)5411 (69.1)1061 (13.6)6756 (86.4)
       No248 (6.1)3811 (93.9)964 (23.8)3088 (76.2)367 (9.1)3682 (90.9)
       Not applicable19 (10.2)167 (89.8)69 (37.1)117 (62.9)16 (8.6)170 (91.4)
      low asterisk Chi-square test.
      The chances of increased tobacco use were 36 % lower among female professionals (OR = 0.64; CI = 0.55–0.75; p < 0.01). Being a professional from the Midwest, Southeast and South increased the chances of using tobacco by 1.44, 1.57 and 1.40, respectively, compared to being from the Northeast region.
      Professionals who reported no religious preference had increased chances of using tobacco by almost double compared to those who declared a religion (OR = 1.95; CI = 1.10–2.32; p < 0.01). On the other hand, higher education and postgraduate studies' professionals had decreased chances of using hypnotics/sedatives, by 23 % and 37 %, respectively, compared to those who only finished high school.
      Not having worked in a field hospital reduced the chances of using tobacco by 22 % compared to those who worked in a field hospital (OR = 0.78; CI = 0.67–0.91; p = 0.002). Reporting no family isolation increased the chances of using tobacco by 24 % compared to those who had been isolated from their families (OR = 0.76; CI = 0.65–0.89; p < 0.01).
      Regarding the analysis of increased use of alcoholic beverages during the COVID-19 pandemic, professionals from the Midwest, Southeast and South regions had increased chances of increased consumption of alcoholic beverages by 1.27, 1.38 and 1.18, respectively, compared to professionals from the Northeast region. Professionals who did not have a religious preference had increased chances of consuming alcoholic beverages by 1.58 compared to those who had a religion (OR = 1.58; CI = 1.41–1.77; p < 0.01).
      Regarding professional training, participants who had higher education and postgraduate studies increased their consumption of alcoholic beverages by 1.26 and 1.30, respectively, compared to those who only finished high school. Professionals who worked with ‘both’ types (patients with suspected COVID-19 and patients with other clinical conditions) had increased chances of increasing their consumption of alcoholic beverages by 1.22 compared to those who only worked with COVID-19 patients (OR = 1.22; CI = 1.08–1.37; p = 0.001).
      Family isolation contained significant findings. Professionals who were not isolated from family members are 29 % less likely to increase their consumption of alcoholic beverages than those who were isolated from family members (OR = 0.71; CI = 0.65–0.77; p < 0.01).
      For the analysis of hypnotics/sedatives, being female increased the chances of increased consumption by 1.33 compared to males (OR = 1.33; CI = 1.15–1.55; p < 0.01). Being from the North region reduced the chances of using these substances by 27 % compared to being from the Northeast region (OR = 0.73; CI = 0.61–0.88; p = 0.001).
      Professionals without a religious preference had increased chances of using hypnotics/sedatives by 1.29 compared to those who had one (OR = 1.29; CI = 1.10–1.52; p = 0.001). Having a COVID-19 diagnosis increased the odds by 1.23 for the use of hypnotics/sedatives compared to professionals who did not have a COVID-19 diagnosis (OR = 1.23; CI = 1.09–1.38; p = 0.001). Not taking a training course on COVID-19 increased the chances of using hypnotics/sedatives by 1.19 compared to professionals who had completed one (OR = 1.19; CI = 1.06–1.34; p = 0.004) (see Table 2).
      Table 2Odds ratios by logistic regression for substance use. Brazil, 2020.
      Tobacco products
      VariableCrudeAdjusted
      OR (CI95%)p-ValueOR (CI95%)p-Value
      Sex (female)0.59 (0.50–0.68)<0.010.64 (0.55–0.75)<0.01
      p-value < 0.05.
      Region (Midwest compared to Northeast)1.43 (1.16–1.77)<0.011.44 (1.17–1.78)<0.01
      p-value < 0.05.
      Region (Southeast compared to Northeast)1.59 (1.33–1.91)<0.011.57 (1.30–1.89)0.014
      p-value < 0.05.
      Region (South compared to Northeast)1.37 (1.05–1.78)0.0241.40 (1.07–1.83)<0.01
      p-value < 0.05.
      Religion (declared no preference)2.10 (1.78–2.49)<0.011.95 (1.10–2.32)<0.01
      p-value < 0.05.
      Education (college compared to high school)0.80 (0.663–0.97)0.0230.78 (0.64–0.94)0.010
      p-value < 0.05.
      Education (graduate compared to high school)0.63 (0.53–0.75)<0.010.63 (0.53–0.76)<0.01
      p-value < 0.05.
      Provided assistance in a field hospital (no compared to yes)0.750(0.650–0.865)<0.010.78 (0.67–0.91)0.002
      p-value < 0.05.
      Family isolation (no compared to yes)0.752(0.646–0.876)<0.010.76 (0.65–0.89)<0.01
      p-value < 0.05.
      Alcoholic beverages
      VariableCrudeAdjusted
      OR (CI95%)p-ValueOR (CI95%)p-Value
      Region (Midwest compared to Northeast)1.28 (1.14–1.44)<0.011.27 (1.13–1.43)<0.01
      p-value < 0.05.
      Region (Southeast compared to Northeast)1.33 (1.20–1.47)<0.011.38 (1.24–1.53)<0.01
      p-value < 0.05.
      Region (South compared to Northeast)1.15 (0.98–1.34)0.081.18 (1.01–1.37)0.039
      p-value < 0.05.
      Religion (declared no preference)1.64 (1.46–1.83)<0.011.58 (1.41–1.77)<0.01
      p-value < 0.05.
      Education (college compared to high school)1.29 (1.14–1.46)<0.011.26 (1.12–1.43)<0.01
      p-value < 0.05.
      Education (graduate compared to high school)1.33 (1.19–1.48)<0.011.30 (1.16–1.46)<0.01
      p-value < 0.05.
      Provides care to patients with and without a diagnosis of COVID-19 (both, compared to providing care only to patients diagnosed with COVID-19)1.025(0.916–1.146)0.6681.22 (1.08–1.37)0.001
      p-value < 0.05.
      Family isolation (no compared to yes)0.697(0.639–0.761)<0.010.71 (0.65–0.77)<0.01
      p-value < 0.05.
      Hypnotics/sedatives
      VariableCrudeAdjusted
      OR (CI95%)p-ValueOR (CI95%)p-Value
      Sex (female)1.31 (1.132–1.52)<0.011.33 (1.15–1.55)<0.01
      p-value < 0.05.
      Region (North compared to Northeast)0.74 (0.617–0.89)<0.010.73 (0.61–0.88)0.001
      p-value < 0.05.
      Religion (not having religion)1.24 (1.06–1.46)<0.011.29 (1.10–1.52)<0.01
      COVID diagnosis (yes)1.18 (1.06–1.33)<0.011.23 (1.09–1.38)<0.01
      Training on COVID-19 (no)1.19 (1.06–1.34)<0.011.19 (1.06–1.34)<0.01
      Crude OR = Crude odds ratio; OR adjusted = Odds ratio adjusted.
      low asterisk p-value < 0.05.
      When we consider only the nursing professionals, the chances of increased tobacco use were 40.0 % lower among female professionals (OR = 0.60; CI = 0.49–0.73; p < 0.01). Being a professional from the Midwest, Southeast and South increased the chances of using tobacco by 1.57, 1.71 and 1.64, respectively, compared to being from the Northeast region.
      Nursing professionals who reported no religious preference had increased chances of using tobacco by almost double compared to those who declared a religion (OR = 1.64; CI = 1.19–2.27; p < 0.01). Furthermore, professionals who reported marital status married had decreased chance of using tobacco (OR = 0.75; CI = 0.64–0.89; p < 0.01). Professionals who reported ethnicity black had increased chance of using tobacco (OR = 1.34; CI = 1.02–1.76; p = 0.03). On the other hand, higher education and postgraduate studies' professionals had decreased chances of using hypnotics/sedatives, by 21 % and 32 %, respectively, compared to those who only finished high school.
      Professionals that have qualification reduced the chances of using tobacco by 19 % compared to those who worked in a field hospital (OR = 0.81; CI = 0.68–0.96; p < 0.01). Reporting no family isolation decreased the chances of using tobacco by 19 % compared to those who had been isolated from their families (OR = 0.81; CI = 0.67–0.97; p < 0.01).
      Regarding the analysis of increased use of alcoholic beverages during the COVID-19 pandemic, nursing professionals from the Midwest and Southeast regions had increased chances of increased consumption of alcoholic beverages by 1.32 and 1.42, respectively, compared to professionals from the Northeast region. Nursing professionals who did not have a religious preference had increased chances of consuming alcoholic beverages by 1.56 compared to those who had a religion (OR = 1.56; CI = 1.35–1.79; p < 0.01). Nursing professionals who reported marital status married had decreased chances of consuming alcoholic beverages by 24 % compared to those who reported marital status single (OR = 0.76; CI = 0.69–0.83; p < 0.01).
      Nursing professionals who reported education college and graduate had increased chances of consuming alcoholic beverages by 1.21 and 1.26, respectively, compared to those who reported high school. Furthermore, nursing professionals who reported provides care to patients with COVID 19 had decreased chances of consuming alcoholic beverages by 12 % compared to those who reported provides care to patients with both types of patients.
      Family isolation contained significant findings for these professionals. Nursing Professionals who were not isolated from family members are 31 % less likely to increase their consumption of alcoholic beverages than those who were isolated from family members (OR = 0.69; CI = 0.63–0.77; p < 0.01).
      For the analysis of hypnotics/sedatives, being female increased the chances of increased consumption by 1.36 compared to males (OR = 1.36; CI = 1.12–1.65; p < 0.01).
      Professionals without a religious preference had increased chances of using hypnotics/sedatives by 1.23 compared to those who had one (OR = 1.23; CI = 1.02–1.50; p = 0.03).
      Nursing professionals who reported marital status married had decreased chances of consuming alcoholic beverages by 15 % compared to those who reported marital status single (OR = 0.85; CI = 0.74–0.97; p < 0.01).
      Nursing professionals with qualification had decreased chances of consuming alcoholic beverages by 21 % compared to those without qualification (OR = 0.79; CI = 0.69–0.90; p < 0.01).
      Family isolation contained significant findings for these professionals. Nursing Professionals who were not isolated from family members are 39 % less likely to increase their consumption of alcoholic beverages than those who were isolated from family members (OR = 0.61; CI = 0.52–0.70; p < 0.01) (see Table 3).
      Table 3Odds ratios by logistic regression for substance use – nursing professionals. Brazil, 2020.
      Tobacco products
      VariableCrudeAdjusted
      OR (CI95%)p-ValueOR (CI95%)p-Value
      Sex (female)0.55 (0.46, 0.67)<0.010.60 (0.49–0.73)<0.01
      Region (Midwest compared to Northeast)1.45 (1.14, 1.86)<0.011.57 (1.22–2.02)<0.01
      Region (Southeast compared to Northeast)1.70 (1.37, 2.11)<0.011.71 (1.36–2.15)<0.01
      Region (South compared to Northeast)1.48 (1.09, 2.01)0.011.64 (1.19–2.27)<0.01
      Religion (declared no preference)2.11 (1.72, 2.58)<0.011.89 (1.53–2.33)<0.01
      Marital status (Married compared to single)0.71 (0.60, 0.83)<0.010.75 (0.64–0.89)<0.01
      Ethnicity (Black compared to White)1.41 (1.09, 1.83)0.011.34 (1.02–1.76)0.03
      Education (college compared to high school)0.76 (0.61, 0.94)0.010.791 (0.64–0.98)0.03
      Education (postgraduate compared to high school)0.60 (0.49, 0.72)<0.010.68 (0.56–0.83)<0.01
      Provided assistance in a field hospital (no compared to yes)0.73 (0.62, 0.86)<0.010.73 (0.62–0.87)0.002
      p-value < 0.05.
      Qualification (yes compared to no)0.82 (0.70, 0.98)0.030.81 (0.68–0.96)<0.01
      Family isolation (no compared to yes)0.82 (0.69, 0.98)0.030.81 (0.67–0.97)<0.01
      p-value < 0.05.
      Alcoholic beverages
      VariableCrudeAdjusted
      OR (CI95%)p-ValueOR (CI95%)p-Value
      Sex (female compared to male)0.81 (0.72, 0.92)<0.010.86 (0.76–0.98)0.02
      Region (Midwest compared to Northeast)1.28 (1.11, 1.46)<0.011.32 (1.15–1.52)<0.01
      Region (Southeast compared to Northeast)1.33 (1.18, 1.51)<0.011.42 (1.26–1.61)<0.01
      Religion (declared no preference)1.65 (1.44, 1.90)<0.011.56 (1.35–1.79)<0.01
      Marital status (Married compared to single)0.74 (0.67, 0.81)<0.010.76 (0.69–0.83)<0.01
      Education (college compared to high school)1.22 (1.07, 1.40)<0.011.21 (1.05–1.39)<0.01
      Education (graduate compared to high school)1.25 (1.11, 1.41)<0.011.26 (1.12–1.43)<0.01
      Provides care to patients with and without a diagnosis of COVID-19 (patients diagnosed with COVID-19 both, compared to both)0.71 (0.63, 0.79)0.020.88 (0.79–0.98)0.02
      Family isolation (no compared to yes)0.67 (0.61, 0.75)<0.010.69 (0.63–0.77)<0.01
      Hypnotics/sedatives
      VariableCrudeAdjusted
      OR (CI95%)p-ValueOR (CI95%)p-Value
      Sex (female)1.32 (1.09, 1.60)<0.011.36 (1.12–1.65)<0.01
      Religion (not having religion)1.22 (1.01, 1.48)0.041.23 (1.02–1.50)0.03
      Marital status (Married compared to single)0.83 (0.73, 0.95)<0.010.85 (0.74–0.97)0.01
      Qualification (yes compared to no)0.79 (0.69, 0.91)<0.010.79 (0.69–0.90)<0.01
      Family isolation (no compared to yes)0.61 (0.52, 0.70)<0.010.61 (0.52–0.70)<0.01
      Crude OR = Crude odds ratio; OR adjusted = Odds ratio adjusted.
      low asterisk p-value < 0.05.
      Furthermore, the results show that there is evidence of an association between the region where the professional works and the consumption of tobacco and alcohol (See Table 4). The results show, for the nursing professionals that consumes tobacco, that 22.8 % of professionals are from the Northeast region, 14 % are from the North region, 19.1 % are from the Midwest region, 34.5 % are from the Southeast region and 9, 7 % are from the southern region. Also, for the nursing professionals that consumes alcohol, 27.7 % of professionals are from the Northeast region, 13 % are from the North region, 19.5 % are from the Midwest region, 31.4 % are from the Southeast region and 8, 5 % are from the southern region.
      Table 4Analysis of region associated with increased substance use among nursing professionals who worked during the pandemic (N = 8990). Brazil, 2020.
      VariablesTobacco productsAlcoholic beveragesHypnotics/sedatives
      YesNop*YesNop*YesNop*
      n (%)n (%)n (%)n (%)n (%)n (%)
      Region<0.01<0.010.075
       Northeast148(22,8)2565(30,8)681(27,7)2032(31,1)326(31,2)2387(30,0)
       North91(14,0)1282(15,4)319(13,0)1054(16,1)132(12,6)1241(15,6)
       Midwest124(19,1)1478(17,7)480(19,5)1122(17,2)191(18,3)1411(17,8)
       Southeast224(34,5)2279(27,3)773(31,4)1730(26,5)312(29,8)2191(27,6)
       South63(9,7)736(8,8)209(8,5)590(9,0)85(8,1)714(9,0)

      Discussion

      During the pandemic, health professionals were overworked, fatigued and faced stressful situations, fears and stigmas (
      • Klimkiewicz A.
      • Schmalenberg A.
      • Klimkiewicz J.
      • Jasińska A.
      • Jasionowska J.
      • Machura W.
      • Wojnar M.
      COVID-19 pandemic influence on healthcare professionals.
      Journal of Clinical Medicine. 2021; 10: 1280https://doi.org/10.3390/jcm10061280
      ), which significantly contributed to their well-being and habits and lifestyles that can compromise mental health. Those changes include alcohol, tobacco and other substance use patterns. In this sense, the present study estimated the prevalence of, and factors associated with increased use of psychoactive substances (tobacco and derivatives, alcoholic beverages, and hypnotics or sedatives) among health professionals during the COVID-19 pandemic across all five macro-regions of Brazil.
      The increased use of tobacco products during the pandemic was reported by 17.8 % of health professionals, comparable to the increase in daily cigarette consumption observed during the lockdown among doctors in Italy (
      • Sio S.
      • Buomprisco G.
      • Torre G.L.
      • Lapteva E.
      • Perri R.
      • Greco E.
      • Mucci N.
      • Cedrone F.
      The impact of COVID-19 on doctors' well-being: Results of a web survey during the lockdown in Italy.
      European Review for Medical and Pharmacological Sciences. 2020; 24: 7869-7879https://doi.org/10.26355/eurrev_202007_22292
      ) and also across health professionals in Turkey (
      • Firat M.
      • Gökmen B.D.
      • Karakurt P.
      An investigation of smoking habits and mental well-being in healthcare personnel during COVID-19.
      Perspectives in Psychiatric Care. 2021; 1–6https://doi.org/10.1111/ppc.12819
      ), whose proportions were 43.61 % and 22.4 %, respectively. Furthermore, in a study by
      • Papa S.
      • Barnett J.
      • Berges I.
      • Sakkas N.
      Tired, worried and burned out, but still resilient: A cross-sectional study of mental health workers in the UK during the covid-19 pandemic.
      International Journal of Environmental Research and Public Health. 2021; 18https://doi.org/10.3390/ijerph18094457
      , health professionals reported starting smoking more tobacco during the pandemic, suggesting that health professionals confronted various stressors during the pandemic that can activate behavioural responses such as relapsing, in the case of ex-smokers (
      • Patwardhan P.
      COVID-19: Risk of increase in smoking rates among England's 6 million smokers and relapse among England's 11 million ex-smokers.
      BJGP Open. 2020; 4https://doi.org/10.3399/BJGPOPEN20X101067
      ), starting smoking or increasing daily cigarette consumption (
      • Bao Y.
      • Sun Y.
      • Meng S.
      • Shi J.
      • Lu L.
      2019-nCoV epidemic: Address mental health care to empower society.
      The Lancet. 2020; 395: e37-e38https://doi.org/10.1016/S0140-6736(20)30309-3
      ;
      • Phua D.H.
      • Tang H.K.
      • Tham K.Y.
      Coping responses of emergency physicians and nurses to the 2003 severe acute respiratory syndrome outbreak.
      Academic Emergency Medicine. 2005; 12: 322-328https://doi.org/10.1197/j.aem.2004.11.015
      ).
      Therefore, stressful and worrying factors such as fear of becoming infected, fear of taking the disease home, work overload and frustration, among others, predispose individuals to the use of cigarettes and their derivatives (
      • Stubbs B.
      • Veronese N.
      • Vancampfort D.
      • Prina A.M.
      • Lin P.Y.
      • Tseng P.T.
      • Evangelou E.
      • Solmi M.
      • Kohler C.
      • Carvalho A.F.
      • Koyanagi A.
      Perceived stress and smoking across 41 countries: A global perspective across Europe, Africa, Asia and the Americas.
      Scientific Reports. 2017; 7https://doi.org/10.1038/s41598-017-07579-w
      ). However, attitudes beneficial to health can also be adopted during crises. For example, in England, smokers had a higher rate of attempts to quit smoking or reduce alcohol consumption during the lockdown (
      • Jackson S.E.
      • Garnett C.
      • Shahab L.
      • Oldham M.
      • Brown J.
      Association of the COVID-19 lockdown with smoking, drinking and attempts to quit in England: An analysis of 2019–20 data.
      Addiction. 2021; 116: 1233-1244https://doi.org/10.1111/add.15295
      ). These changes can be explained as the pandemic served as a ‘moment for reflection’ on health and healthy habits, leading some people to change health-related behaviours, although the opposite can also occur significantly.
      Female gender was a protective factor for increased tobacco and derivative use in this study, unlike that observed in a Canadian study in which no difference was observed between the sexes concerning changes in the pattern of tobacco consumption among workers in general during the COVID-19 pandemic (
      • Zajacova A.
      • Jehn A.
      • Stackhouse M.
      • Denice P.
      • Ramos H.
      Changes in health behaviours during early COVID-19 and socio-demographic disparities: A cross-sectional analysis.
      Canadian Journal of Public Health. 2020; 111: 953-962https://doi.org/10.17269/s41997-020-00434-y
      ). This result corroborates data in the literature, which shows that women smoke less often or practice less harmful behaviours for health than men.
      Regarding excessive alcohol consumption, a cohort study by
      • Fat L.N.
      • Bell S.
      • Britton A.
      A life-time of hazardous drinking and harm to health among older adults: Findings from the Whitehall II prospective cohort study.
      Addiction. 2020; 115: 1855-1866https://doi.org/10.1111/add.15013
      indicated that men have much greater cultural patterns of alcohol consumption than women. However, if this same trend is considered for the use of other drugs, since the literature shows that women practice less harmful behaviours related to health than men (
      • Tan J.
      • Yoshida Y.
      • Ma K.S.K.
      • Mauvais-Jarvis F.
      Gender differences in health protective behaviors during the COVID-19 pandemic in Taiwan: An empirical study.
      MedRxiv, 2021https://doi.org/10.1101/2021.04.14.21255448
      ), in this study, the female sex had a higher risk of reporting increased use of hypnotics and sedatives compared to males. In addition, a study performed in Sweden revealed that women were more likely than men to use benzodiazepines (adjusted OR = 1.11; 95 % CI 1.07–1.14) and benzodiazepine-related drugs (adjusted OR = 1.14; 95 % CI 1.12–1.17) (
      • Johnell K.
      • Fastbom J.
      Gender and use of hypnotics or sedatives in old age: A nationwide register-based study.
      International Journal of Clinical Pharmacy. 2011; 33: 788-793https://doi.org/10.1007/s11096-011-9536-8
      ).
      Increasing cigarette consumption was negatively associated with higher educational levels (higher education and postgraduate studies). In addition, the literature has shown that the impact of the COVID-19 pandemic on mental health is related to education, with a significant adverse effect (
      • Bekele F.
      • Mechessa D.F.
      • Sefera B.
      Prevalence and associated factors of the psychological impact of COVID-19 among communities, health care workers and patients in Ethiopia: A systematic review.
      Annals of Medicine and Surgery. 2021; 66102403https://doi.org/10.1016/j.amsu.2021.102403
      ).
      Several studies have documented the influences of religion on the adoption of lifestyle habits and consequently, the consequences on physical and mental health (
      • Kang M.
      • Park L.Y.
      • Kang S.Y.
      • Lim J.
      • Kim Y.S.
      Religion and health behaviors in primary care patients.
      Korean Journal of Family Medicine. 2020; 41: 105-110https://doi.org/10.4082/KJFM.18.0107
      ;
      • Umucu E.
      • Lee B.
      Examining the impact of COVID-19 on stress and coping strategies in individuals with disabilities and chronic conditions.
      Rehabilitation Psychology. 2020; 65: 193-198https://doi.org/10.1037/rep0000328
      ;
      • Zacher H.
      • Rudolph C.W.
      Individual differences and changes in subjective well-being during the early stages of the COVID-19 pandemic.
      American Psychologist. 2021; 76: 50-62https://doi.org/10.1037/amp0000702
      ). In the present study, not having a religion was associated with a higher risk of reporting increased consumption for all substances analysed.
      The role of regional predictors in the risk of increased consumption of the analysed substances is unclear. However, the initial phase of the COVID-19 pandemic affected Brazilian regions differently, possibly influencing the behaviour of health professionals involved in care during the pandemic. Compared to the Northeast region, professionals from the North, Midwest, Southeast and South regions showed higher risks of increased tobacco consumption, while a higher risk of consumption of alcoholic beverages was found in the Midwest and Southeast regions. In contrast, the risk of increased consumption of hypnotics/sedatives was significantly lower only in the North region. Given the regional variations in the risks of increased substance use presented here, one cannot simply expect that the larger the region, the greater the risk of increased substance use (
      • Dixon M.A.
      • Chartier K.G.
      Alcohol use patterns among urban and rural residents.
      Alcohol Research. 2016; 38: 69-77
      ). Instead, these increases depend on the spread of the pandemic in each state in each region, the levels of other stressors present in other cities in the region and restrictions on the sale of alcoholic beverages in each city in the region, as established by law.
      Increased use of alcoholic beverages during the pandemic was reported by 69 % of health professionals in the present sample. In addition, research with doctors in Italy (
      • Sio S.
      • Buomprisco G.
      • Torre G.L.
      • Lapteva E.
      • Perri R.
      • Greco E.
      • Mucci N.
      • Cedrone F.
      The impact of COVID-19 on doctors' well-being: Results of a web survey during the lockdown in Italy.
      European Review for Medical and Pharmacological Sciences. 2020; 24: 7869-7879https://doi.org/10.26355/eurrev_202007_22292
      ), with health workers in London (
      • Papa S.
      • Barnett J.
      • Berges I.
      • Sakkas N.
      Tired, worried and burned out, but still resilient: A cross-sectional study of mental health workers in the UK during the covid-19 pandemic.
      International Journal of Environmental Research and Public Health. 2021; 18https://doi.org/10.3390/ijerph18094457
      ), with workers in Finland (
      • Oksanen A.
      • Savolainen I.
      • Savela N.
      • Oksa R.
      Psychological stressors predicting increased drinking during the COVID-19 crisis: A longitudinal national survey study of workers in Finland.
      Alcohol and Alcoholism. 2021; 56: 299-306https://doi.org/10.1093/alcalc/agaa124
      ), with university students (
      • Moura A.A.M.
      • Bassoli I.R.
      • Silveira B.V.
      • Diehl A.
      • Santos M.A.
      • Santos R.A.
      • Wagstaff C.
      • Pillon S.C.
      Is social isolation during the COVID-19 pandemic a risk factor for depression?.
      Revista Brasileira de Enfermagem. 2022; 75e20210594https://doi.org/10.1590/0034-7167-2021-0594
      ) and population-based research in Germany (
      • Koopmann A.
      • Georgiadou E.
      • Kiefer F.
      • Hillemacher T.
      Did the general population in Germany drink more alcohol during the COVID-19 pandemic lockdown?.
      Alcohol and Alcoholism (Oxford, Oxfordshire). 2020; 55: 698-699https://doi.org/10.1093/alcalc/agaa058
      ) and Poland (
      • Szajnoga D.
      • Klimek-Tulwin M.
      • Piekut A.
      COVID-19 lockdown leads to changes in alcohol consumption patterns. Results from the Polish national survey.
      Journal of Addictive Diseases. 2021; 39: 215-225https://doi.org/10.1080/10550887.2020.1848247
      ), reported increased consumption of alcoholic beverages during the COVID-19 pandemic, showing that the trend of increasing consumption of alcoholic beverages occurs in the population as a whole. However, it is expected that public policies for control and regulation would reduce consumption as they reduce the areas where alcohol can be consumed, such as bars, restaurants, parties and celebrations.
      On the other hand, social isolation per se can induce an increase in home consumption due to the low cost and easy access to supermarkets and convenience stores, places considered below the regulation of sales (
      • Garcia L.P.
      • Sanchez Z.M.
      Consumo de álcool durante a pandemia da COVID-19: Uma reflexão necessária Para o enfrentamento da situação.
      Cadernos de Saúde Pública. 2020; 36https://doi.org/10.1590/0102-311x00124520
      ;
      • Reynolds J.
      • Wilkinson C.
      Accessibility of ‘essential’ alcohol in the time of COVID-19: Casting light on the blind spots of licensing?.
      Drug and Alcohol Review. 2020; 39: 305-308https://doi.org/10.1111/dar.13076
      ) and which, sometimes primarily sell alcohol, and this is similar to people in remote work as found in a national survey in Poland (
      • Szajnoga D.
      • Klimek-Tulwin M.
      • Piekut A.
      COVID-19 lockdown leads to changes in alcohol consumption patterns. Results from the Polish national survey.
      Journal of Addictive Diseases. 2021; 39: 215-225https://doi.org/10.1080/10550887.2020.1848247
      ) and Brazil (
      • Garcia L.P.
      • Sanchez Z.M.
      Consumo de álcool durante a pandemia da COVID-19: Uma reflexão necessária Para o enfrentamento da situação.
      Cadernos de Saúde Pública. 2020; 36https://doi.org/10.1590/0102-311x00124520
      ).
      In the present study, the increased consumption of alcoholic beverages was associated with higher educational levels (higher education and postgraduate studies), as observed in a study in Canada that involved workers in general during the COVID-19 pandemic (
      • Zajacova A.
      • Jehn A.
      • Stackhouse M.
      • Denice P.
      • Ramos H.
      Changes in health behaviours during early COVID-19 and socio-demographic disparities: A cross-sectional analysis.
      Canadian Journal of Public Health. 2020; 111: 953-962https://doi.org/10.17269/s41997-020-00434-y
      ).
      Occupation and educational status are still factors that place women at a socioeconomic disadvantage and exacerbate the vulnerable situations of those abusing or dependent on psychoactive substances. Moreover, other factors related to social and economic issues can also explain the greater use of substances among more educated women, as observed in recent decades (
      • Moura A.A.M.
      • Bassoli I.R.
      • Silveira B.V.
      • Diehl A.
      • Santos M.A.
      • Santos R.A.
      • Wagstaff C.
      • Pillon S.C.
      Is social isolation during the COVID-19 pandemic a risk factor for depression?.
      Revista Brasileira de Enfermagem. 2022; 75e20210594https://doi.org/10.1590/0034-7167-2021-0594
      ;
      • Santos J.A.T.
      • Perruci L.G.
      • Pegoraro N.P.J.
      • Scherer Z.A.P.
      • Souza J.
      • Pillon S.C.
      Use of psychoactive substances in women in outpatient treatment.
      Rev. Bras. Enferm. 2019; 72: 178-183https://doi.org/10.1590/0034-7167-2018-0399
      ).
      These factors include female empowerment, dual family and work responsibilities, financial independence, family and professional pressures, and long working hours. Indeed, purchasing power and the consumer environment shape substance use and dependence patterns, while higher incomes facilitate access to a greater variety of substances, with women also having access to prescribed medicines (
      • Santos J.A.T.
      • Perruci L.G.
      • Pegoraro N.P.J.
      • Scherer Z.A.P.
      • Souza J.
      • Pillon S.C.
      Use of psychoactive substances in women in outpatient treatment.
      Rev. Bras. Enferm. 2019; 72: 178-183https://doi.org/10.1590/0034-7167-2018-0399
      ).
      A Brazilian study indicated that educational level was associated with the consumption of alcoholic beverages. Adults with a higher educational level showed a prevalence of alcohol use 30.5 % higher than adults with lower levels of education (
      Instituto Brasileiro de Geografia e Estatística (IBGE)
      Pesquisa Nacional de Saúde: 2013: acesso e utilização dos serviços de saúde, acidentes e violências. (cited January 17, 2022). Brasil, grandes regiões e unidades da federação/IBGE, Coordenação de Trabalho e Rendimento.
      https://biblioteca.ibge.gov.br/visualizacao/livros/liv94074.pdf
      Date: 2013
      ).
      Furthermore, regarding the use of psychoactive substances, behavioural responses such as increased use of these substances were reported in different post-crisis periods, such as the attacks of 11 September 2001, the SARS-COV-1 outbreak in 2003 and disasters such as Hurricane Katrina in 2005 (
      • Beaudoin C.E.
      Hurricane Katrina: Addictive behavior trends and predictors.
      Public Health Reports. 2011; 126: 400-409https://doi.org/10.1177/003335491112600314
      ;
      • Jordan H.T.
      • Osahan S.
      • Li J.
      • Stein C.R.
      • Friedman S.M.
      • Brackbill R.M.
      • Cone J.E.
      • Gwynn C.
      • Mok H.K.
      • Farfel M.R.
      Persistent mental and physical health impact of exposure to the september 11, 2001 world trade center terrorist attacks.
      Environmental Health. 2019; 18https://doi.org/10.1186/s12940-019-0449-7
      ;
      • Lau J.T.F.
      • Yang X.
      • Pang E.
      • Tsui H.Y.
      • Wong E.
      • Wing Y.K.
      SARS-related perceptions in Hong Kong.
      Emerging Infectious Diseases. 2005; 11: 417-424https://doi.org/10.3201/eid1103.040675
      ;
      • Makwana N.
      Disaster and its impact on mental health: A narrative review.
      Journal of Family Medicine and Primary Care. 2019; 8: 3090-3095https://doi.org/10.4103/jfmpc.jfmpc
      ;
      • Wu P.
      • Liu X.
      • Fang Y.
      • Fan B.
      • Fuller C.J.
      • Guan Z.
      • Yao Z.
      • Kong J.
      • Lu J.
      • Litvak I.J.
      Alcohol abuse/dependence symptoms among hospital employees exposed to a SARS outbreak.
      Alcohol and Alcoholism. 2008; 43: 706-712https://doi.org/10.1093/alcalc/agn073
      ). These behaviours can help people cope with a multifaceted crisis that generates stressors that activate the behavioural immune system (
      • Schaller M.
      • Park J.H.
      The behavioral immune system (and why it matters).
      Current Directions in Psychological Science. 2011; 20: 99-103https://doi.org/10.1177/0963721411402596
      ). However, this confrontation may reflect psychological problems triggered during the pandemic, such as anxiety disorders, depression, stress and frustration, among others (
      • Singh J.
      • Sood M.
      • Chadda R.K.
      • Singh V.
      • Kattula D.
      Mental health issues and coping among health care workers during COVID19 pandemic: Indian perspective.
      Asian Journal of Psychiatry. 2021; 61
      ). Therefore, this increased use should be seen as a potential risk factor for health and well-being, especially for professionals who fit into the high-risk categories of the variables identified in this study.
      People face the challenges and problems of everyday life in different ways, and with the restrictions and quarantine measures since the beginning of the pandemic, some people were forced to change their daily lives and quickly adapt to new social and circulation rules, which can be a source of psychological stress. Thus, the stress experienced contributes positively to the use or increased use of psychoactive substances (
      • Koob G.
      • Kreek M.J.
      Stress, dysregulation of drug reward pathways, and the transition to drug dependence.
      American Journal of Psychiatry. 2007; 164: 1149-1159https://doi.org/10.1176/appi.ajp.2007.05030503.Stress
      ). In these situations, using substances can be self-medication, an alternative for relieving stress or psychological distress, being used to distance themselves from the problems they have experienced (
      • Rehm J.
      • Kilian C.
      • Ferreira-Borges C.
      • Jernigan D.
      • Monteiro M.
      • Parry C.D.H.
      • Sanchez Z.M.
      • Manthey J.
      Alcohol use in times of the COVID 19: Implications for monitoring and policy.
      Drug and Alcohol Review. 2020; 39: 301-304https://doi.org/10.1111/dar.13074
      ;
      • Rodriguez L.M.
      • Litt D.M.
      • Stewart S.H.
      Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and mandarin on the novel coronavirus COVID- 19. The COVID-19 resource centre is hosted on Elsevier connect, the company's public news and information.
      Addictive Behaviors. 2020; 110
      ).
      Evidence of the influence of the COVID-19 pandemic on the use of psychoactive substances, both among health professionals and in the general population, remains limited. However, excessive alcohol consumption is a significant risk factor for mental illness, with an association between increased alcohol consumption for the relief of anxiety with depression, stress and low life satisfaction (
      • Boschloo L.
      • Vogelzangs N.
      • Van Den Brink W.
      • Smit J.H.
      • Veltman D.J.
      • Beekman A.T.F.
      • Penninx B.W.J.H.
      Alcohol use disorders and the course of depressive and anxiety disorders.
      British Journal of Psychiatry. 2012; 200: 476-484https://doi.org/10.1192/bjp.bp.111.097550
      ;
      • Keyes K.M.
      • Allel K.
      • Staudinger U.M.
      • Ornstein K.A.
      • Calvo E.
      Alcohol consumption predicts incidence of depressive episodes across 10 years among older adults in 19 countries.
      International Review of Neurobiology. 2019; 148: 1-38https://doi.org/10.1016/bs.irn.2019.09.001.Alcohol
      ;
      • McHugh R.K.
      • Weiss R.D.
      Alcohol use disorder and depressive disorders.
      Alcohol Research: Current Reviews. 2019; 40: e1-e8https://doi.org/10.35946/arcr.v40.1.01
      ;
      • Sæther S.M.M.
      • Knapstad M.
      • Askeland K.G.
      • Skogen J.C.
      Alcohol consumption, life satisfaction and mental health among Norwegian college and university students.
      Addictive Behaviors Reports. 2019; 10100216https://doi.org/10.1016/j.abrep.2019.100216
      ). For example, in the Chinese province of Hubei, during the pandemic,
      • Ahmed M.Z.
      • Ahmed O.
      • Aibao Z.
      • Hanbin S.
      • Siyu L.
      • Ahmad A.
      Epidemic of COVID-19 in China and associated psychological problems.
      Asian Journal of Psychiatry. 2020; 51102092https://doi.org/10.1016/j.ajp.2020.102092
      identified an increase in harmful alcohol consumption associated with high rates of stress, depression and low levels of mental well-being.
      Excessive use of tobacco and alcohol can directly increase the risk of COVID-19 due to adverse immunological mechanisms (
      • Enos G.
      Effects on lung, immune function offer warning for drinking in crisis.
      Alcoholism & Drug Abuse Weekly. 2020; 32: 6-7https://doi.org/10.1002/adaw.32693
      ), as well as the indirect risk due to the reduction of surveillance (
      • Koelega H.S.
      Alcohol and vigilance performance: A review.
      Psychopharmacology. 1995; 118: 233-249https://doi.org/10.1007/BF02245951
      ) – compliance with precautionary and protective measures, hand hygiene, physical distance, or respiratory etiquette. In addition, consequences from excessive use of these substances can persist in the long term, even after the triggering, stressful event has passed.
      Not having experienced ‘family isolation’ was a protective factor for reporting increased alcohol consumption. For some workers, even in non-crisis moments, the family is a powerful psychological support system, especially in a crisis such as that experienced by health professionals during the pandemic. Thus, professionals who were not isolated from their families during the pandemic, even if they had developed coping mechanisms for the crisis, resorted less to increased consumption of alcoholic beverages as an ‘escape’. However, elements of each person's personality strongly contributed to their behaviour during the pandemic (
      • Zajenkowski M.
      • Jonason P.K.
      • Leniarska M.
      • Kozakiewicz Z.
      Who complies with the restrictions to reduce the spread of COVID-19?: Personality and perceptions of the COVID-19 situation.
      Personality and Individual Differences. 2020; 166110199https://doi.org/10.1016/j.paid.2020.110199
      ), so the increase in the consumption of psychoactive substances cannot be attributed to the pandemic crisis in a deterministic way.
      The World Health Organization has released a book with five sections (Grounding, Unhooking, Acting on your values, Being kind and Making room) each containing a new idea and technique to cope with stress. These strategies can be useful in times of great stress such as those experienced during the COVID-19 pandemic (
      World Health Organization (WHO)
      Doing What Matters in Times of Stress.
      https://iris.paho.org/handle/10665.2/54659
      Date: 2021
      ).

      Conclusions

      The findings of this study indicate the need to identify groups that are more vulnerable to these behavioural changes and consequently, to the harmful effects of the increased use of psychoactive substances during the COVID-19 pandemic. It also identifies an urgency to begin interventions that minimise, in the short and long term, the direct adverse effects of substance use and indirect effects of the pandemic on the mental health of health professionals.
      Furthermore, stress caused by the COVID-19 pandemic can be both a trigger for and a consequence of the use of psychoactive substances. Therefore, it is urgent to develop strategies that promote the interests of public health in the context of non-pharmacological measures to prevent COVID-19, given the association between social isolation and the increased use of psychoactive substances observed in this study.

      Limitations

      The cross-sectional methodological design of the present research that does not allow cause–effect relationships to be established is a limitation, along with the use of a self-report survey to measure the increase in the use of alcohol beverages, tobacco and derivatives, and hypnotics or sedatives. Another limitation refers to the recruitment of participants because, as the research was developed online, there may have been an overrepresentation of professionals who are skilled in the use of computers and social networks.

      Funding

      The Brazilian Development Agency, National Council for Scientific and Technological Development/Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

      Declarations of interest

      None.

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      Article info

      Publication history

      Published online: September 10, 2022
      Accepted: September 4, 2022
      Received in revised form: September 4, 2022
      Received: September 21, 2021

      Identification

      DOI: https://doi.org/10.1016/j.apnu.2022.09.004

      Copyright

      © 2022 Published by Elsevier Inc.

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