Hardening or softening? An observational study of changes to the prevalence of hardening indicators in Victoria, Australia, 2001-2016.

BACKGROUND: The hardening hypothesis predicts that as smoking prevalence declines, remaining smokers will be more heavily addicted to nicotine and/or less interested in quitting. We tested this hypothesis in a population exposed to a comprehensive tobacco control programme over a 16-year period. METHODS: Annual cross-sectional surveys randomly sampled adults (aged 26+) in the state of Victoria, Australia, between 2001 and 2016. Until 2010, participants were recruited through random digit dialling to landline telephones; from 2011, sampling frames also included mobile phones. Logistic regressions assessed changes over time in the prevalence of smoking and each hardening indicator; additional models examined interactions by sex, age, education and socioeconomic status. RESULTS: Smoking prevalence declined significantly between 2001 and 2016 (20.1%-13.0%), as did the prevalence of seven hardening indicators: daily smoking, heavy consumption, no quit attempt in the past 5 years or past 12 months, no intention to quit in the next 6 months or next 30 days, and happiness to keep smoking. In addition, the proportion of smokers defined as 'hardcore' decreased from 17.2% to 9.1%. On the whole, hardening indicators decreased to a similar extent among demographic subgroups. CONCLUSIONS: These results are inconsistent with the hardening hypothesis. Rather, they suggest that a comprehensive tobacco control programme that combines provision of cessation support to individual smokers with implementation of population-level interventions to drive all smokers towards quitting, can successfully reduce both smoking prevalence and levels of dependence and desire to keep smoking among the remaining population of smokers.

Prevalence of hardcore smoking in the Netherlands between 2001 and 2012: a test of the hardening hypothesis.

BACKGROUND: Hardcore smokers are smokers who have smoked for many years and who do not intend to quit smoking. The "hardening hypothesis" states that light smokers are more likely to quit smoking than heavy smokers (such as hardcore smokers). Therefore, the prevalence of hardcore smoking among smokers would increase over time. If this is true, the smoking population would become harder to reach with tobacco control measures. In this study we tested the hardening hypothesis. METHODS: We calculated the prevalence of hardcore smoking in the Netherlands from 2001 to 2012. Smokers were 'hardcore' if they a) smoked every day, b) smoked on average 15 cigarettes per day or more, c) had not attempted to quit in the past 12 months, and d) had no intention to quit within 6 months. We used logistic regression models to test whether the prevalence changed over time. We also investigated whether trends differed between educational levels. RESULTS: Among smokers, the prevalence of hardcore smoking decreased from 40.8 % in 2001 to 32.2 % in 2012. In the general population, it decreased from 12.2 to 8.2 %. Hardcore smokers were significantly lower educated than non-hardcore smokers. Among the general population, the prevalence of hardcore smoking decreased more among higher educated people than among lower educated people. CONCLUSIONS: We found no support for the hardening hypothesis in the Netherlands between 2001 and 2012. Instead, the decrease of hardcore smoking among smokers suggests a 'softening' of the smoking population.

Smoking dependence in 18 European countries: Hard to maintain the hardening hypothesis.

OBJECTIVE: When the prevalence of smoking decreases in a population, there is a hypothesis-the so-called "hardening hypothesis"-that the remaining smokers form a subgroup of "hardcore smokers." Our aims were to test the hardening hypothesis and to analyze the determinants of high dependence taking into account both individual and country-level characteristics. METHOD: Within the Pricing Policies and Control of Tobacco in Europe (PPACTE) project, we conducted a face-to-face survey on smoking between January and July 2010 in 18 European countries, including 2882 male and 2254 female smokers with complete information on smoking dependence. The Heaviness of Smoking Index (HSI) was used as a measure of tobacco dependence. We correlated smoking prevalence and dependence using the country as unit of analysis. Moreover, we fitted multilevel logistic regression models. RESULTS: Country-specific prevalence of smoking was positively, although not significantly, correlated with the proportion of highly tobacco-dependent smokers (overall rsp=0.203, p=0.419), both in men (rsp=0.235, p=0.347) and women (rsp=0.455, p=0.058). Using individual-level analysis, high dependence was positively related to age, and, although not significantly, to smoking prevalence, and inversely related to level of education. The lack of a smoking ban at home was positively related to smoking dependence. CONCLUSIONS: Using both ecological and individual-level analyses, the relations between smoking prevalence and HSI were not significant, but in the opposite direction as compared to that assumed by the "hardening hypothesis." Therefore, our data provide empirical evidence against this theory, thus supporting the feasibility of an endgame strategy.

Trends and correlates of hardcore smoking in India: findings from the Global Adult Tobacco Surveys 1 & 2 [version 2; peer review: 1 approved].

Background: Data on prevalence of hardcore smoking (HCS) among different socioeconomic status (SES) groups in low- and middle-income countries are limited. We looked at the prevalence and pattern of HCS in India with the following objectives: 1) to analyse the association between SES and HCS, 2) to find trends in HCS in different SES groups and 3) to find state-wide variations in hardcore smoking. Methods: Data of individuals aged ≥25 years from the Global Adult Tobacco Survey (GATS) India 2009-10 (N= 9223) and 2016-17 (N= 7647) were used for this study. If an individual met all the following criteria: (1) current smoker, (2) smokes 10 or more cigarettes/day, (3) smokes first puff within 30 minutes after waking up, (4) no quit attempt in last 12 months, (5) no intention to quit at all or in the next 12 months, (6) lack of knowledge of harmful effect of smoking, s/he was identified as a hardcore smoker. Multiple regression analysis was done to find the factors associated with HCS. Results: Prevalence of HCS deceased from 2.5% in GATS 1 to 1.9% in GATS 2: males from 6.2% to 3.9% and females from 0.3% to 0.2%. Compared to the richest group the poorest, poor and those who belonged to the middle-income group were more likely to report HCS in GATS 1 and 2. However, only in the poorest SES group there was an increase in the proportion of hardcore smokers in GATS 2 compared to GATS 1. Other factors that were significantly associated with HCS in both surveys were male gender, working adults, those with lower education, early initiation of smoking and households without any rules for smoking inside the home. Conclusions: Tobacco control and cessation efforts need to focus on individuals of poor SES groups particularly in the high prevalence Indian states.

Depression with Chronic Disease Is Associated with Increased Use of Medical Services and Medical Expenses in Hardcore Smokers.

We aimed to investigate the association of chronic disease and depression with medical service use and expenses in hardcore smokers and provide basic data for health management system of hardcore smokers. This was a secondary data study involving 1735 smokers. Propensity score matching (PSM) was conducted to match hardcore smokers with regular smokers, and a two part model (TPM) was used based on the matched groups. In the case of general smokers, subjects with both depression and chronic disease had a significant relation to medical service use. In the case of hardcore smokers, subjects without depression and with chronic disease or with both depression and chronic disease had increased the use of medical services. The depression and chronic disease of general smokers did not affect the use of medical services. In the case of hardcore smokers, subjects who do not have depression and have only chronic disease (ß = 0.20, p = 0.002) or with depression and chronic disease (ß = 0.20, p = 0.014) significantly related the use of medical services. Conclusion: It is necessary to establish a health management system that considers both emotional states and chronic disease for hardcore smokers.

Factors Associated with Attempt for Smoking Cessation among Hardcore Smokers in Taiwan.

Background: Tobacco control activities have mostly influenced those smokers who found it easier to quit and, thus, remaining smokers are those who are less likely to stop smoking. This phenomenon is called "hardening hypothesis," which individuals unwilling or unable to quit smoking and likely to remain so. The aim of this study was to identify the factors correlated with smoking cessation among hardcore smokers. Methods: A cross-sectional descriptive correlational research design was employed. Hardcore smokers from communities in Taiwan were recruited to participate in the study (N = 187). Self-report questionnaires were used to collect demographic data as well as data on nicotine dependence, quitting self-efficacy, social smoking motives, attitudes towards the Tobacco Hazards Prevention Act (THPA), and smoking cessation. Logistic regression analysis was used to examine the factors that were related to quit smoking. Results: About 30.3% (n = 54) reported having experienced quitting smoking over 7 days in the past year. Logistic regression analysis indicated that attitudes towards the THPA was identified as a particularly important factor contributing to the increase in smoking cessation among hardcore smokers. Conclusions: Nurses should cooperate with smoking cessation coaches to facilitate the improvement of attitudes towards the THPA as a key means through which to increase the smoking cessation rate among hardcore smokers.

Targeting hardcore smokers: The effects of an online tailored intervention, based on motivational interviewing techniques.

OBJECTIVES: Hardcore smokers have smoked for many years and do not intend to quit. They also seem unreceptive to information about smoking cessation. We developed a 30-min, tailored web-based intervention that includes motivational interviewing principles. It aims to increase hardcore smokers' intention to quit and their receptivity to information about smoking cessation. DESIGN: In a two-arm experiment, we compared outcome scores of the experimental intervention (n = 346) with those of a control intervention (n = 411). METHODS: Our main outcomes were receptivity to information about quitting, intention to quit, quitting self-efficacy, and interest in a subsequent online intervention. Our secondary outcomes were cigarettes smoked per day and quit attempts. All outcomes were measured directly post-experiment (t1 ), after 2 weeks (t2 ), and after 2 months (t3 ). RESULTS: At t1 , hardcore smokers in the intervention condition were more receptive to information about quitting than controls. At both t2 and t3 , those in the experimental group had reduced the number of cigarettes more than those in the control group. At t2 , but not t3 , more participants in the experimental group had reduced their cigarette consumption by at least 50% than among controls. We found no significant differences in intention to quit, quitting self-efficacy, interest in a subsequent online quitting intervention, and number of quit attempts. CONCLUSIONS: The intervention increased hardcore smokers' receptivity to information about smoking cessation and decreased their cigarette consumption by about 1 cigarette per day. Although the results are positive, the clinical relevance may be limited. We recommend further developing this intervention for practical use in health care settings. Statement of contribution What is already known on this subject? Hardcore smokers have smoked for many years and do not intend to quit. There are currently no online interventions for hardcore smokers. What does this study add? This study tested an online intervention for hardcore smokers. The intervention increased hardcore smokers' receptivity to information about quitting. It also helped to reduce the number of cigarettes per day.

Hardcore smokers: what do we know?

AIMS: The existence of smokers who are resistant to smoking cessation treatment has long been noted in the literature. There has been ongoing debate as to whether the proportion of these smokers is increasing as smoking prevalence rates stagnate. Studies define hardcore smokers inconsistently and within the context of specific illnesses, addiction, population, and/or theoretical paradigms. This review examines the existing literature related to hardcore smokers to develop a better understanding of what is known and not known about this group to guide smoking cessation treatment. METHODS: PubMed MESH search and review of research publications from 1998 to 2012 (N=61). RESULTS: Inconsistent definitions of hardcore smoking make it difficult to estimate prevalence rates and to identify specific characteristics of persistent smokers. Generally, persistent smokers have higher levels of nicotine dependence, are disproportionately from lower socioeconomic groups, start smoking at an earlier age, and are more likely to have a psychological co-morbidity. DISCUSSION: Defining some smokers as hardcore is limiting. Targeted and tailored interventions for smoking cessation for persistent smoking have demonstrated effectiveness in a small number of studies. Treatment access barriers need to be addressed to improve the reach and effectiveness of cessation with persistent smokers. Efforts to limit early age initiation of tobacco use are a critical element in averting persistent smoking.