Hardening is dead, long live softening; time to focus on reducing disparities in smoking

Abstract

The hardening hypothesis proposes that as smoking prevalence declines, the proportion of ‘hard-core’ or ‘hardened’ smokers increases. The intuitively plausible logic is that less addicted and more motivated smokers are more likely to quit, leaving behind a growing proportion of ‘hardened’ smokers. If true, the hypothesis has implications for policy formulation and smoking cessation practice. For example, smokefree policies, health promotion campaigns and smoking cessation support services may need to be modified to ensure they reach and support quitting among the growing proportion of hardened smokers. Also, hardening would strengthen the justification for harm reduction strategies due to the need to provide less harmful alternatives to the increasing proportion of ‘hardened’ smokers who struggle to quit.\n\nThere are many ways in which hardening could manifest, creating multiple hypotheses which can be tested. For example, the population of smokers could become: (1) more highly addicted (eg, an increase in heavier or more dependent smokers); (2) less motivated to quit (eg, more smokers with no or low intention to quit, not making quit attempts or with lower self-efficacy about quitting); and (3) increasingly disadvantaged and marginalised (eg, more smokers who are disadvantaged or have mental health conditions). The net effect should be a reduced rate of quitting among the smoking population over time.\n\nSo what is the evidence for hardening? Most studies that have looked at the different aspects of hardening, either singly or in combination, are repeated surveys from the same population. Investigations from a variety of countries have generally found little or no …