“Hard core” smokers are melting away in response to established tobacco control policies

The whole argument for promoting e-cigarettes, heated tobacco and other “potentially reduced risk” tobacco products is built on the assumption that there is a “hard-core” of smokers who “cannot or will not quit” using established smoking cessation therapies or in response to population level tobacco control interventions (e.g., clean indoor air laws, media campaigns, or tax increases). Under this assumption it necessary — indeed ethically required — to provide them with “less risky” tobacco products to service their nicotine addiction.

If this assumption is correct, as smoking prevalence comes down the remaining smokers should “harden,” which would be manifest by higher levels of addiction and fewer and less successful quit attempts among the remaining smokers. In 2022, Miranda Harris and colleagues completed a systematic review of evidence on the hardening assumption, Smokers Increasingly Motivated and Able to Quit as Smoking Prevalence Falls: Umbrella and Systematic Review of Evidence Relevant to the “Hardening Hypothesis,” Considering Transcendence of Manufactured Doubt. They found evidence from around the world shows just the opposite: as smoking prevalence comes down the remaining smokers smoke less and make more and more successful quit attempts. in other words, they “soften,” eliminating this widely used justification for promoting tobacco industry product is a form of harm reduction for smokers.

• They examined the literature through 2019 and found 3 earlier reviews and 10 repeated cross-sectional studies on measures of hardening over time as smoking prevalence came down. None of the three reviews (including one by current e-cigarette champion Ken Warner) found evidence of hardening.
• Of the 10 studies of hardening, five examined smokers motivation nine examined measures of dependence five examined hard-core smoking and to examined quit outcomes over time. The studies were from the United States, 31 countries across Europe, Australia, New Zealand, Canada, Norway and England.

Overall, they concluded, “there is no evidence [hardening] is happening in smoking populations in the countries examined, with virtually all indicators consistent with softening or showing no significant change.”

Implications

Harris and colleagues have an excellent discussion of the policy and political implications of continuing to promote the hardening assumption and how doing so promotes tobacco industry interests. It is worth quoting at length:

Alongside clear evidence-based grounds to embrace “softening” as the reality of tobacco control, there are a range of other important considerations. The concept of the hard-core smoker perpetuates stigma and neither recognizes nor addresses appropriately the complex factors related to ongoing smoking.^13,30 The continuing use of “hardening” metaphors risks reinforcing misleading and detrimental beliefs about factors that contribute to smoking cessation. Metaphors can shape the way people think about and view health hurdles, influencing their perceptions of personal control, how fatalistic they feel, and how challenging a given health goal, such as quitting smoking, seems to be.¹¹ These linguistic devices can also be used by those with vested interests, including the tobacco industry, to influence public debate and policy outcomes.³¹ The concern here is that a given claim or idea—e.g., those who haven’t quit yet likely won’t, or need help via e-cigarettes—can accumulate credibility and belief via nonprobative evidence, such as how easy it is to imagine that scenario. Indeed, claims that evoke imagery tend to feel true, and once an idea like hardening has been repeated several times, such claims—whether they are true or false—tend to feel right.³² Even with knowledge that a claim like hardening came from the tobacco industry (a source that might be untrustworthy in this context), people often forget the source of a claim or fail to use it in their assessments of truth—so even in the face of a questionable source, simple repetition and high imagery tends to increase belief.^33,34 The familiarity produced by the repetition of a claim or idea can also signal social consensus—that many others think so too,³⁵ a psychological cue that guides how we think and how we act.

Having powerful metaphors and making them widely heard has the potential to shape public perceptions of health issues, public discourse, and what feels true, regardless of the current state of empirical evidence. Voltaire is paraphrased as saying that “Those who can make you believe absurdities can make you commit atrocities” ³⁶ highlighting not only the importance of belief in governing action, but also the nature of power and influence, using misinformation. Portraying heavy addiction among smokers as an immutable property of the smoker themselves denies the active role the tobacco industry plays in creating and prolonging addiction and supports its calculated shift from perpetrator to “savior”—through investment in and promotion of products such as e-cigarettes and heated tobacco products—while continuing to profit from tobacco and nicotine products.³⁷

More importantly, these data demonstrate a clear need to actively challenge and replace the hardening discourse with an evidence-based discourse about what truly happens as smoking prevalence falls. The greater the extent to which the scientific and public discourse centers around hardening, the more people may believe the hardening hypothesis.³² Even more worrying would be in the context of policy development, in which decisions around smoking interventions could be influenced by messages that felt intuitively appealing, rather than those with a foundation of robust empirical evidence. Such mistakes have been made in the past—for example, with tobacco smoking itself and with the intuitive appeal of “light” cigarettes—with devastating consequences that health systems around the world are still trying to address.³¹

Returning to metaphors and the power of language, when one is attempting to correct an unsupported or disputed claim, setting the rhetorical frame around a myth or unsubstantiated idea such as there is “no evidence for hardening,” without an attempt to carefully debunk it and provide alternative explanations, may actually increase the familiarity and perceived truth of the to-be-corrected content. Increasing evidence in cognitive psychology supports a different communication approach that makes the empirically supported fact the center of the discussion, making the core finding—in this case, evidence of softening—more memorable.^32,38 Increasing evidence also suggests that warning people about classic disinformation tactics and refuting them in advance (e.g., the use of “Fake Experts” to sow doubt and distort perceived scientific consensus) can work to reduce vulnerability to misinformation.^39,40 This “prebunking” teaches people about the “go-to” tactics of those intending to insert doubt or persuade and has been effective in helping people to identify when those tactics appear in information they encounter.⁴¹ The studies we have reviewed here suggest that such interventions may be warranted in the future if a hardening rhetoric continues, given that the large volume of evidence indicates shifting to softening is empirically valid and will lead to more evidence-based policy, practice, and public awareness.

Comprehensive and multifaceted tobacco control measures have proved effective in reducing the prevalence of smoking in many countries. These measures include smoke-free policies, mass media campaigns, plain packaging, graphic health warnings on packaging, price increases, and prohibitions on tobacco advertising, promotion, and sponsorship.^7,42 Such measures actually act through softening: they make it more challenging for smokers to continue smoking large numbers of cigarettes by reducing opportunities to smoke, making it very expensive to do so, and reducing its social acceptability. These measures also increase smokers’ motivation to quit, including through awareness of harms. [emphasis added]

This is all the more important because in the real world e-cigarettes are neither an “off ramp from smoking” nor substantially less dangerous than cigarettes.

Here is the abstract:

Introduction: The “hardening hypothesis” proposes that as the prevalence of smoking in a population declines, there will be a “hardening” of the remaining smoker population. This review examines the evidence regarding smokers’ motivation, dependence, and quitting behavior as smoking prevalence declines, to assess whether population “hardening” (decreasing propensity to quit) or “softening” (the converse) is occurring.

Methods: MEDLINE, PsychINFO, Scopus, Web of Science, and Cochrane Library were searched to July 2019, using terms related to smoking and hardening, for reviews and large, population-based repeat cross-sectional studies. There were additional searches of reference lists and citations of key research articles. Two reviewers screened half the titles and abstracts each, and two reviewers screened full texts independently using tested criteria. Four reviewers independently and systematically extracted data from eligible publications, with one reviewer per study, checked by another reviewer.

Results: Of 265 titles identified, three reviews and ten repeat cross-sectional studies were included. Reviews concluded that hardening has not occurred among the general smoking population over time. Among repeated cross-sectional studies, five examined motivation, nine examined dependence, five examined hardcore smoking, and two examined quit outcomes. All but one study found a lack of hardening. Most found softening within the smoking population, consistent across hardening indicators, definitions, countries (and tobacco control environments), and time periods examined.

Conclusions: Tobacco control reduces smoking prevalence and fosters a smoking population more amenable to evidence-based interventions. Based on the weight of the available evidence, the “hardening hypothesis” should be rejected and the reality of softening accepted.

Implications: This umbrella review and systematic review provides a critical consideration of evidence from epidemiology and psychology and other fields regarding the “hardening hypothesis”-a persistent myth undermining tobacco control. It reaches the conclusion that the sum-total of the worldwide evidence indicates either “softening” of the smoking population, or a lack of hardening. Hence, tobacco control reduces smoking prevalence and fosters a smoking population more amenable to evidence-based interventions. The review indicates that the time has come to take active steps to combat the myth of hardening and to replace it with the reality of “softening.”

The full citation is: Harris M, Martin M, Yazidjoglou A, Ford L, Lucas RM, Newman E, Banks E. Smokers Increasingly Motivated and Able to Quit as Smoking Prevalence Falls: Umbrella and Systematic Review of Evidence Relevant to the “Hardening Hypothesis,” Considering Transcendence of Manufactured Doubt. Nicotine Tob Res. 2022 Jul 13;24(8):1321-1328. doi: 10.1093/ntr/ntac055. PMID: 35239960; PMCID: PMC9278822. It is available here.

Here are papers we have written in softening, which are consistent with Harris and colleagues’ findings:

1. Kulik MC, Glantz SA. The smoking population in the USA and EU is softening not hardening. Tob Control. 2016;25(4):470-5.
2. Kulik MC, Glantz SA. Softening Among U.S. Smokers With Psychological Distress: More Quit Attempts and Lower Consumption as Smoking Drops. American Journal of Preventive Medicine. 2017;53(6):810-7.
3. Kulik MC, Lisha NE, Glantz SA. E-cigarettes Associated With Depressed Smoking Cessation: A Cross-sectional Study of 28 European Union Countries. American Journal of Preventive Medicine. 2018;54(4):603-9.
4. Kulik MC, Glantz SA. Similar softening across different racial and ethnic groups of smokers in California as smoking prevalence declined. Preventive Medicine. 2019;120:144-9.