ArticleTobacco control2016
The smoking population in the USA and EU is softening not hardening.
Article in Tobacco control, 2016. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 26 papers, 1 of them a synthesis that pooled it.
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
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Who cites it
26 citing papers in PubMed, 1 synthesis or guideline pooled it, 53 citations in OpenAlex.
- 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 & tobacco research : official journal of the Society for Research on Nicotine and Tobacco · 2022Pooled it
- E-cigarettes increase harm and should be discouraged.Nature human behaviour · 2026Article
- Demographic Trends and Disparities in Cigarette Consumption Among U.S. Older Adults, 2006-2022.Journal of racial and ethnic health disparities · 2025Article
- A cross-sectional investigation of softening indicators among South African smokers: Results from the South African Social Attitudes Survey between 2007 and 2018.Preventive medicine reports · 2022Article
- Changes in adult smoking behaviours in ten global adult tobacco survey (GATS) countries during 2008-2018 - a test of 'hardening' hypothesis'.BMC public health · 2021Article
- A dynamic modelling analysis of the impact of tobacco control programs on population-level nicotine dependence.Scientific reports · 2021Article
- Article
- Cigarette taxes, prices, and disparities in current smoking in the United States.SSM - population health · 2020Article
- Smoking trends in Mexico, 2002-2016: before and after the ratification of the WHO's Framework Convention on Tobacco Control.Tobacco control · 2020Article
- Burden of male hardcore smokers and its characteristics among those eligible for lung cancer screening.BMC public health · 2020Article
- An experimental study of messages communicating potential harms of electronic cigarettes.PloS one · 2020Article
- Changes in urban and rural cigarette smoking and cannabis use from 2007 to 2017 in adults in the United States.Drug and alcohol dependence · 2019Article
- Similar softening across different racial and ethnic groups of smokers in California as smoking prevalence declined.Preventive medicine · 2019Article
- Are there hardened smokers in low- and middle-income countries? Findings from the Global Adult Tobacco Survey.Tobacco induced diseases · 2019Article
- Invisible smoke: third-party endorsement and the resurrection of heat-not-burn tobacco products.Tobacco control · 2018Article
- Public versus internal conceptions of addiction: An analysis of internal Philip Morris documents.PLoS medicine · 2018Article
- Softening Among U.S. Smokers With Psychological Distress: More Quit Attempts and Lower Consumption as Smoking Drops.American journal of preventive medicine · 2017Article
- Article
- Characteristics of hardcore smokers in South Korea from 2007 to 2013.BMC public health · 2017Article
- Tobacco use disparities by racial/ethnic groups: California compared to the United States.Preventive medicine · 2016Article
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Authors and funding
2 authors at 1 institution in 1 country.
Funding
Abstract
backgroundIt has been argued that as smoking prevalence declines in countries, the smokers that remain include higher proportions of those who are unwilling or unable to quit (a process known as 'hardening'). Smokeless tobacco and e-cigarettes have been promoted as a strategy to deal with such smokers. If hardening is occurring, there would be a positive association between smoking prevalence and quitting, with less quitting at lower prevalence. There would also be a neutral or negative association between prevalence and the number of cigarettes smoked.
methodsWe examined US state-level associations using the Tobacco Use Supplement (1992/1993-2010/2011) and Eurobarometer surveys for 31 European countries (2006-2009-2012) using regressions of quit attempts, quit ratios, and number of cigarettes smoked on smoking prevalence over time.
resultsFor each 1% drop in smoking prevalence, quit attempts increase by 0.55%±.07 (p<0.001) in the USA and remain stable in Europe (p=0.53), US quit ratios increase by 1.13%±0.06 (p<0.001), and consumption drops by 0.32 cig/day±0.02 (p<0.001) in the USA and 0.22 cig/day±0.05 (p<0.001) in Europe. These associations remain stable over time (p>0.24), with significantly lower consumption at any given prevalence level as time passed in the USA (-0.15 (cig/day)/year±0.06, p<0.05).
conclusionsConsistent with prior research using different data and methods, these population-level results reject the hypothesis of hardening as smoking prevalence drops, instead supporting softening of the smoking population as prevalence declines.
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