Hardening and the hard-core smoker: concepts, evidence, and implications.

A nascent debate pits researchers who believe that hard-core smokers are coming to dominate the remaining population of smokers against others who perceive the hardening of the target as a far more distant concern. At stake is the future emphasis of tobacco control: should we alter the current allocation of resources between treatment of individual smokers and modification of the psychosocial environment through public education and policy measures? We review the evidence and conclude that: (1) hardening is probably occurring in the sense that, compared with earlier generations, many of today's smokers possibly do have greater difficulty quitting, or are inherently less willing to do so. (2) Hardening may be most usefully construed in the context of specific groups of smokers, such as the mentally ill, who may constitute a growing fraction of the remaining smoking population. (3) Using conventional measures, however, we find little evidence that the population of smokers as a whole is hardening. Cessation rates have not decreased. (4) Truly hard-core smokers necessarily constitute a very small fraction of the population. Quitting-susceptible smokers continue to dominate the smoking population. (5) Hardening and the potential existence of true hard-core smokers recommend creative thinking about, and devotion of resources to, finding new ways to help the most dependent smokers to quit. (6) Sound research recommends the expansion of comprehensive tobacco-control programs in both the public and private sectors, and does not support reallocation of resources from such programs toward more intensive individualized treatment. We can afford both.