Smokers Increasingly Motivated and Able to Quit as Smoking Prevalence Falls: Umbrella and Systematic
Thursday, August 18, 2022
Posted by: Natalia Gromov
Harris M, Martin M,
Yazidjoglou A, et al.
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;24(8):1321-1328. doi:10.1093/ntr/ntac055
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."
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