Hard-Core Smokers are Softening Over Time: Smokers with High Psychological Distress Are Smoking Less and More Are Trying to Quit

Just published in American Journal of Preventive Medicine
 
Cigarette smokers with high levels of psychological distress are often heavy smokers, and thus identified as a “hard core” group who are less willing or able to quit than other smokers. However, a study by UC San Francisco researchers shows that over the course of 19 years, from 1997 to 2015, this hard core group smoked progressively fewer cigarettes per day and tried to quit in increasingly greater numbers, along with every other group of smokers in the United States.
 
“Even though they smoke more than the general population, smokers with high psychological distress have been smoking less and trying to quit more, as the overall level of smoking has decreased,” said Margarete C. Kulik, PhD, a postdoctoral fellow with the UCSF Center for Tobacco Control Research and Education (CTCRE) and the lead author of the study. “This shows that with effective tobacco control policies, even hard-core smokers will soften over time.” 
 
The study, published on Oct. 10, 2017, in the American Journal of Preventive Medicine, draws on data from the U.S. National Health Interview Survey (NHIS) administered annually by the U.S. Centers for Disease Control and Prevention. Current smokers were asked how many cigarettes they smoked per day and whether they had tried to quit smoking for one day or longer in the past 12 months. Based on answers to the Kessler Psychological Distress Scale, which is included in the NHIS, smokers were assigned to one of three categories: no distress, moderate distress and serious psychological distress. Responses from a total of 118,604 smokers were analyzed. 
 
The researchers found that from 1997 to 2015, cigarette consumption declined significantly among all three groups. Among the no distress group, cigarettes smoked per day decreased from 16.3 to 11.2, while cigarette consumption in the high distress group decreased from 19.6 to 14.5. The proportion of smokers who reported trying to quit increased in all groups and was highest among those with serious distress. 
 
“The finding that there were more quit attempts among smokers with the highest levels of distress might reflect the fact that although these smokers are motivated and willing to quit, they may need more help quitting successfully,” said senior author Stanton Glantz, PhD, UCSF professor of medicine and director of CTCRE. “This indicates that we should be encouraging our mental health providers to treat tobacco dependence along with other problems. Contrary to popular belief, treating nicotine addiction does not complicate the treatment of other substance abuse or mental health issues and in fact has been shown to improve outcomes among people in substance abuse treatment and recovery. Even smokers with the greatest psychological distress can be reached and helped to quit.” 
 
Glantz added that the new findings, combined with earlier research that also showed softening among the general population, “seriously challenge the tobacco industry’s position that ‘harm reduction’ products such as e-cigarettes and heat-not-burn products are the only way out of the tobacco epidemic. These products are premised on the unproven assumption that there is an intractable hard core of smokers who cannot be reached using established tobacco control policies.”
 
The study was supported by funds from the UC Tobacco Related Disease Research Program and the National Institute on Drug Abuse.
 
The UCSF Center for Tobacco Control Research and Education specializes in tobacco control research focused on policy change, smoking cessation, nicotine addiction, health disparities in smoking, novel tobacco devices and tobacco marketing. It also houses the Truth Tobacco Documents Library, a rich resource of previously confidential tobacco industry documents.
 
Here is the abstract from the paper:
 
Introduction: It has been argued that as smoking prevalence declines, the remaining smokers represent a “hard core” who are unwilling or unable to quit, a process known as hardening. However, as recently shown, the general smoking population is softening not hardening (i.e., as prevalence falls, more quit attempts and lower consumption among continuing smokers). People with psychological distress smoke more, so they may represent hard-core smokers.
Methods: Using cross-sectional time series analysis, in 2016–2017 changes in quit attempts and cigarette consumption were evaluated over 19 years among smokers with serious psychological distress (Kessler-6 score ≥13) based on the National Health Interview Survey (1997–2015), controlling for sociodemographic variables.
Results: People with psychological distress had higher smoking prevalence and consumed more cigarettes/day than people without distress. The percentage of those with at least one quit attempt was higher among those with psychological distress. The increase in quit attempts over time was similar among smokers in each of the distress levels. For every 10 years, the OR of a quit attempt increased by a factor of 1.13 (95% CI¼1.02, 1.24, po0.05). Consumption declined by 3.35 (95% CI: –3.94, –2.75, p<0.01) cigarettes/day for those with serious psychological distress.
Conclusions: Although smoking more heavily than the general population, smokers with psychological distress, like the general population, are softening over time. To improve health outcomes and increase health equity, tobacco control policies should continue moving all subgroups of smokers down these softening curves, while simultaneously incorporating appropriately tailored quitting help into mental health settings.
 
The full citation is:  Kulik M, Glantz S. Softening Among U.S. Smokers With Psychological Distress: More Quit Attempts and Lower Consumption as Smoking Drops.  American Journal of Preventive Medicine 2017 epub ahead of print 10 Oct 2017 http://www.ajpmonline.org/article/S0749-3797(17)30439-7/abstract