More evidence that the key assumption behind harm reduction is wrong and should not be the basis for FDA and other health policy: The “hard core” is melting away

The core principle that undermines the tobacco industry, the FDA, and our friends in England ‘s idea that there is a “hard core” of smokers who “can not or will not quit”  and that the existence of this group should drive policy.

Under this logic, e-cigarettes, IQOS, and smokeless tobacco all continue to be promoted as the better alternative than “abandoning all the smokers to die.”

Now there is yet another study showing that, in response to tried and true tobacco control policies (smokefree laws, strong media, taxes, warning labels and plain packaging) the remaining smokers are smoking less and quitting more.

That’s just the opposite of what the hardening hypothesis predicts.

It is particularly important to reject these new “less risky” products because their net effect is to reduce quitting, increase initiation, promote relapse and generally prolong the tobacco epidemic.

It is time for the FDA, England, and everyone else to abandon this outdated idea and stop promoting these product.

The latest paper is “Hardening or softening? An observational study of changes to the prevalence of hardening indicators in Victoria, Australia, 2001-2016” published in Tobacco Control.  Here is the abstract:

Background The hardening hypothesis predicts that as smoking prevalence declines, remaining smokers will be more heavily addicted to nicotine and/or less interested in quitting. We tested this hypothesis in a population exposed to a comprehensive tobacco control programme over a 16-year period.

Methods Annual cross-sectional surveys randomly sampled adults (aged 26+) in the state of Victoria, Australia, between 2001 and 2016. Until 2010, participants were recruited through random digit dialling to landline telephones; from 2011, sampling frames also included mobile phones. Logistic regressions assessed changes over time in the prevalence of smoking and each hardening indicator; additional models examined interactions by sex, age, education and socioeconomic status.

Results Smoking prevalence declined significantly between 2001 and 2016 (20.1%–13.0%), as did the prevalence of seven hardening indicators: daily smoking, heavy consumption, no quit attempt in the past 5 years or past 12 months, no intention to quit in the next 6 months or next 30 days, and happiness to keep smoking. In addition, the proportion of smokers defined as ‘hardcore’ decreased from 17.2% to 9.1%. On the whole, hardening indicators decreased to a similar extent among demographic subgroups.

Conclusions These results are inconsistent with the hardening hypothesis. Rather, they suggest that a comprehensive tobacco control programme that combines provision of cessation support to individual smokers with implementation of population-level interventions to drive all smokers towards quitting, can successfully reduce both smoking prevalence and levels of dependence and desire to keep smoking among the remaining population of smokers.

There is also a good accompanying editorial, “Hardening is dead, long live softening; time to focus on reducing disparities in smoking,” by Richard Edwards from New Zealand.

The full citations are:

Brennan, E., Greenhalgh, E. M., Durkin, S. J., Scollo, M. M., Hayes, L., Wakefield, M. A.  Hardening or softening? An observational study of changes to the prevalence of hardening indicators in Victoria, Australia, 2001-2016.  Tobacco Control 2019 Epub ahead of print tobaccocontrol-2019-05493-tobaccocontrol-2019-05493.  It is available here. 

Edwards, R.  Hardening is dead, long live softening; time to focus on reducing disparities in smoking.      Tobacco Control 2019 Epub ahead of print.  tobaccocontrol-2019-05506-tobaccocontrol-2019-05506.  It is available here.