The new ITC study of US smokers is a treasure trove of data; shows continuing "softening" of smoking

The International Tobacco Control Policy Evaluation Project released an extensive report summarizing data collected from US smokers last week that provides a very detailed view of what has and has not changed for smokers' between 2002 (when the first wave was collected) through 2011 (when the last wave was collected).

The ITC project is a longitudinal study, which follows the same people forward in time, so it gives the best view of what is changing and what is staying the same for smokers.

In order to keep their sample size big enough to draw reasonably precise conclusions, however, the ITC project recruits additional smokers at each survey wave (roughly annually) to replace smokers who quit or die, so there is the possibility that the nature of the cohort is changing over time. This could be a particularly important effect if, as smoking prevalence drops, the remaining smokers are increasingly the "hard core" who harm reduction advocates describe as people who "will not or cannot quit."

During the 9 years covered by the survey there was a major drop in adult smoking prevalence in the US, from 22.5% in 2002 to 18.7% in 2011 (an average of 19.3% in 2010 and 18.1% in 2012). If we were running in to the hypothesized "hard core," one would expect that the remaining smokers would be smoking more, less interested in quitting, and less successful at quitting. The evidence shows just the opposite. Between 2002 and 2011 remaining smokers:

Reduced cigarette consumption from 19 cig/day to 17 cig/day (an 11% drop)
Time to first cigarette remained stable
Intention to quit remained stable, but
Were more likely to make a quit attempt from 35% to 46% (a 31% relative increase)
Quitting success remained stable (around 5% for 6 months and 8% for 1 month)

Taken together, these data indicate that rather than getting down to a "hard core" who requires providing them alternative "cleaner" ways to self administer nicotine (like e-cigarettes), as smoking is continuing to drop, the remaining smokers are smoking less (not more, as the hardening hypothesis would predict), show about the same levels of addiction (not more as hardening would predict), are more likely (not less) to make a quit attempt, and have about the same level (not less) of success.

The fact that quitting success remained stable despite the fact that quit attempts increased raises questions about whether the tobacco companies are making cigarettes more addictive or whether the availability of e-cigarettes as a way to deal with smokefree environments is reducing quitting success.

In any event, this evidence seriously undermines the whole logic of harm reduction that is being used to justify e-cigarettes (and which I expect the FDA, when it issues its e-cigarette deeming rule, to embrace). If the FDA does this, they will undermine the steady progress that we have been making in ending the tobacco epidemic.

What the evidence shows is that there is continuing softening of the remaining smokers, as they continue to smoke less, try to quit more, and succeed at the same rate. That reality, not outdated ideas of the "hard core" is what should be driving public health policy making.

Here is a summary of the report from the ITC press release:

US smokers – what do they really do and think?
Across Waves 1 – 8 of the ITC US Survey, conducted between 2002 and 2011, a representative national sample of adult smokers were asked questions related to issues such as their use of tobacco, their knowledge of the harms of tobacco, and their knowledge of and agreement with tobacco control legislation. Significant findings of the study include:
Addiction and quitting

Nearly 9 in 10 smokers expressed regret about having ever started to smoke
Over 60% of current smokers perceive themselves to be “very addicted” to tobacco
Between 22% and 30% of smokers say they never intend to quit
Only about one quarter of current smokers felt “very sure” or “extremely sure” that they could succeed in quitting smoking within the next 6 months
Two-thirds of smokers believed that quitting would significantly improve their health
Around 40% said that smoking has damaged their health “a fair amount” or “a great deal”
Up to a third of smokers have spent money on cigarettes that they knew would have been better spent on household essentials like food

Tobacco use

Over 90% of current smokers are daily smokers
Over a quarter (27%) smoke menthol cigarettes; African American smokers, females and younger smokers are more likely to smoke menthol cigarettes
There has been a significant increase in the use of smokeless tobacco among current smokers during the Survey period, from 3% to 10%
The use of moist snuff (e.g.“snus”, a form of tobacco that originated in Sweden and adopted by several major cigarette brands) tripled from 2% in 2002 to 7% in 2011
In the Wave 8 Survey (i.e., 2010-11) the majority of smokers (73%) were aware of e-cigarettes and 15% of current and former smokers had tried using them
Most respondents who use e-cigarettes use them daily (39%) or less than monthly (30%); 18% use them at least once a week, and 12% used them at least monthly
A further 30% said that they were interested in trying e-cigarettes

Tobacco Control

Nearly three-quarters of smokers think cigarette companies should be legally obliged to reduce the nicotine in cigarettes to make them less addictive
Between 41% and 47% of current smokers believe that tobacco companies should take responsibility for the harm caused by smoking and around 40% support governments suing tobacco companies to recover healthcare costs
Half of current smokers believe the government should do more to tackle the harm caused by smoking
Between 45% and 50% of current smokers support a ban on flavored cigarettes
A third of current and former smokers support additional restrictions on where cigarettes can be sold and two-thirds agree with strict restrictions on tobacco advertising and marketing
A fifth of smokers support a complete ban on the sale of all tobacco products
Smokers’ support for complete smoking bans in workplaces increased from 38% in 2002 to 67% in 2011
By 2011, only 6% of respondents believed that smoking should be allowed inside restaurants
More respondents report observing smoking in public places like bars (around one-third) and restaurants (around one-tenth) compared with countries like Australia, Canada, France and the United Kingdom, where less than one-tenth observe smoking in bars and smoking in restaurants has almost been eliminated

Health warnings and plain packaging

Less than one-third (24% to 33%) of current smokers noticed warning labels on cigarettes “often” or “very often” in the last month
Fewer than 15% of smokers say health warnings discourage them from smoking
This is lower than in other ITC Survey countries where graphic warnings are used, such as Australia, Canada, France, and the United Kingdom
Around 40% of current and former smokers in the US think there should be more health information on cigarette packs and nearly a third of current smokers support plain packaging
The number of respondents who noticed anti-smoking information “often” or “very often” dropped significantly from 46% in 2002 to 27% in 2011

The full report is available here.