BMJ  2003;326:1061 (17 May), doi:10.1136/bmj.326.7398.1061

Paper

Prevalence of hardcore smoking in England, and associated attitudes and beliefs: cross sectional study

¹ Cancer Research UK Health Behaviour Unit, Department of Epidemiology and Public Health, University College London, London WC1E 6BT, ² Health Development Agency, London SW1 2HW

Abstract

Objective To quantify the prevalence and characteristics of hardcore smokers in England.

Design Cross sectional survey.

Setting Interview in respondents' household.

Participants 7766 adult cigarette smokers.

Main outcome measures Hardcore smoking defined by four criteria (less than a day without cigarettes in the past five years; no attempt to quit in the past year; no desire to quit; no intention to quit), all of which had to be satisfied.

Results Some 16% of all smokers were categorised as hardcore. Hardcore smoking was associated with nicotine dependence, socioeconomic deprivation, and age, rising from 5% in young adults aged 16-24 to 30% in those aged 65 years. Hardcore smokers displayed distinctive attitudes towards and beliefs about smoking. In particular they were likely to deny that smoking affected their health or would do so in the future. Prevalence of hardcore smoking was almost four times higher than in California.

Conclusion Hardcore smoking presents a serious challenge to public health efforts to reduce the prevalence of smoking, but the proportion of hardcore smokers does not necessarily increase as overall prevalence in a population declines. More hardcore smokers could be persuaded to quit, but this will require interventions that are targeted to the particular needs and perceptions of both socially disadvantaged and older smokers.

Introduction

The idea that there might exist a group of cigarette smokers who are especially resistant to giving up has attracted considerable interest.^{1 2} No generally accepted definition of a hardcore smoker exists, but by consensus they are those who are very unlikely to give up, either because they are determined not to or because they lack any confidence in their ability to do so successfully.

There have been few attempts to quantify the extent of hardcore smoking. Recent estimates from California have indicated that about 5% of smokers aged 26 and above could be considered hard core.³ The Californian study adopted an operational definition based on three principal characteristics: no attempts to quit in the past 12 months; an expectation of never quitting in the future; and cigarette consumption of at least 15 cigarettes per day. Typical hardcore smokers were older, white, male, of low income, poorly educated, and living alone.

We examined the prevalence and demographic correlates of hardcore smoking in Britain. We did not include cigarette consumption as one of our criteria but placed additional weight on the absence of quitting in the past and on the lack of desire to give up smoking as well as lack of intention. The main justification for including cigarette consumption as a criterion is as an indicator of dependence on tobacco. We prefer a concept that is based entirely on measures reflecting motivation. However, for purposes of comparison, we also estimated the prevalence of hardcore smoking using the Californian definition.

Methods

Data were gathered in four surveys of adults in England by the Health Education Authority in 1994, 1995, 1996, and 1997. These surveys monitored smoking prevalence and consumption, provided information about smokers' attitudes and beliefs, and examined smokers' recent attempts at quitting and their desires, intentions, and confidence of succeeding in future attempts. Households were selected by a random probability sampling technique, using the postcode as the sampling frame.

Interviewers collected basic demographic details and smoking habits for each adult in the household. In households where it was established that a current cigarette smoker (or someone who had given up within the past six months) lived, a more detailed interview was attempted with that person. Response rates for the initial household interview averaged just over 80% across the four surveys, and for the more detailed interview 67%, 63%, 61% and 63%, in surveys one to four, respectively. The survey methods are described more fully elsewhere.⁴

To be classified as a hardcore smoker, respondents had to satisfy all of the following criteria: less than a day without cigarettes in the past five years; no attempt to give up smoking in the past 12 months; no desire to give up smoking; and no intention to give up smoking.

Several indicators of socioeconomic status, based on occupational class, housing tenure, and age of completing full time education, were combined into a summary index. Available indicators of dependence on smoking included time to first cigarette of the day, average daily cigarette consumption, and age at starting to smoke regularly.

We examined the univariate significance of associations between hardcore smoking and variables of interest using ² tests and conducted multiple logistic regression analyses to assess the independent predictive contribution of age, sex, socioeconomic deprivation, and tobacco dependence. We combined the data from all four surveys. An indicator variable for wave of survey was entered into all multivariate statistical analyses.

Results

Information was available for 7766 current cigarette smokers. Of these, 1216 (16%) were classified as hardcore smokers (table). Hardcore smokers were about 10 years older on average and tended to be more dependent on tobacco. Significantly more hardcore smokers had manual occupations, lived in rented accommodation, and had completed their full time education by the age of 16 years. There was no difference by sex.

View this table: [in this window] [in a new window]   Characteristics of hardcore and other smokers. Figures are numbers (percentage) of people unless stated otherwise

 

We examined the independent association of these predictor variables with hardcore smoking in a multiple logistic regression analysis. The strongest predictor was age. The odds of being a hardcore smoker rose in a linear fashion with increasing age in those aged 65 years compared with smokers aged 16-24 years (figure). There was also a significant trend of higher odds with increasing socioeconomic deprivation. All three of the dependence indicators had independent predictive value, but the association was strongest with time to first cigarette.

View larger version (22K): [in this window] [in a new window]   Prevalence of hardcore smoking by age and sex: England 1994-7

 

Differences in attitudes and beliefs
A third of hardcore smokers thought that their current health was completely unaffected by smoking compared with 13% of other smokers. They were also much less willing to acknowledge that stopping smoking would lead to an improvement in health and much less likely to see an improvement in health as a personal advantage if they were to give up. Hardcore smokers were more likely to see smoking as their main pleasure in life (31% v 14%) and were likely to strongly agree that they enjoyed smoking too much to give it up (58% v 21%). They were very ready to agree that there were things that were far worse for them than smoking (41% v 25%).

Hardcore smokers were less tolerant of social pressure to quit (56% v 32% strongly agreed that smokers are now put under too much pressure to quit) and were less prepared to accept that their smoking would have a modelling influence on younger people (40% v 27% thought it very unlikely that their smoking would influence the uptake of smoking by children living in the household).

Differences in attitudes and beliefs by level of dependence
To test whether it was appropriate to exclude a measure of cigarette dependence from our criteria for defining hardcore smoking we compared attitudes and beliefs by dependence in hardcore and other smokers. For most items, beliefs were similar in low and high dependence hardcore smokers but strikingly different from those of other smokers. For example, almost 60% of both low and high dependency non-hardcore smokers agreed that improved health would be a major benefit from quitting whereas among hardcore smokers only 27% of low dependency and 32% of high dependency smokers agreed.

Comparison with Californian estimates
Using the same definition of hardcore smoking as in the Californian study, we found a prevalence of 17% across all age groups and 19% among smokers aged 26 compared with a figure of 5% for this group in the US study. When we added the Californian requirement of 15 cigarettes a day to our criteria we found a prevalence of 10% among smokers aged 26, still twice the prevalence in California.

What is already known on this topic There are concerns that hardcore smoking could become more common as overall cigarette smoking prevalence declines Some 5% of smokers in California scored as hardcore, but there has been relatively little study of this phenomenon What this study adds A total of 16% of English smokers were classified as hardcore Hardcore smokers tended to be older, more dependent, and from more socioeconomically deprived backgrounds They were likely to dismiss any effect of smoking on their health

Discussion

Our findings indicate that as many as 16% of smokers in England could be considered hard core by our criteria. There is no generally accepted definition of hardcore smoking. Our decision to exclude an indicator of dependence was supported by the finding that attitudes and beliefs were generally similar in low and high dependency hardcore smokers but markedly different from other smokers. Hardcore smoking was associated with higher levels of nicotine dependence and also increased with socioeconomic deprivation. The strongest association was with age.

Age and hardcore smoking
Nearly a third of all smokers aged 65 scored as hard-core compared with only 5% of smokers in early adulthood. Part of the increase in the proportion of hardcore smokers with age may be due to selective loss from the smoking population of those who are more highly motivated to quit. However, among young adults aged 16-24, some 2% of the whole age group are hardcore smokers (cigarette prevalence of 35%,⁵ of whom 5% are hardcore). Among those aged 65 this figure rises to 5% (cigarette prevalence of 16%,⁵ of whom 30% are hardcore). This suggests that the absolute number and not just the proportion of hardcore smokers increases.

Older smokers are likely to be especially resistant to stopping smoking. This could be through denial of personal risk, the feeling that smoking is too enjoyable and their only pleasure in life, or a feeling that it is too late because the damage is done. All of these could be true, for different smokers.

Comparison with California
Our estimate of the prevalence of hardcore smoking was much higher than that reported in California. There has been an intensive campaign against smoking in California over the past decade or so. Cigarette smoking prevalence in California in 1997 was 18%⁶ compared with 23% in the United States as a whole and 28% in Britain.⁵ California has both lower cigarette prevalence and a markedly lower proportion of hardcore smokers.

Other studies have also found that older smokers are more recalcitrant in their views than younger smokers.^{7 8} Their short term health gains from giving up smoking will be greater. Recent reports indicate that smokers who give up as late as age 65 gain an average of more than two years of additional life expectancy.⁹ Interventions need to be targeted to the particular needs and perceptions of both socially disadvantaged and older hardcore smokers.

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This is an abridged version; the full version is on bmj.com

Contributors: See bmj.com

Funding: MJJ, JW, and JW are funded by Cancer Research UK. The guarantor accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.

Competing interests: None declared.

References

1. Warner KE, Burns DM. Hardening and the hard-core smoker: concepts, evidence, and implications. Nicotine Tob Res 2003;5: 37-48.[Web of Science][Medline]
2. National Cancer Institute. Those who continue to smoke: Is achieving abstinence harder and do we need to change our interventions? Washington DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute (Smoking and Tobacco Control Monograph No 15) (in press).
3. Emery S, Gilpin EA, Ake C, Farkas AJ, Pierce JP. Characterizing and identifying "hard-core" smokers: implications for further reducing smoking prevalence. Am J Public Health 2000;90: 387-94.[Abstract/Free Full Text]
4. Turtle J, Hamlyn B, Lewis D. Smoking in England 1994-1997. London: BMRB International, 1998 [BMRB] . (Report No 1153-266.)
5. Thomas M, Walker A, Wilmot A, Bennett N. Living in Britain: Results from the 1996 general household survey. London: Stationery Office, 1998.
6. Bolen J, Rhodes L, Powell-Griner E, Bland S, Holtzman D. State-specific prevalence of selected health behaviors, by race and ethnicity—behavioral risk factor surveillance system, 1997. MMWR CDC Surveill Summ 2000;49: 1-60.[Medline]
7. Orleans CT, Jepson C, Resch N, Rimer BK. Quitting motives and barriers among older smokers. The 1986 Adult Use of Tobacco Survey revisited. Cancer 1994;74(7 suppl): 2055-61.[CrossRef][Web of Science][Medline]
8. Kviz FJ, Clark MA, Crittenden KS, Freels S, Warnecke RB. Age and readiness to quit smoking. Prev Med 1994;23: 211-22.[CrossRef][Web of Science][Medline]
9. Taylor J, Hasselblad V, Henley S, Thun M, Sloan F. Benefits of smoking cessation for longevity. Am J Public Health 2002;92: 990-6.[Abstract/Free Full Text]

(Accepted March 20, 2003)

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