Softening Among U.S. Smokers With Psychological Distress: More Quit Attempts and Lower Consumption as Smoking Drops

  • Margarete C. Kulik
    Affiliations
    Center for Tobacco Control Research and Education, and Department of Medicine, University of California, San Francisco, San Francisco, California
    Search for articles by this author
  • Stanton A. Glantz
    Correspondence
    Address correspondence to: Stanton A. Glantz, PhD, Center for Tobacco Control Research and Education, University of California, San Francisco, 530 Parnassus, Suite 366, San Francisco CA 94143
    Affiliations
    Center for Tobacco Control Research and Education, and Department of Medicine, University of California, San Francisco, San Francisco, California
    Search for articles by this author
Published:October 10, 2017DOI:https://doi.org/10.1016/j.amepre.2017.08.004

      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% CI=1.02, 1.24, p<0.05). 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.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Warner K.E.
        • Burns D.M.
        Hardening and the hard-core smoker: concepts, evidence, and implications.
        Nicotine Tob Res. 2003; 5: 37-48https://doi.org/10.1080/1462220021000060428
        • Winter K.M.
        Hardcore smoking does not necessarily indicate hardening.
        Addiction. 2014; 109: 681https://doi.org/10.1111/add.12453
        • Cohen J.E.
        • McDonald P.W.
        • Selby P.
        Softening up on the hardening hypothesis.
        Tob Control. 2012; 21: 265-266https://doi.org/10.1136/tobaccocontrol-2011-050381
        • Docherty G.
        • McNeill A.
        The hardening hypothesis: does it matter?.
        Tob Control. 2012; 21: 267-268https://doi.org/10.1136/tobaccocontrol-2011-050382
        • Costa M.L.
        • Cohen J.E.
        • Chaiton M.O.
        • Ip D.
        • McDonald P.
        • Ferrence R.
        “Hardcore” definitions and their application to a population-based sample of smokers.
        Nicotine Tob Res. 2010; 12: 860-864https://doi.org/10.1093/ntr/ntq103
        • Kulik M.C.
        • Glantz S.A.
        The smoking population in the USA and EU is softening not hardening.
        Tob Control. 2016; 25: 470-475https://doi.org/10.1136/tobaccocontrol-2015-052329
        • Fernandez E.
        • Lugo A.
        • Clancy L.
        • Matsuo K.
        • La Vecchia C.
        • Gallus S.
        Smoking dependence in 18 European countries: hard to maintain the hardening hypothesis.
        Prev Med. 2015; 81: 314-319https://doi.org/10.1016/j.ypmed.2015.09.023
        • Edwards R.
        • Tu D.
        • Newcombe R.
        • Holland K.
        • Walton D.
        Achieving the tobacco endgame: evidence on the hardening hypothesis from repeated cross-sectional studies in New Zealand 2008–2014.
        Tob Control. 2017; 26: 399-405https://doi.org/10.1136/tobaccocontrol-2015-052860
        • Lasser K.
        • Boyd J.W.
        • Woolhandler S.
        • Himmelstein D.U.
        • McCormick D.
        • Bor D.H.
        Smoking and mental illness: a population-based prevalence study.
        JAMA. 2000; 284: 2606-2610https://doi.org/10.1001/jama.284.20.2606
      1. Substance Abuse and Mental Health Services Administration, SAMHS. The CBHSQ Report. July 18, 2013. Smoking rate among adults with serious psychological distress remains high. www.samhsa.gov/data/sites/default/files/spot120-smokingspd_/spot120-smokingSPD.pdf. Accessed June 2016.

      2. Seidman D.F. Covey L.S. Helping the Hard-Core Smoker—A Clinician’s Guide. Lawrence Erlbaum, Mahwah, NJ1999
        • Darville A.
        • Hahn E.J.
        Hardcore smokers: what do we know?.
        Addict Behav. 2014; 39: 1706-1712https://doi.org/10.1016/j.addbeh.2014.07.020
        • Kessler R.C.
        • Andrews G.
        • Colpe L.J.
        • et al.
        Short screening scales to monitor population prevalences and trends in non-specific psychological distress.
        Psychol Med. 2002; 32: 959-976https://doi.org/10.1017/S0033291702006074
        • Kessler R.C.
        • Barker P.R.
        • Colpe L.J.
        • et al.
        Screening for serious mental illness in the general population.
        Arch Gen Psychiatry. 2003; 60: 184-189https://doi.org/10.1001/archpsyc.60.2.184
      3. CDC. National Health Interview Survey. www.cdc.gov/nchs/nhis/. Accessed June 2016.

        • Prochaska J.J.
        • Sung H.Y.
        • Max W.
        • Shi Y.
        • Ong M.
        Validity study of the K6 scale as a measure of moderate mental distress based on mental health treatment need and utilization.
        Int J Methods Psychiatr Res. 2012; 21: 88-97https://doi.org/10.1002/mpr.1349
      4. Design and estimation for the National Health Interview Survey, 1995–2004.
        Vital Health Stat 2. 2000; 130: 1-31
        • Parsons V.L.
        • Moriarity C.
        • Jonas K.
        • Moore T.F.
        • Davis K.E.
        • Tompkins L.
        Design and estimation for the National Health Interview Survey, 2006–2015.
        Vital Health Stat 2. 2014; 165: 1-53
        • Cook B.L.
        • Wayne G.F.
        • Kafali E.N.
        • Liu Z.
        • Shu C.
        • Flores M.
        Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation.
        JAMA. 2014; 311: 172-182https://doi.org/10.1001/jama.2013.284985
        • Cooper J.
        • Borland R.
        • McKee S.A.
        • Yong H.H.
        • Dugue P.A.
        Depression motivates quit attempts but predicts relapse: differential findings for gender from the International Tobacco Control Study.
        Addiction. 2016; 111: 1438-1447https://doi.org/10.1111/add.13290
        • Smith P.H.
        • Mazure C.M.
        • McKee S.A.
        Smoking and mental illness in the U.S. population.
        Tob Control. 2014; 23: e147-e153https://doi.org/10.1136/tobaccocontrol-2013-051466
        • Prochaska J.J.
        Smoking and mental illness—breaking the link.
        N Engl J Med. 2011; 365: 196-198https://doi.org/10.1056/NEJMp1105248
        • Prochaska J.J.
        Failure to treat tobacco use in mental health and addiction treatment settings: a form of harm reduction?.
        Drug Alcohol Depend. 2010; 110: 177-182https://doi.org/10.1016/j.drugalcdep.2010.03.002
        • Prochaska J.J.
        • Hall S.M.
        • Tsoh J.Y.
        • et al.
        Treating tobacco dependence in clinically depressed smokers: effect of smoking cessation on mental health functioning.
        Am J Public Health. 2008; 98: 446-448https://doi.org/10.2105/AJPH.2006.101147
        • Hall S.M.
        • Tsoh J.Y.
        • Prochaska J.J.
        • et al.
        Treatment for cigarette smoking among depressed mental health outpatients: a randomized clinical trial.
        Am J Public Health. 2006; 96: 1808-1814https://doi.org/10.2105/AJPH.2005.080382
        • Prochaska J.J.
        • Schane R.
        • Leek D.
        • Hall S.E.
        • Hall S.M.
        Investigation into the cause of death of a 56-year-old man with serious mental illness.
        Am J Psychiatry. 2008; 165: 453-456https://doi.org/10.1176/appi.ajp.2007.07091455
        • McKelvey K.
        • Thrul J.
        • Ramo D.
        Impact of quitting smoking and smoking cessation treatment on substance use outcomes: an updated and narrative review.
        Addict Behav. 2017; 65: 161-170https://doi.org/10.1016/j.addbeh.2016.10.012
        • Prochaska J.J.
        • Delucchi K.
        • Hall S.M.
        A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery.
        J Consult Clin Psychol. 2004; 72: 1144-1156https://doi.org/10.1037/0022-006X.72.6.1144
        • Thurgood S.L.
        • McNeill A.
        • Clark-Carter D.
        • Brose L.S.
        A systematic review of smoking cessation interventions for adults in substance abuse treatment or recovery.
        Nicotine Tob Res. 2016; 18: 993-1001https://doi.org/10.1093/ntr/ntv127
        • Taylor G.
        • McNeill A.
        • Girling A.
        • Farley A.
        • Lindson-Hawley N.
        • Aveyard P.
        Change in mental health after smoking cessation: systematic review and meta-analysis.
        BMJ. 2014; 348: g1151https://doi.org/10.1136/bmj.g1151
        • Prochaska J.J.
        Quitting smoking is associated with long term improvements in mood.
        BMJ. 2014; 348: g1562https://doi.org/10.1136/bmj.g1562