Everything Old Is New Again: Maintaining a Population-Level “Shared Reality” of Health Risks Associated With Cigarette Use

In this issue, Banks et al. review the state of the current evidence for the hardening hypothesis.¹ The chief motivation being that “if a population hardens,” this indicates that, “previous effective population-level interventions could become less effective” in continuing to bring the prevalence lower at an international population level. Using “hardening” metrics that relate to motivation, dependence, interest, and intention to quit and quit success, Banks et al. conclude that current tobacco control methods continue to reduce smoking prevalence resulting in a current population of cigarette smokers who are “amenable to evidence-based interventions.”

Yet, in the United States (US), most individuals who use cigarettes have at least one empirically documented barrier to smoking cessation.^2–5 Based on our analysis of 2020 nationally representative data from the National Survey of Drug Use and Health (NSDUH), see below, 51.7% of Americans aged 12 years and older who reported past 30-day cigarette use met the criteria for at least one of the following: serious psychological distress, major depressive episode, heavy alcohol use, or daily cannabis use month. Each of the aforementioned problems is linked with lower quit rates, increased relapse and increased initiation. Cigarette sales increased in the US for the first time in several decades in 2020.⁶ What was once viewed largely as a unique subgroup of cigarette smokers—those with mental health problems—now encompasses the majority of Americans who use cigarettes.

How do we reconcile the conclusion that we should continue with current tobacco control methods with the fact that a majority of Americans who smoke have at least one attribute which compromises their ability to access and/or respond standard public health and clinical treatments?

In this editorial, we discuss several ways in which seemingly contradictory material from different disciplines within the field of nicotine and tobacco research can be integrated to reveal the actions that will enable us to not only lower the population-level prevalence, but to eliminate the expanding disparities in tobacco use. Acknowledging that these are two distinct problems is a requisite first step.

Among individuals in cancer treatment settings, Jose et al. report promising findings showing that “cancer diagnosis and treatment prompt smoking abstinence, with most maintaining abstinence after treatment is complete.”⁷ This is remarkable and especially encouraging given that being tobacco-free improves treatment response and long-term prognosis.

Relatedly, Land et al. examine cigarette use among adults living with cancer with two notable results.⁸ First, perception of risk associated with cigarette use differs significantly among those with and without a history of cancer diagnosis. Adults with a history of cancer diagnosis perceive a significantly greater risk of harms associated with cigarette use, relative to those with no history. Second, among those with and without cancer, perception of risk associated with cigarette use is inversely related to the use and frequency of cigarette use among people living with cancer, consistent with this association noted in other populations.

In contrast, among adults seeking help to stop using cigarettes via the New York State Quitline, we found that daily cannabis use at baseline was inversely associated with sustained abstinence from cigarette use at a 7-month follow-up relative to those who did not use cannabis.⁹

This confluence of results raises the question: How is cancer diagnosis history associated with increased quitting success whereas daily cannabis use is associated with decreased quitting success? Daily cannabis users who call and follow through with a Quitline 7 months later are, by definition, not hardened. Yet, adults who use cannabis daily are (1) less “successful” at remaining abstinent (even) from cigarette use with standard treatment,⁹ (2) a rapidly growing segment of the US population,^10–12 and (3) make up an increasing proportion of Americans who use cigarettes.^13,14

To understand this divergence, we used national data to examine whether the perceived risk associated with smoking a pack or more of cigarettes a day differs among adults who use cannabis daily (see Table 1). We found that adults who use cannabis daily were significantly less likely to report that smoking a pack or more a day of cigarettes is a “great” health risk (see Table 1), relative to those who do not use cannabis.

Daily cannabis use is increasing rapidly in the United States and is much more common among those who smoke cigarettes.^10–12 Cannabis use and daily cannabis use are even more prevalent among adults who use cigarettes and reside in states where cannabis is legal for recreational use, a rapidly growing proportion of the US.¹⁴ Taken together, these findings suggest that diminished risk perception of cigarette use may be growing among Americans.

To begin to address the latter at a population health level, Public Service Announcements informing the public that common problems (eg, daily cannabis use, depression) may interfere with efforts to quit smoking seem like a reasonable next step. Widespread dissemination of this type of novel information may create inroads for change by reaching both adults who are currently smoking, and those who are not yet smoking, thereby increasing public awareness of the myriad risks associated with cigarette use.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr

Declaration of Interest

The authors have no conflicts to disclose.

References