An alternative understanding of the hardening hypothesis could be

An alternative understanding of the hardening hypothesis could be that remaining smokers are more nicotine dependent now because of dual or triple use of nicotine products, selleck compound like smokeless tobacco (snus) and/or nicotine replacement therapy in combination with cigarette smoking. The prevalence of double use of tobacco is reported to be low in Norway, 4.5% of the adult population (Norwegian Directorate of Health, 2010). The logistic regression analysis in this study showed that the OR for being HCS was significantly lower for those who use snus daily or occasionally, indicating that dual use is not a HCS phenomenon. Other explanations of the hardening hypothesis highlight changes in the social composition of the remaining population of smokers. These changes may mean that it is harder to quit today than previously (Warner & Burns, 2003).

One such factor is the strong association between smoking and low socioeconomic position found in Northern Europe, including Norway (K. E. Lund & Lund, 2005; M. Lund & Lund, 2005; Schaap, van Agt, & Kunst, 2008). In this study, we found higher odds for being a HCS among smokers with a low level of education but no indication for an increasing association over time (no significant interaction between education and survey year). Low education or socioeconomic position is associated with lower smoking success rates (Gilman, Abrams, & Buka, 2003; Kotz & West, 2009; Reid, Hammond, & Driezen, 2010). Explanations for these differences may be found in the experience of socioeconomic hardship and deprivation (Layte & Whelan, 2009).

Preventing smoking behavior by using population intervention strategies could also have some unintended consequences with relevance for the hardening versus softening debate. Repeated exposure of an antismoking message over a long time could desensitize smokers and lead to a boomerang effect where the target group react in the opposite way to the intended response (Hyunyi & Salmon, 2007). Recent studies have focused on the increasing social denormalization of smoking, which is defined as strategies that seeks to change the norms around using tobacco, making tobacco use an abnormal behavior (Hammond, Fong, Zanna, Thrasher, & Borland, 2006). Negative consequences of denormalization have been outlined, such as increased social stigma toward smokers (Stuber, Galea, & Link, 2008) and that increasing stigma would exacerbate the existing social inequality in smoking (Bell, Salmon, Bowers, Bell, & McCullough, 2010).

Such a boomerang effect could result in an increasing relative proportion of HCS over time and/or hide a hardening effect among remaining smokers by increasing psychological reactance and hostility toward changing their smoking behavior. Strengths Batimastat and Limitations of the Study The strength of this study was the sample��s representativeness for the adult population in Norway.

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