ATTUD Journal Club Postings

Blog on Hardening

As many of you know, I have been enamored of the hardening hypothesis (in terms of ability to quit on a given attempt). However, attached is what I think is the best test of that hypothesis from Robert West’s Smoking Tool Kit and clearly it is refuting it. Also, the CA survey has found similar results. So, I am abandoning the hardening hypothesis in terms of the general population. However, I must say the logic around the hardening hypothesis (social pressure gets those who find quitting easy to stop first) makes so much sense, I am at a loss why this is not true.

The only face-saving post-hoc hypothesis is that hardening is occurring only among those seeking treatment. For example, the severity of depression may not be increasing over time, but those who are referred to psychiatrists for treatment are clearly more severe than in the past. This could be due to more frequent and better treatment by non-psychiatrists such as psychologists and primary care clinicians who then only refer the really severe to the more expensive psychiatrists. This possibility was covered in our prior review on hardening. The importantly corollary is that more severe psychiatric problems is associated with higher comorbidity. This is consistent with anecdotal reports that those seeking phone counseling  have more psychiatric problems than those seen in the past.  If this can be shown in empirical data (I cannot find such a study – if you know one pass it on), then it means that tobacco treatment counselors need more training in detecting and referring psychiatric problems.