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Hardcore smokers in a challenging tobacco control environment: the case of Missouri
  1. Amy Sorg1,2,
  2. James Xu1,
  3. Syamsundara Babu Doppalapudi1,
  4. Sarah Shelton2,
  5. Jenine K Harris2,3
  1. 1Saint Louis University School of Public Health, St Louis, Missouri, USA
  2. 2Center for Tobacco Policy Research, Washington University in St Louis, St Louis, Missouri, USA
  3. 3George Warren Brown School of Social Work, Washington University in St Louis, St Louis, Missouri, USA
  1. Correspondence to Jenine K Harris, George Warren Brown School of Social Work, Washington University in St Louis, 1 Brookings Drive, St Louis, MO 63130, USA; jharris{at}

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Smoking rates in the USA declined from 42.4% in 1965 to 20.6% in 2008 but have remained essentially unchanged in recent years.1 2 This plateau has caused public health advocates to evaluate current programming and seek better understanding of smoking subpopulations.3 One subpopulation of interest is ‘hardcore’ smokers, who are more addicted, less open to cessation interventions and have been deemed a ‘small but intractable public health problem.’3

Previous studies have examined the prevalence of hardcore smokers and compared them to other smokers,4–7 finding hardcore smokers comprise 5.2%–14% of US smokers.4 5 Part of the variability in prevalence estimates is likely due to definitional differences between studies.8 State-level hardcore prevalence has only been assessed in California, a state with very low smoking rates and strong tobacco control.5 This study aims to determine the prevalence and characteristics of hardcore smokers in Missouri, a state with high smoking rates and weak tobacco control programs and policies.9–11


We examined current smokers over age 25 from the 2007 Missouri County-level Study (CLS). The CLS is a representative survey about health administered to 49 513 Missouri adults and described in detail here: Current smokers had smoked at least 100 cigarettes in their lifetime and currently smoked cigarettes every day or some days.

Based on Emery et al's definition (2000), current smokers were hardcore if they reported (1) no quit attempt in the last 12 months, (2) smoking 15+ cigarettes daily on average and (3) that they ‘never intend to quit.’ Smokers 25 years or younger were excluded as their smoking patterns and quit intentions were not likely established yet.4

Hardcore and non-hardcore smokers were compared on demographics, smoking habits, environmental characteristics, health status, health beliefs and cessation. T tests and χ2 statistics were used.


Using the definition described earlier, 7.8% of Missouri smokers were hardcore. Hardcore smokers were more likely to be older, male, non-Hispanic white, live in rural areas, have less education and lower annual incomes (p<0.001) (table 1). Table 1 shows additional significant differences (p<0.05) between Missouri's hardcore and non-hardcore smokers.

Table 1

Comparison of hardcore and non-hardcore smokers in Missouri


The 7.8% hardcore prevalence (approximately 77 000 Missourians) is 67% higher than the 5.2% hardcore prevalence calculated using the same definition in the California study.4 This disparity may be due in part to the large differences between the states' tobacco control programmes, policies and funding.

The demographic profile, smoking habits and environment of hardcore Missouri smokers were consistent with previous research.4–6 Hardcore smokers' minimisation of health effects related to smoking behaviour for themselves and the people around them were also consistent with previous studies.4–6 This may represent a lack of knowledge regarding smoking and health or cognitive dissonance, where hardcore smokers may not apply what they know about smoking and health to themselves. Finally, the high level of cessation awareness among hardcore smokers demonstrates that awareness is insufficient in encouraging cessation in this group.

Our findings indicate that educational campaigns about smoking and health, tailored cessation messages and interventions, and targeted strategies to increase cessation self-efficacy are needed to motivate hardcore smokers to quit. Finally, a comprehensive state tobacco control programme may aid in decreasing the prevalence of hardcore smoking.

What this paper adds

  • With adult smoking prevalence in the USA stalled near 21% in recent years, understanding those who continue to smoke is critical to public health. One subgroup of current smokers, hardcore smokers, has higher addiction levels and is difficult to reach. Prior studies have found that 5.2–14% of US smokers are hardcore; however, only California has assessed hardcore smoking at the state level. This study examined hardcore smokers in Missouri, which has a notably challenging tobacco control environment.

  • Hardcore smokers represented 7.8% of Missouri smokers, a rate 67% higher than in California. This indicates hardcore smoking may be influenced by the tobacco control environment. Our findings suggest several ways to address hardcore smoking, including development of tailored cessation interventions and strategies to increase quitting self-efficacy, along with implementation of comprehensive state tobacco control programmes.



  • Correction notice This article has been corrected since it was published Online First. It has been changed from a Letter to a Research letter.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.