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Increase of unmotivated and hardened smokers in Hong Kong: a repeated cross-sectional trend analysis
  1. Sheng Zhi Zhao1,
  2. Yongda Wu1,
  3. Derek Yee Tak Cheung1,
  4. Tzu Tsun Luk1,
  5. Xue Weng1,2,
  6. Henry Sau Chai Tong3,
  7. Vienna Lai3,
  8. Sophia Siu Chee Chan1,
  9. Tai Hing Lam4,
  10. Man Ping Wang1
  1. 1 School of Nursing, The University of Hong Kong, Hong Kong, Hong Kong SAR
  2. 2 Institute of Advanced Studies in Humanities and Social Sciences, Beijing Normal University, Zhuhai, China
  3. 3 Hong Kong Council on Smoking and Health, Wanchai, Hong Kong
  4. 4 School of Public Health, The University of Hong Kong, Hong Kong, Hong Kong SAR
  1. Correspondence to Dr Yongda Wu, The University of Hong Kong, Hong Kong 999077, Hong Kong; yongdang{at}


Objectives To examine the trends in the prevalence of hardening indicators and hardened smokers in Hong Kong, where the low smoking prevalence has plateaued in the recent decade.

Methods This is an analysis of repeated cross-sectional data from 9 territory-wide smoking cessation campaigns conducted annually from 2009 to 2018 (except 2011). Participants were 9837 biochemically verified daily cigarette smokers aged ≥18 years (18.5% female, mean age 43.2±14.2 years) recruited from the communities. Hardening indicators included heavy smoking (>15 CPD), high nicotine dependence (Heaviness of Smoking Index ≥5), no intention to quit within next 30 days and no past-year quit attempt. Perceived importance, confidence and difficulty of quitting were measured (each ranged 0–10). Multivariable regressions were used to model the changes in hardening indicators by calendar year, adjusting for sociodemographic characteristics.

Results From 2009 to 2018, the prevalence of heavy smoking decreased from 57.6% to 39.4% (p<0.001), high nicotine dependence also decreased from 10.5% to 8.6% (p=0.06). However, the proportion of smokers with no intention to quit (12.7%–69.0%) and no past-year quit attempt (74.4%–80.4%) significantly increased (both p values <0.001). Hardened smokers (heavy smoking, no intention to quit, no past-year attempt quit attempt) significantly increased from 5.9% to 20.7% (p<0.001). Mean perceived importance (from 7.9±2.3 to 6.6±2.5) and confidence (from 6.2±2.6 to 5.3±2.4) of quitting also decreased significantly (all p values <0.001).

Conclusions Daily cigarette smokers in Hong Kong were motivational hardening, but not dependence hardening. Effective tobacco control policies and interventions are warranted to motivate quitting to further reduce smoking prevalence.

  • addiction
  • cessation
  • end game
  • nicotine

Data availability statement

Data are available on reasonable request.

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Data availability statement

Data are available on reasonable request.

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  • Contributors MPW, YW and SZZ conceptualised the study. YW and SZZ conducted data preparation and statistical analyses. SZZ drafted the first version of the manuscript. All authors reviewed the manuscript, interpreted the data, critically revised the manuscript and approved the final version of the manuscript. SZZ is responsible for the overall content as guarantor.

  • Funding This study was supported by the Hong Kong Council on Smoking and Health.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.