Are smokers in the European Union actually “hardening”? A multi-level and ecological approach

Introduction Tobacco control policies are proven to reduce smoking prevalence. It has been suggested that tobacco control measures are less effective where smoking prevalence has significantly declined, as the remaining smokers have “hardened”. Our aim was to empirically evaluate the “hardening hypothesis” at the population-level in the European Union and analyse the determinants of hardcore smoking. Methods We conducted two separate analyses in the 28 EU Member States using data on smoking from the Eurobarometer surveys (2009-2017, n=110,241); a multilevel logistic regression analysis with two levels (individual and country) with hardcore (daily smokers, smoking ≥15 cigarettes per day [cpd] that have not attempted to quit in the last 12 months) and light (