Hardcore smokers in a challenging tobacco control environment: the case of Missouri.

Smoking rates in the USA declined from 42.4% in 1965 to 20.6% in 2008 but have remained essentially unchanged in recent years. 2 This plateau has caused public health advocates to evaluate current programming and seek better understanding of smoking subpopulations. 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.’ Previous studies have examined the prevalence of hardcore smokers and compared them to other smokers, finding hardcore smokers comprise 5.2%e14% of US smokers. 5 Part of the variability in prevalence estimates is likely due to definitional differences between studies. State-level hardcore prevalence has only been assessed in California, a state with very low smoking rates and strong tobacco control. 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.