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The escalation in opioid use among current smokers may be especially important, considering the current opioid epidemic in the United States,52,53 and especially in light of data that suggest certain smoking cessation medications (eg, varenicline) may be less efficacious in the presence of opioid use.54 Although the hardening hypothesis has received mixed support, especially in terms of observed increases in nicotine dependence among smokers over time,5559 our findings are not incongruous with the basic premise of this hypothesis, which is to suggest that todays remaining smokers may have more trouble quitting because of an increasing preponderance of potential barriers to smoking