Introduction

Korea launched the National Tobacco Control Centers in 2015, centralizing most tobacco control efforts that were previously managed by the Ministry of Health and Welfare [1]. Since then, the Centers have implemented a variety of smoking cessation services in schools, community health centers, and healthcare facilities. As a result, smoking rates in Korea have steadily declined from 22.6% in 2015 to 19.6% in 2023 [2]. Notably, the National Tobacco Control Centers established 18 regional centers, providing support to these centers—particularly to reach underrepresented groups of smokers. These groups include women, workers in small businesses, heavy smokers with frequent relapses, university students, individuals with disabilities, and inpatients, all of whom are targeted through tailored smoking cessation programs [3].

Among the services, inpatient and residential programs have been shown to be the most effective [4]. The guidelines of the regional tobacco control centers clearly specify the eligibility criteria for service use, the components of the services, and the methods for outcome evaluation [3]. Inpatient programs are a consultation service for patients in tertiary-level hospitals and are provided by smoking cessation counselors from regional tobacco control centers. Once inpatients are identified as smokers and are willing to receive smoking cessation counseling, they can be referred to the regional tobacco control center. Thereafter, smoking cessation counselors visit the patients, provide smoking cessation counselling, and assist them in receiving pharmacotherapy as well as standard care. After discharge, patients can continue to receive counseling when they visit outpatient departments for follow-up.

According to the guidelines [3], residential programs, in contrast, consist of a 5-day overnight stay for individuals who have smoked for more than 20 years and have failed to quit after multiple attempts. Participants are required to stay overnight in a designated facility, usually a hospital setting, and receive intensive services from 9 a.m. to 6 p.m. These services include medical examinations, pharmacotherapy, individual and group counseling, physical activity, and daily education on smoking and the prevention or management of tobacco-related diseases. These programs are originally modeled after the Mayo Clinic program in the United States [5], which was an 8-day program emphasizing cognitive behavioral therapy, a strictly tobacco-free environment, and pharmacotherapy. The national smoking cessation services adapted this program into a 5-day format, while retaining its theoretical foundations and core components [3]. Detailed information on program contents, follow-up, and outcome assessment has been previously reported [6].

Both programs share common components, including individual counseling, pharmacotherapy (if eligible), and a strict tobacco-free environment during the critical first week after quitting. Quit rates for inpatient programs among Korean smokers have ranged from 21.6% to 66.2% [7,8]. International studies have reported that 6-month abstinence rates for inpatient programs range from 26.0% to 40.0% [9,10]. In comparison, quit rates for residential programs over the same period were even higher, ranging from 46.1% to 63.2% [6,7,11].

However, these studies were based on a single regional center and did not explain why residential programs consistently demonstrate higher quit rates than inpatient programs. Residential programs are both cost- and labor-intensive. To determine their true added value, it is essential to evaluate whether the type of program independently influences quit rates while adequately controlling for potential confounding factors, such as participant selection, intervention components, and misclassification of quit outcomes.

For example, the national smoking cessation services guideline indicates that the eligibility criteria for the two programs differ slightly [3]. Participants in the residential program are required to have a smoking history of at least 20 pack-years and a strong willingness to quit. In contrast, the inpatient program does not require a 20 pack-year history; it only requires a strong willingness to quit and a referral from a physician. In terms of program content, the residential program requires at least five in-person counseling sessions, whereas the inpatient program provides two in-person counseling sessions during hospitalization and one within one month after discharge. Quit outcomes for both programs can be assessed using self-report, exhaled carbon monoxide (CO) levels, or urinary cotinine. However, previous studies have shown that these methods may yield discordant results [12]. For instance, Kim and colleagues [12] reported that age and education level were associated with discrepancies between self-reported and cotinine-verified smoking status. When participants face barriers to visiting the center for biochemical testing—such as full-time employment—self-report may become the sole method for assessing smoking status.

Therefore, a simple comparison of quit rates between the two programs may be insufficient. Furthermore, individual characteristics such as level of nicotine dependence, confidence, readiness and self-efficacy to quit, and use of pharmacotherapy are known to be associated with smoking cessation success and must be considered [13-15]. Thus, the purpose of this study was to evaluate whether program type affects quit outcomes and their predictors among participants in these two programs, using nationally representative data and comparing results based on outcome measure—self-reported versus biochemically verified quit.

Methods

Study design

This is a cross-sectional descriptive study based on secondary data analysis.

Study participants

Participants in inpatient programs numbered 9,149; participants in residential programs numbered 8,280. We excluded those who were younger than 19 years old. Thus, data on 9,022 (98.6%) participants in inpatient programs and 8,268 (99.9%) participants in residential programs were analyzed (Figure 1).

Data source

We obtained data on the national smoking cessation services from the Korea Health Promotion Institute, which is publicly available [16]. That data included demographics, health and smoking history, the experience of smokers in inpatient programs or residential smoking cessation programs from all 18 regional tobacco control centers in the nation during 2018, 2019, and 2020, and quit outcomes at 4 weeks, 12 weeks, and 6 months after quitting. The pilot phase of the inpatient smoking cessation program began in 2016 and regular services started in 2017. Residential programs started in 2015. The dataset was selected because both programs had become stable and comparable between 2018 and 2020, supported by sufficient funding and adequately trained staff.

Study variables

Dependent variables included continuous abstinence at 4 weeks, 12 weeks, and 6 months after quitting, as determined by self-report and/or biochemical verification [3]. Self-reported quit success was defined as answering “no” to the question, “Have you smoked even a single cigarette since you started this program?” at the 4-week follow-up, and “Have you smoked more than three cigarettes since you started this program?” at the 12-week and 6-month follow-ups.

Biochemical verification was based on an exhaled carbon monoxide (CO) level of less than 10 ppm or a negative urinary cotinine result, as assessed by each smoking cessation center. To minimize potential overestimation of success rates, missing data or loss to follow-up was classified as a failure to quit.

Independent variables included demographics, health and smoking history, and experience of program participation. Demographics included year of registration, age, gender, education, and occupation. Health history included insurance status, past medical history, alcohol use and exercise in the past year, blood pressure and body mass index (BMI) which both were measured by personnel in smoking cessation center. Smoking history included number of cigarettes smoked per day, age of smoking initiation, smoking years, Fagerström score, quit attempts, and duration of quitting in the past year. The experience of program participation included importance; confidence and readiness to quit at registration; withdrawal symptoms during the program; use of bupropion, varenicline, and nicotine replacement therapy (NRT); and the number of counseling sessions received in person, by telephone, and in total.

The Fagerström score is a six-item questionnaire used to assess the level of nicotine dependence, ranging from 0 to 10. A score greater than 7 indicates a high level of nicotine dependence [17]. Perceived importance, confidence, and readiness to quit at registration were each measured using a single-item, 11-point Likert scale (0-10), in response to the following questions: “How important is quitting to you?”, “How confident are you in your ability to quit?”, and “How ready are you to quit?” Higher scores indicate greater perceived importance, confidence, and readiness. Use of bupropion, varenicline, and NRT was determined based on any recorded prescription. Further details on these measurements have been reported previously [14].

Data analysis

We analyzed the data using IBM SPSS Statistics ver.25.0 (IBM CO., Armonk, NY, USA). Descriptive statistics included frequency with percentage and mean with standard deviation. Differences between means were tested using the t-test, and the differences between the percentages were tested using the χ² test.

We conducted multivariate logistic regression to identify predictors of continuous abstinence at 6 months of quitting, as determined by self-report or biochemical verification. Cut-off points for continuous variables were selected based on either the sample means or clinically meaningful thresholds. Continuous variables were dichotomized using the following cut-offs: age ≥65 years; systolic blood pressure ≥140mmHg; diastolic blood pressure ≥90mmHg; BMI ≥25kg/m²; number of cigarettes smoked per day ≥10; age at smoking initiation ≥20 years; duration of smoking ≥10 years; Fagerström score ≥6; duration of quitting in the past year ≥48 days; perceived importance, confidence, readiness, and self-efficacy to quit ≥8; number of in-person counseling sessions ≥4; number of telephone counseling sessions ≥4; and total number of counseling sessions ≥4. The analysis results are presented as adjusted odds ratios (aORs) with 95% confidence intervals (CIs) and p-values. All tests were two-tailed, and a significance level of .05 was used.

Ethical consideration

This study was approved by the Institutional Review Board (IRB NO.: 200827-2A) of the authors’ institution. The informed consent was exempted because the study was a secondary data analysis and the data was de-identified.

Results

The total number of cases analyzed was 17,290. Participants in the two programs differed significantly with regard to demographics, health and smoking history, and experience of program participation (Table 1). Their mean age was 54.80±12.04 years old; 14.5% were women. Compared with participants in residential programs, participants in inpatient programs were younger (54.10±13.18 vs. 55.57±10.60 years old), fewer had graduated high school (56.2% vs. 78.7%), fewer had jobs (60.9% vs. 66.5%), and fewer had national health insurance (75.5% vs. 83.8%). Fewer drank (46.5% vs. 72.3%), exercised in the past year (24.1% vs. 30.2%), and had lower systolic (125.38±14.29 vs. 127.41±44.44mmHg) and diastolic (78.28±9.77 vs. 80.22±10.47mmHg) blood pressure and BMI (23.65±3.81 vs. 23.84±3.28kg/m²).

Compared with participants in residential programs, participants in inpatient programs smoked fewer cigarettes (19.78±10.40 vs. 20.52±8.43/day), smoked for fewer years (35.12±13.42 vs. 36.76±10.38 years), and presented lower Fagerström scores (4.80±2.42 vs. 5.19±2.43). The data also showed that fewer tried quitting in the past year (33.5% vs. 47.2%), and their duration of quitting in the past year was also shorter (37.86±155.29 vs. 58.79±190.13 days). Their level of importance (8.72±1.94 vs. 8.83±1.75), confidence (7.28±2.42 vs. 7.43±2.26) and readiness (7.63±2.42 vs. 8.07±2.10) to quit were also lower. Fewer participants reported withdrawal symptoms during the program (2.9% vs. 7.6%) and used bupropion (0.3% vs. 2.1%), varenicline (15.3% vs. 43.7%) or NRT (18.9% vs. 27.2%). They received fewer counseling sessions during the program and follow-up period (6.31±3.41 vs. 9.76±3.16).

Table 2 presents the quit rates for the two programs at 4 weeks, 12 weeks, and 6 months after quitting, as assessed by both self-report and biochemical verification. Quit rates were consistently higher in the residential program across all follow-up periods, regardless of the assessment method. When quit status was assessed by self-report, quit rates in the inpatient program ranged from 78.0% at 4 weeks to 16.5% at 6 months. In comparison, self-reported quit rates in the residential program ranged from 92.6% at 4 weeks to 26.0% at 6 months.

At the 6-month follow-up, approximately 43.5% to 55.7% of participants in the inpatient program completed biochemical testing, compared to a higher proportion—45.9% to 74.4%—in the residential program. When quit status was assessed solely by biochemical verification, quit rates in the inpatient program declined to 23.2% at 4 weeks and 8.6% at 6 months. Similarly, in the residential program, biochemically verified quit rates declined to 64.6% at 4 weeks and 11.9% at 6 months.

Table 3 summarizes the results of multivariate logistic regression analyses identifying predictors of self-reported and biochemically verified smoking cessation at six months. After adjusting for covariates, participants in the inpatient program were significantly less likely to report quitting than those in the residential program (aOR=0.80, 95% CI=0.72-0.89, p<.001). Several factors were associated with a higher likelihood of self-reported quitting. These included older age (aOR=1.21, 95% CI=1.09-1.34, p<.001), being employed (aOR=1.17, 95% CI=1.06-1.29, p=.003), and having a past medical history (aOR=1.10, 95% CI=1.01-1.19, p=.024). Participants who began smoking at age 20 or older (aOR=1.23, 95% CI=1.14-1.33, p<.001), had smoked for more than 20 years (aOR=1.60, 95% CI=1.19-2.16, p=.002), or had maintained quitting for more than 48 days in the past year (aOR=1.20, 95% CI=1.07-1.36, p=.003) were also more likely to report quitting. Additionally, scoring above 8 in readiness to quit (aOR=1.24, 95% CI=1.12-1.38, p<.001), experiencing withdrawal symptoms during the program (aOR=1.19, 95% CI=1.01-1.41, p=.040), and using varenicline (aOR=1.35, 95% CI=1.23-1.47, p<.001) were positively associated with self-reported quitting. Frequent counseling was also a strong predictor of quitting, including in-person counseling (aOR=3.45, 95% CI=3.09-3.87, p<.001), telephone counseling (aOR=2.34, 95% CI=2.14-2.55, p<.001), and the total number of sessions (aOR=5.53, 95% CI=4.95-6.20, p<.001). On the other hand, several factors were associated with a lower likelihood of self-reported quitting. These included registering in 2019 (aOR=0.59, 95% CI=0.54-0.64, p<.001) or 2020 (aOR=0.13, 95% CI=0.12-0.15, p<.001), being female (aOR=0.76, 95% CI=0.64-0.89, p=.001), and receiving Medicaid (aOR=0.61, 95% CI=0.53-0.71, p<.001). In addition, having a Fagerström score above 6 (aOR=0.79, 95% CI=0.72-0.86, p<.001) and using NRT (aOR=0.77, 95% CI=0.70-0.84, p<.001) were associated with lower odds of self-reported quitting.

When the outcome assessment was limited to biochemically verified quitting, program type was not a statistically significant predictor of cessation (aOR=0.91, 95% CI=0.82-1.01, p=.082). Furthermore, some previously significant predictors—such as age, occupation, past medical history, readiness to quit, and withdrawal symptoms, and the number of counseling session on telephone during the program—were no longer statistically significant in this model. Instead, new predictors emerged. Alcohol use was associated with lower odds of verified quitting (aOR=0.83, 95% CI=0.76-0.91, p<.001), whereas having exercised in the past year was associated with higher odds (aOR=1.14, 95% CI=1.04-1.24, p=.006). Participants who had attempted to quit in the past year were less likely to succeed in biochemically verified cessation (aOR=0.83, 95% CI=0.75-0.92, p<.001). Notably, the use of varenicline remained a significant predictor but was inversely associated with quitting success in this model (aOR=0.88, 95% CI=0.80-0.97, p=.007).

Discussion

This descriptive study explored quit rates and predictors of quitting among participants in two national smoking cessation programs in Korea: the inpatient program and the residential smoking cessation program. Quit rates were high in both programs, with the rates for the residential program approximately twice as high as those for the inpatient program. This finding is consistent with previous research conducted by Korean scholars who analyzed the same dataset, though in different years and using data from only one regional center [7]. Lee and colleagues [7] examined data from 996 participants in the inpatient program and 477 participants in the residential program between 2018 and 2020, all from a single regional center. They reported 6-month quit rates based on self-report, which were 21.6% for the inpatient program and 62.1% for the residential program.

Similarly, Park and colleagues [6] analyzed data from 570 participants in a residential program between 2017 and 2018 at another regional center. They reported self-reported quit rates of 63.2% and biochemically verified quit rates of 46.1%.

The effectiveness of smoking cessation programs for patients in hospital has been well-reported internationally [18]. The degree of effectiveness on quit rates is similar to our findings. In their retrospective study, Kuo and colleagues assessed the effectiveness of an inpatient counseling program for 1,943 patients and reported a 40.0% quit rate at 6 months, including self-reports [10]. Meanwhile, the quit rates of residential programs in our study were higher than those of similar residential programs reported in other countries. Hays et al. evaluated the quit rates of 226 smokers who participated in an 8-day residential program and reported 52% of 7-day point prevalence smoking abstinence rate at 6 months including self-reports [5]. In their study, Ho et al. [11] evaluated quit rates of 40 smokers who participated in a 3-day residential program and reported 57.5% of self-reported 7-day point prevalence abstinence rate at 26 weeks.

However, our multiple logistic regression analysis showed that program type was not an independent predictor of biochemically verified quitting. This finding suggests that the higher quit rates observed in the residential program, compared to the inpatient program in the simple comparison, may be attributable to differences in participant characteristics, program content, and outcome measurement methods. First of all, the participants of the residential programs were heavier smokers but highly motivated. They smoked more cigarettes daily, smoked for more years, and had higher Fagerström scores than those in inpatient programs, which is consistent with recruiting policy for the program [3]. Lee and colleagues compared participants, quit outcomes, and predictors of quit in an inpatient program and a residential program [7]. They also reported that participants in the residential program were heavier smokers, older, and were more likely to be college educated and have white collar jobs.

At the same time, participants presented higher perceived importance, confidence, and readiness to quit. Their high motivation might reflect what they had to overcome to participate in the residential program: time commitments and probably paid leave. Paid leave for nicotine addiction treatment has been controversial, but studies have shown that smoking cessation decreases the risk and the number of sick leaves at work [19]. Therefore, smoking cessation programs in the work place benefit both employers and employees alike. However, employers’ knowledge of and attitude toward smoking cessation programs in the workplace leaves much to be desired. In their study of 580 companies in Hong Kong, Wang and colleagues found that only 10% of companies had voluntarily promoted smoking cessation programs [20]. No data were available about employer-initiated smoking cessation programs in workplaces in Korea. It makes sense, then, that employees have a better chance to receive quality services in an intensive residential smoking cessation program offered by a regional tobacco control center.

In addition, participants were more likely to quit when they received more frequent, in-person counseling. The number of counseling sessions reflects a program’s intensity and is a well-known predictor of quitting with other variables in this study such as male gender, receiving more frequent counseling, being less addicted to nicotine, having health insurance, late onset (age) of smoking, fewer smoking years, and lower Fagerström scores [8,18]. Because the length of residential programs varied from 8 days to 3 days in earlier studies, the content and format of programs also varied [5,11]. Hays et al. designed a program that included 12 hours of individual and group counseling for 8 days, but follow-up counseling was not mandatory [5]. In their residential program, Ho et al. offered group counseling for only 3 days and individual counseling sessions as follow-up [11]. The residential programs described in this study seem more intensive than those in previously reported programs.

In our study, the number of counseling sessions was the only variable that reflected the contents of a program. Considering that the average of length of hospital stay in Korea is 7.8 days [21], most participants might have had one or two counseling sessions during their hospital stay with the remainder of counseling taking place during follow-up periods. However logistic regression to predict biochemically proved quit rates at 6 months revealed that the rates for inpatient and residential programs did not differ, after adjusting for various factors, including the number of counseling sessions.

Lastly, it is noteworthy that a higher proportion of participants in the residential program completed biochemical verification of smoking status at the 6-month follow-up. The specific characteristics of the residential program that may contribute to this increased likelihood of follow-up verification remain unclear. Previous studies have suggested that providing souvenirs or incentives can improve smoking cessation outcomes; however, many smokers participating in national smoking cessation programs are unaware that such items are available upon program completion [22]. Participants in the residential program may have been more informed about these incentives due to more frequent and closer interactions with program staff throughout the intervention.

This study has several limitations. First, because it was an observational study, causal relationships cannot be established. Several potential confounding factors, such as depression and the use of electronic cigarettes, were not included in our analysis. Additionally, we lacked information on the duration of participants’ stays in the inpatient program and their primary diagnoses, which could influence the length of stay. We also did not have data on whether participants in the residential program were on paid leave or received other forms of financial compensation. Some employers may offer incentives to employees who successfully quit smoking. Furthermore, due to the lack of detailed product information, we were unable to assess the accuracy and consistency of biochemical verification methods across different centers.

Some variables showed unexpected associations with biochemically verified quitting at 6 months—for example, past-year quit attempts, use of varenicline, and use of NRT. These variables may have bidirectional effects on smoking cessation or may reflect measurement or misclassification bias. For instance, individuals for whom quitting is particularly difficult may become less motivated over time or may relapse more quickly. Likewise, the use of varenicline or NRT may indicate more severe withdrawal symptoms, suggesting a higher risk of cessation failure [23]. However, we did not have data on the total dosage used or whether participants experienced side effects from NRT.

Participants who enrolled in 2020 showed the lowest quit rates. This finding aligns with our results highlighting the importance of in-person counseling. During the COVID-19 pandemic, participation in many health promotion programs declined. Kim and Lee analyzed tobacco sales and national smoking cessation clinic data to examine annual trends, including the pandemic period [24]. They reported that tobacco sales increased by 4.8% in 2020 compared to 2019, while the number of program participants decreased in the first half of 2020. Furthermore, the 6-month quit rate dropped by 13 percentage points—from 35.1% in 2019 to 22.3% in early 2020. These findings suggest a need for well-designed online programs as substitutes for in-person services, as well as long-term follow-up support for individuals who are busy or live in remote areas.

Conclusions

This retrospective observational study explored the quit rates of two national smoking cessation programs in Korea: inpatient programs and 5-day residential programs. These environments made smoking abstinence during the most risky time for relapse. Analysis indicated that both programs offered high quit rates, more in-person counseling sessions, and better quit outcomes.

In order to mitigate the adverse health risks associated with tobacco use among individuals characterized as heavy smokers who have experienced repeated failures in quitting attempts, a comprehensive and culturally sensitive intervention of high intensity is warranted. Among the potential interventions, both a residential smoking cessation program and an inpatient program for patients admitted to healthcare facilities offer distinct opportunities for quitting. We propose that behavioral health professionals seriously consider the feasibility and potential efficacy of these intervention modalities, given their ability to yield significant cessation outcomes, particularly when complemented by adequate health insurance coverage.

We recommend that more frequent, in-person counseling is necessary to improve quit outcomes in inpatient programs. However, such counseling is often not feasible due to patients’ condition or risk of infection. Well-designed, no-contact services can be an alternative way to provide service, particularly during the post pandemic era. However, further study is needed to determine its feasibility and effectiveness as compared with in-person programs. Varenicline and NRT are standard interventions for smokers, but they may not be effective enough to achieve lasting abstinence. Literature reported that those medications are under-utilized in certain ethnicity [25]. Future researchers should evaluate compliance, side-effects, inconvenience, and individual and cultural barriers to taking medication to assess its effectiveness on quit outcomes.

Figure 1.

Overview of study participants.

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Figure & Data

References

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