User characteristics of national smoking cessation services in Korea: who chooses each type of tobacco cessation program?

Smoking is recognized as an addictive behavior that needs systematic help from society for discontinuation; thus, active intervention for smoking cessation is considered crucial [1‐3]. Therefore, tobacco cessation services have been developed [4, 5] and offered in many countries [6]. Although the type of service differs among countries depending on the available resources, at least two types of cessation services are offered together to achieve user convenience and increase coverage in some countries [7‐9]. Relatively little is known about which characteristics of smokers are related to choosing a specific type of service within the same society.

In the Republic of Korea, where the prevalence of smoking is high despite significant progress in reducing that rate from 28.8% in 2005 to 23.2% in 2013 and smoking-attributable mortality has been increased from 30.8% in 2003 to 34.7% in 2012 for male (from 5.78% in 2003 to 7.2% in 2012 for female), three types of smoking cessation services have been developed and adopted at the national level with governmental support. [10, 11] Thus, a large proportion (57.5%) of current Korean smokers has tried to quit, and PHC-based SCCs has been described as highly cost effective service. [12, 13].

However, there has been little cross-comparison of user characteristics of different types of cessation services, which is important to determine the most appropriate type of service for the target population and to make each service could focus more on appropriate target population.

In this context, the present study aimed to identify which type of smokers choose which type of cessation service as well as how the users of cessation services differ from smokers in the general population.

The proportion of female smokers was smaller among users of PHC-based SCCs (9.6%) than among users of the WSCS and Quitline as well as in the general population (Table 1). The proportion of smokers over the age of 50 was greatest among users of a PHC-based SCC (38.0%), while the proportions of smokers aged 19–29 and 30–39 were highest among the users of the WSCS (45.7%) and Quitline (40.6%), respectively. The distribution of smokers by area of residence was similar among users of all three types of services and in the general population, except that overseas users were identified only in the WSCS.

While manufacturing and production (30.3%) was the most prevalent occupational category among smokers in the general population, office workers were most prevalent among the users of Quitline (32.8%) and “others” (e.g., housewives, unemployed people, and university students) were the most prevalent among users of PHC-based SCCs (35.1%). These occupational categories were followed by “others” and small business owners, respectively.

The number of cigarettes smoked per day was about twice as high among service users as in the general population. Smokers who had greater nicotine dependency were most prevalent among users of the WSCS and least prevalent among the users of Quitline.

This study analyzed and compared the general characteristics of users who accessed three types of national smoking cessation services in one country to determine which smokers chose which type of cessation service. The user characteristics for the three types of smoking cessation services differed by sex, age, occupation, and level of nicotine dependency. They also differed from the characteristics of smokers in the general population. The cessation rate of each service is different or not directly comparable because service contents and form of delivery are different by the type of service. In addition, WSCS do not calculate and suggest the cessation rate, Quitline usually accounts smoking cessation rate as the 1-year abstinence rate (25.2% in 2009) which do not allow only one puff of cigarette smoke after starting quit, and SCCs suggested 6-month cessation rate (44.0% in 2009) which is not strict as much as abstinence rate in Quitline.

Based on our results, WSCS could be appropriate for younger smokers who are more familiar with using the internet and are more engaged in Internet-based social networks and activities than offline ones [16, 17]. As identified, WSCS could also be appropriate for overseas users. This information could be used to develop smoking cessation strategies for immigrants who come from countries where smoking is common and who therefore have different social and cultural contexts for smoking and cessation behaviors [18‐20].

In contrast, Quitline could focus on middle-aged office workers who are less comfortable using a WSCS than younger smokers and who are engaged in their jobs during the daytime. These users could receive individualized support for cessation tailored to their own needs and daily schedules. A telephone-based service can be timed to maximize the level of support around a planned quit date and can be scheduled in response to the needs of the recipient and Quitline itself [21].

For older smokers (over the age of 50), housewives, and retired or unemployed people, who are the predominant users of free community-based health services, PHC-SCCs could be prioritized. These people might have enough time to visit a PHC- SCCs, have easy access to the services and expect emotional support via direct human contact. In particular, older smokers, those who have been smoking for a long time, and those who have previous experience quitting may feel it is little for them to learn from behavioral treatment, but their experience of past failures may fuel a perceived need for pharmacological treatment, including NRT [22, 23].

For female smokers, web- and telephone-based cessation services, which offer an anonymous form of service delivery, would be highly desirable because of the social stigma associated with female smoking in Korea. How manufacturing and production workers could be effectively reached by cessation services should be considered since most smokers in the general population are manufacturing and production workers, but most service users are not. Different levels of user nicotine dependency among users of the three types of cessation services should be considered carefully because smokers showing higher levels of nicotine dependency were more prevalent among users of the WSCS, which is a stand-alone program and therefore is not usually appropriate for highly addicted smokers.

Regarding the main study results mentioned above, differences on the familiarity on the service channel, accessibility on each service offered, a form of service delivery in terms of confidentiality, and availability of contents offered by each service might cause smokers to choose a different type of service. Although access and availability of each type of cessation service are not directly linked to the effectiveness of cessation, it is an important issue how much cessation service can reach to smokers without regard to user characteristics and service type deciding accessibility and availability of each cessation service. Furthermore, to achieve the effectiveness of cessation service delivery, it looks necessary to make smokers could access to the appropriate type of cessation service not only for their convenience and service accessibility but also for their smoking behaviors including nicotine dependency and cessation contents offered by each service.

Limited information on user characteristics was available for the comparison and information on occupation was not available for WSCS participants. As well, even though some of smokers might have experience to use more than one type of cessation services, it was not accounted in the comparison of user characteristics by the type cessation services. Therefore, it was not fully explained what factors associated with the difference of user characteristics in each service, even the differences in user characteristics shown in the present study. Those are the limitation of the present study due to using secondary data with the cross-sectional design. However, they could not affect the main result of the present study which is cessation service preferred might be different by the user characteristics and preference depending on the contents and accessibility of each cessation service offers.

Recently, more different type of cessation services, which are hospital-based cessation camp, cessation clinics supported by national health insurance cooperation, outreach program to help cessation for specific target population such as female, adolescents, and military serviceman, have been developed and launched at the national level to expand accessibility of smokers to cessation service. Therefore, in the future, repeating the comparison study including other service types newly launched could be expected. In addition, studies to clarify the reasons for the differences in user characteristics shown in the present study are needed. These results could be referred to by other countries where cessation services are planned or under development as well as they could provide practical feedback for improving national smoking cessation services in Korea in terms of how appropriate types of services could be suggested regarding user characteristics and preferences. Furthermore, offering specific type of cessation services regarding the characteristics or situation of smokers which is related to the accessibility to the services, easiness of service use, confidentiality on the privacy, and etc. could contribute to reduce the smoking prevalence, more effectively.