Introduction

A residential smoking cessation therapy program was developed as an intensive form of smoking cessation treatment targeting heavy smokers who face difficulties in trying to quit smoking on their own [1]. In particular, the program targeted individuals who have high nicotine dependence and experience repeated relapses, as well as those with acute or chronic illnesses that require urgent smoking cessation [1]. Previous studies have demonstrated that residential smoking cessation programs are more effective than outpatient smoking cessation therapy [2]. Two studies found that the 6-month rate of abstinence was significantly higher for residential programs than for outpatient programs (52% vs. 27% and 45% vs. 26%, respectively) [2,3].

Previous studies on treatment programs for residential smoking cessation identified associations between smoking cessation success and factors such as the average number of cigarette packs smoked per day, total years of smoking, nicotine dependence, age, body mass index (BMI), and alcohol consumption [4,5]. Furthermore, a previous study analyzed the relationship between smoking cessation success and psychological status, including the perception of smoking cessation effects, stress, and depression [6]. The results indicated that depression and stress did not affect smoking behavior or other smoking-related psychological states. However, to our knowledge, no studies have assessed how changes in the thoughts and attitudes of smokers are associated with success in quitting smoking after completion of a residential smoking cessation therapy program. This study aims to investigate smoking-related psychological status and changes in smoking cessation-related characteristics before and after a residential smoking cessation therapy program for heavy smokers and to analyze their association with smoking cessation success.

Methods

Ethics statement: This study was conducted in accordance with the guidelines of the Declaration of Helsinki and was approved by the Institutional Review Board (IRB) of Pusan National University Hospital (IRB No: 2308-008-1292). Participant consent was waived because of the anonymity of the data and the retrospective nature of the study.

1. Participants and treatment

From January 2017 to December 2018, 371 participated in a residential smoking cessation therapy program at Pusan National University Hospital. In this study, 291 male participants were included, while 15 female participants and 65 participants with missing data were excluded. The inclusion criteria required participants to satisfy at least one of the following conditions: having smoked for ≥20 pack-years or smoking >20 cigarettes per day, which were defined as indicators of severe smoking in a previous study [6].

During the treatment program, participants received two individual and five group counseling sessions for a duration of 4 nights and 5 days in the hospital. A trained smoking cessation counselor provided counseling using motivational and cognitive behavioral techniques. Participants also attended lectures on various topics, including smoking-related diseases, stress management, and smoking cessation medications.

At a pre-visit 2 weeks prior to the program, participants completed a questionnaire that included information on education level, marital status, smoking, drinking, and exercise. At the pre-visit and on the 5th day of the program, participants were required to complete five psychological questionnaires aimed at investigating smoking cessation-related characteristics, including the Fagerström Test for Nicotine Dependence (FTND), Perceived Smoking Cessation Effect Scale (PSCES), Kim’s Smoking Cessation Motivation Scale (KSCMS), and self-efficacy/temptation. The FTND was used to assess nicotine dependence, the PSCES was used to evaluate perception of the positive and negative effects of smoking cessation, and the KSCMS was used to assess motivation for smoking cessation. Self-efficacy/temptation was used to evaluate the degree of endurance to smoking temptation and temptation to smoke. Additionally, to assess smoking-related psychological status, the following questionnaires were administered: Center for Epidemiologic Studies Depression Scale, Perceived Stress Scale for Koreans (PSS-K), and Emotion Regulation Strategy Questionnaire (ERSQ).

Evaluations of smoking cessation and regular maintenance counseling sessions were conducted at 4, 6, 12, and 24 weeks through face-to-face or phone consultations. The final assessment of smoking cessation success was based on a urine cotinine test performed at 24 weeks. Failure was defined as either resumption of smoking or loss of contact. Participants had the option of using smoking cessation medications or nicotine replacement therapy as needed.

2. Statistical analysis

The general characteristics, smoking cessation-related characteristics, and smoking-related psychological variables of the participants were compared using t-tests and chi-square tests. Paired t-tests were used to compare the PSCES, KSCMS, and self-efficacy/temptation scores before and after the residential program. Pearson correlation test was used to examine the correlation between general characteristics, smoking cessation-related characteristics, and psychological status variables. Logistic regression was used to evaluate the effects of smoking cessation-related characteristics and psychological status variables on smoking cessation success, after adjusting for age, marital status, BMI, FTND, total smoking period, average daily smoking, drinking, and exercise. IBM SPSS ver. 26.0 for Windows (IBM Corp., Armonk, NY, USA) was used for statistical analyses, and p-values of <0.05 were considered statistically significant.

Results

The success group participants had a significantly longer total smoking period (39.51±9.31 years, p=0.038), a higher average age (58.32±9.51 years, p=0.025), and a higher marriage rate (89.2%, p=0.002). The proportion of participants with moderate or high nicotine dependence was lower in the success group (n=170, 76.7%). However, this difference was not statistically significant (p=0.114), as shown in Table 1. The ERSQ inadequate strategy score was higher in the failure group (33.30%±15.33% vs. 26.90%±12.43%, p=0.002), indicating that maladaptive emotion regulation strategies were more frequently adopted by participants in this group. The proportion of participants who had high scores for levels of stress (PSS-K ≥24) was higher in the failure group (43.5% vs. 26.6%, p=0.008).

The majority of smoking cessation-related characteristics improved in both groups after the program, as shown in Fig. 1. However, in the failure group, perception of the negative effects of smoking cessation (p=0.593) and the degree of temptation to smoke (p=0.261) were not significantly different before and after the residential therapy program. In addition, among the five smoking cessation-related characteristics, no significant differences were observed in the score changes after the program between the two groups in terms of motivation for smoking cessation (mean±standard deviation: success, 2.63±0.36 and failure, 1.94±0.64; p=0.355), perception of the positive effects of smoking cessation (success, 6.61±0.88 and failure, 5.06±1.58; p=0.390), and degree of endurance to smoking temptation (success, 7.15±0.63 and failure, 5.87±0.91; p=0.302). However, the perception of the negative effects of smoking cessation (success, –6.85±1.21 and failure, –1.45±2.70; p=0.042) and the degree of temptation to smoke (success, –4.18±0.63 and failure, –1.30±1.15; p=0.028) showed a smaller reduction in the failure group than in the success group.

Next, we tested the correlation between changes in the perception of the negative effects of smoking cessation, the degree of temptation to smoke, and other clinical factors in both the success and failure groups separately, as shown in Table 2. Age and smoking period showed a significant positive correlation with changes in perception of negative effects in the success group (age: r=0.190, p=0.005; smoking period: r=0.164, p=0.015) and failure group (age: r=0.266, p=0.027; smoking period: r=0.245, p=0.042). The ERSQ ineffective strategy score was correlated with a change in perception of negative effects (r=–0.313, p=0.009) in the failure group. The change in perception of negative effects showed a significant negative correlation with the KSCMS in both the success (r=–0.135, p=0.044) and failure (r=–0.297, p=0.013) groups, and a significant correlation with change in degree of temptation (r=0.311, p≤0.001) and degree of endurance to smoking temptation (r=–0.206, p=0.002) in the success group. The change in degree of temptation showed a significant negative correlation with change in degree of endurance in both the success (r=–0.377, p<0.001) and failure (r=–0.275, p=0.022) groups.

We identified several key factors believed to be associated with successful smoking cessation as outlined in Table 3. Participants whose perception of negative effects increased (odds ratio [OR], 0.982; 95% confidence interval [CI], 0.967–0.997) after the program, and those whose degree of temptation to smoke increased (OR, 0.960; 95% CI, 0.929–0.993) had lower success in smoking cessation.

Discussion

We conducted a study to test the hypothesis that changes in the smoking-related characteristics of heavy smokers affect smoking cessation success after a residential smoking cessation therapy program. The residential treatment program enhanced smokers’ motivation for smoking cessation, reduced negative perceptions of smoking cessation and the degree of temptation to smoke, and increased positive perceptions. In particular, a decrease in negative perceptions of smoking cessation and the degree of temptation to smoke were key factors in successful smoking cessation. Moreover, the success rate of smoking cessation decreased in participants who used higher-frequency maladaptive emotion regulation strategies to manage unpleasant emotions.

The program was effective in helping participants successfully quit smoking. In particular, a reduction in the perception of the negative effects of smoking was associated with increased motivation for smoking cessation, and in the success group, it was related to a decrease in the temptation to smoke and an increase in the endurance to smoking temptation. The greater the extent of change in the degree of temptation and perception of negative effects, the more positive the influence on success in quitting smoking. Previous studies have indicated that increased motivation and enhanced self-efficacy for smoking cessation are positively associated with successful smoking cessation. In this study, they correlated with a decrease in the perception of the negative effects of smoking cessation. This suggests that a reduction in the perception of the negative effects of smoking cessation influences other positive factors related to smoking cessation [7,8].

Self-efficacy in smoking cessation was evaluated in terms of temptation to smoke and smoking temptation endurance. The success group exhibited a significant decrease in temptation to smoke at program completion compared to the initial measurement, whereas the failure group did not show a significant difference. According to Bandura’s self-efficacy theory [9], self-efficacy determines the initiation and maintenance of behavioral changes when faced with certain situations. Previous studies have shown that self-efficacy for smoking cessation impacts the success of cessation [8,9].

A higher score on the negative effects of smoking cessation after the program was associated with lower rates of smoking cessation success. Additionally, a greater reduction in the score for negative effects of smoking cessation after the program was linked to a higher rate of smoking cessation success. These findings align with those of a previous study that found an association between the perception of barriers to smoking cessation and relapse [10].

Individuals who frequently employ maladaptive strategies to cope with negative emotions may face difficulties effectively managing uncomfortable emotional states. Consequently, impulses and cravings to smoke may increase to avoid unresolved negative emotional states. The success rate of smoking cessation was low among participants who frequently used maladaptive emotion regulation strategies. This finding is similar to that of previous research, which found that a higher frequency of using such maladaptive strategies was associated with early relapse, increased smoking cravings, and failed attempts to quit [11,12]. Avoiding negative emotional states is important for maintaining smoking cessation, and negative emotions can increase a smoker’s attention to smoking cues [1,4,13,14]. Previous studies have demonstrated that nicotine diminishes attention to stimuli associated with negative emotions among smokers [15].

This study had some limitations. First, the number of participants was small, which may make it difficult to extrapolate the findings to the general population. Second, a subset of missing data from the psychological questionnaires was not included in the analysis. The results should be interpreted cautiously, as there may be differences in the actual population, because approximately 20% of all participants did not respond to some questions. Third, the actual smoking cessation success rate may have been higher than reported in the analysis, as participants lost to follow-up before 24 weeks among the 291 participants were considered failures. Fourth, the analysis did not consider the effects of concurrent smoking cessation treatments such as medications or nicotine replacement therapy. The influence of these additional treatments may have led to different outcomes.

However, this study examined the impact of changes in smoking cessation-related characteristics after a residential smoking cessation therapy program on 6-month smoking cessation success among heavy smokers. Such research has rarely been conducted. Future studies should be conducted by including a larger sample and implementing comprehensive assessments of smoking-related psychological status and smoking cessation-related characteristics.

Psychological changes in perceptions of the effects of smoking cessation, self-efficacy in smoking cessation, and emotion regulation strategies are related to successful smoking cessation. A residential therapy program for smoking cessation may provide a more successful strategy for reforming cessation therapies and improving the capacity of important therapeutic factors.

Article information

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Funding

This study was supported by the Health Promotion Fund of the Ministry of Health and Welfare, Korea (2019-021). This study was supported by a clinical research grant from Pusan National University Hospital in 2023.

Author contributions

Conceptualization: GLK, YHY; Methodology: JIC, YJR; Software: YJR; Validation: YHY, YL, SYL; Formal analysis, Data curation: JGL; Investigation: YJR, SHL; Resources, Supervision, Funding acquisition: YHY; Visualization: GLK; Project administration: EJP; Writing-original draft: GLK; Writing-review & editing: YHY, YJT, YHC.

Fig. 1.

Comparison of changes in smoking cessation-related characteristics after the residential therapy program between the success and the failure groups. (A) Smoking motivation. (B) Perception of the positive effects of cessation. (C) Perception of the negative effects of cessation. (D) Temptation to smoke. (E) Endurance to smoking temptation. Paired t-tests are used to calculate p-values.

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Figure & Data

References

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