Smoking Cessation and Relapse among Smoking Cessation Scholarship Beneficiaries

Smoking is the leading cause of preventable death in developed countries and is the most important risk factor for cancer worldwide, responsible for approximately 22% of all cancer deaths per year1. Korea’s adult smoking rate is still high among OECD countries; thus, the health and socio-economic burdens caused by smoking are also very high2. As a transition stage from adolescence to adulthood, one’s college years are the peak period for one’s physical, intellectual, and social development3. This period is also important since it forms the basis of one’s lifelong health4. Therefore, health problems during this period may pose a significant threat to one’s lifelong health. However, college students tend to forget or neglect the importance of health. For many students who are living independently from their parents and families for the first time, it is easy to adopt unhealthy lifestyle habits like smoking due to a variety of psychosocial and mental stresses related to employment or academics3,4. In the case of Korea, where smoking is considered to be a form of social deviance during middle and high school, there is growing social acceptance of smoking among college students5. Accordingly, the high school student smoking rate of 21.4%6 increases to 40.5% among men in their 20s, and the smoking rate for women in their 20s is the highest compared to that of women in other age groups. The Korean Government has implemented a variety of Abstract


Introduction
Smoking is the leading cause of preventable death in developed countries and is the most important risk factor for cancer worldwide, responsible for approximately 22% of all cancer deaths per year 1 . Korea's adult smoking rate is still high among OECD countries; thus, the health and socio-economic burdens caused by smoking are also very high 2 .
As a transition stage from adolescence to adulthood, one's college years are the peak period for one's physical, intellectual, and social development 3 . This period is also important since it forms the basis of one's lifelong health 4 . Therefore, health problems during this period may pose a significant threat to one's lifelong health.
However, college students tend to forget or neglect the importance of health. For many students who are living independently from their parents and families for the first time, it is easy to adopt unhealthy lifestyle habits like smoking due to a variety of psychosocial and mental stresses related to employment or academics 3,4 .
In the case of Korea, where smoking is considered to be a form of social deviance during middle and high school, there is growing social acceptance of smoking among college students 5 . Accordingly, the high school student smoking rate of 21.4% 6 increases to 40.5% among men in their 20s, and the smoking rate for women in their 20s is the highest compared to that of women in other age groups.
The Korean Government has implemented a variety of policies to reduce the social damage caused by smoking. From March 2005, government-sponsored smoking cessation clinics have been conducted in health centers nationwide. Therapies include public health counseling (behavioral therapy) and nicotine replacement therapy (nicotine patch, nicotine gum), which provides drug therapy according to smokers' characteristics 7 . Smoking cessation reduces health risks and improves quality of life. In particular, the cumulative risk of dying of cancer or cardiovascular and lung diseases can be drastically reduced by quitting smoking, even at an advanced age [8][9][10] . Based on these considerations, this study aims to identify the factors affecting smoking cessation success among students who received a scholarship to enroll in smoking cessation clinics. The study was conducted to serve as the basis for the improvement of the smoking cessation education programs conducted at the University Health Clinic.

Study Subjects and Ethical Considerations
This research is a descriptive correlation study designed to examine the factors associated with success and failure in smoking cessation among smoking cessation scholarship beneficiaries at N university. The data was collected via structural questionnaires completed by 139 students studying at N university who agreed to participate in this study. All data used was collected according to the approved guidelines and screening procedures of "N University" located in Cheonan. All experiments of the present study were also approved by the Institutional Review Board [IRB No: NSU-151130 -1] at "N" University. We obtained a sample of 139 students who received smoking cessation scholarships. It is a proper sample size with a significance level (α) of 0.05, a power (1-β) of 0.95, and a medium effect size (f) of 1.5 according to the G*power 3.1.9.2 program.

Test Method
The data was collected from September 2015 to November 2015 and was analyzed using SPSS 20.0 (SPSS Inc., Chicago, IL, USA). The general characteristics were analyzed using descriptive statistics, including the means, standard deviations, frequencies, and percentages.
Patterns in the differences among study participants (according to general characteristics related to smoking cessation success) were analyzed with χ2-test. Logistic regression analysis was used to determine the influence on smoking cessation success.
When asked, "What was your motivation to attend a smoking cessation clinic?" 84 students (60.4%) answered "information provided by health clinics", and 27 students (19.4%) answered "difficulty of quitting smoking by oneself ". The main improved symptom after smoking cessation was decreased cough and sputum (72 students, 51.8%). The main changes reported after smoking cessation were weight gain (63 students, 45.3%) and improved health status (34 students, 24.5%). There were 67 students who failed to quit smoking (48.2%). The main reasons for relapse of smoking were as follows: surrounding temptations (21 students, 31.3%); weakness of willpower (19 students, 28.4%); maintaining interpersonal relationships (11 students, 16.4%); withdrawal symptoms (4 students, 6.0%); stress (11 students, 16.4%); and the desire to smoke when drinking alcohol (10 students, 14.9%). The most commonly attempted method of smoking cessation was exerting willpower (86 students, 61.9%). Additionally, in-home smoking was reported by 94 students (67.6%); 45 students did not smoke at home (32.4%). When asked, "Have you received a health checkup within the last 2 years"? 22 students answered "yes" and 113 said "no". To the question of "How much stress do you feel"? 45 students (32.4%) answered "a lot"; 75 students (54.0%) said "a little"; and 19 students (13.7%) said "none at all". When asked, "How do you relieve stress"? 61 students (43.9%) answered "by drinking alcohol". Eighty-one students (53.8%) said they engage in regular exercise. The differences in smoking cessation success among students according to their general characteristics and smoking-related factors are shown in Table 1. The research participants' attitudes on smoking cessation success showed statistically significant differences according to the following factors: CO 2 ppm (χ 2 = -42.238, p<. 001); cigarettes smoked during the period (χ2 = -5.488, p = .027); nicotine dependency (χ 2 = -97.710, p<.001); helpfulness of the smoking cessation clinic (χ2 = -16.820, p<.001); smoking cessation education programs (χ2 = 38.212, p<.001); whether or not the smoking cessation clinic was considered to be helpful (χ2 = 16.820, p<.001); and recognition of the need for followup programs (χ2 = -21.252, p<.001). The differences in smoking cessation success among students according to smoking-related factors are shown in Table 2 and were as follows: Motivation (χ2 = 13.941, p = .004); the most important factor for remaining a non-smoker (χ2 = 6.243, p = .044); the biggest reason for continued smoking cessation (χ2 = 24.989, p<.001); post-cessation changes in symptoms (χ 2 = 28.438, p<.001); the most attempted method of smoking cessation, willpower (χ2 = 37.206, p<.001); and in-home smoking (χ 2 = 54.653, p<.001). The differences in smoking cessation success among students according to physical characteristics are shown in Table 3. The research participants' attitudes on smoking cessation success showed statistically significant differences according to the following factors: Stress (χ 2 = 23.852, p<.001); stress relieving methods (χ2 = 50.512, p<.001); body size (χ 2 = 5.588, p = .013); regular exercise (χ 2 = 17.552, p<.001); and health checkup (χ2 = 6.747, p = .029). To determine the influence of smoking cessation, a logistic regression model was used. For the general characteristics model, the results of the Hosmer-Lemeshow goodness-of fit test were χ 2 = .387, p = 1.000. Among these factors (Table 4), CO 2 /ppm (p<.001), regular education (p = .002), attendance at a smoking cessation clinic (p = .021), and recognition of the need for a follow-up program (p = .006) were shown to exert a significant influence on smoking cessation. The helpfulness of the smoking cessation clinic was shown to have the greatest influence on smoking cessation (B = .212). Among smoking-related characteristics ( Table  5), recognition of the need for follow-up programs (p = .035), weight gain (p<.001), improved self-confidence (p = .001), willpower (p<.001), and in house smoking (p<.001) were shown to exert a significant influence on smoking cessation. Improved self-confidence was shown to have the greatest influence on smoking cessation (B = 18.000). The smoking-related characteristics model was found to be suitable. The results of the Hosmer-Lemeshow goodness-of fit test were χ 2 = 2.268, p = .972. Among physical-related characteristics (Table  6), drinking as a method of relieving stress (p = .002), engaging in regular exercise (p = 0.28), and health checkup (p = .040) were shown to exert a significant influence on smoking cessation. Drinking was shown to have the greatest influence on smoking cessation (B = .185). The physical-related characteristics model was found to be suitable. The results of the Hosmer-Lemeshow goodnessof fit test were χ 2 = 4.765, p = .782.

Discussion
This study is an attempt to identify the factors affecting smoking cessation among students who received a scholarship to enroll in a smoking cessation clinic. It was conducted to develop a smoking education program at the University Health Clinic. In general, the factors which showed statistically significant differences were as follows: CO 2 ppm, cigarettes smoked during the period, nicotine dependency, the helpfulness of the smoking cessation clinic, and recognition of the need for followup programs. These findings are similar to the findings of Lee's paper 11 . The smoking cessation success rate of these participants was significantly high. This indicates that smoking cessation success is likely due to receiving a smoking cessation scholarship. The success rate of smoking cessation was statistically higher in the group that received smoking cessation education. This is similar to the results of a study by 12 . Their finding that a single lecture significantly improved knowledge about tobaccorelated issues one year later is similar to the results of this study and is a finding of considerable interest. Additionally, the finding that the smoking cessation success rate was significantly higher in the group which recognized the need for smoking cessation education is thought to be another reason for the similarity of the research findings. Education has been identified as a potent sociodemographic predictor of smoking cessation, and the Healthy People 2010 goals include the elimination of health disparities attributable to education. This report indicates that poorly educated smokers are less likely to quit smoking than highly educated smokers because they tend to be more nicotine dependent and are employed in settings where there is less support for quitting 13 . Therefore it appears that conducting enhanced smoking cessation education programs is a good way to guide more students to smoking cessation success in the future.
The present findings suggest that targeting willpower may be an important strategy to incorporate into specialized intervention programs for smoking cessation. In this study, when asked "What is the most important thing to remain a non-smoker"? 51 students (36.7%) answered "willpower". Among these students, 64.7% successfully quit smoking. Angela reported that the possession of willpower by an individual was seen to be essential. The ability to mobilize that required willpower was perceived as the key factor of success 14 . Also, further research reported that the effectiveness of nicotine dependence medications on smoking cessation was also related to willpower 15 . These results are similar to the results of the current study.
In this study, among the 63 participants (45.3%) who reported weight gain as the most noticeable symptom after quitting smoking, 22 students (34.9%) ultimately quit smoking successfully, but 41 students (65.1%) failed to quit smoking. This suggests that weight gain is significantly related to smoking cessation failure. Belinda B and Robin M reported that the majority of smokers are concerned about post-cessation weight gain, but few studies have investigated the prospective relationship between weightrelated concerns, weight-related outcomes, and smoking cessation success or a mechanism by which such concerns are related to these outcomes 16 . That is supported by the current study. Weight gain was found to be associated with subsequent relapse.
Smoking cessation is associated with substantial health benefits. Weight gain is cited as a primary reason for not attempting to quit smoking. Smoking was shown to impair glucose tolerance and insulin sensitivity, and cross-sectional studies have demonstrated that smokers   are insulin-resistant and hyperinsulinaemic as compared with non-smokers. Smoking cessation seems to improve insulin sensitivity in spite of weight gain. Nicotine replacement -in particular nicotine gum -appears to be effective in delaying post-cessation weight gain 17 .
Therefore, it appears that during future university smoking cessation education programs it will be necessary to give nicotine replacement products to participants who report post-cessation weight gain.

Conclusions
From February 2012 to August 2015, the smoking cessation success rate of students who enrolled in the smoking cessation scholarship program conducted at the N University Health Clinic was 51.8%. In general, the factors which showed statistically significant differences were as follows: CO 2 ppm, cigarettes smoked during the period, nicotine dependency, the helpfulness of the smoking cessation clinic, and recognition of the need for follow-up programs. In addition, the finding that the smoking cessation success rate was significantly higher in the group that recognized the need for smoking cessation education programs must be considered as a reason for the similarity of this study's results with the results of previous studies. The smoking-related factors and health-related factors which showed statistically significant differences with regard to smoking cessation success were as follows: Motivation, the most important factor that allowed one to remain a non-smoker, symptoms noticed, in-home smoking, stress, and regular exercise. Among the above factors, it is thought that smoking cessation education plays an important role in smoking cessation success. Logistic analysis shows that Co 2 /ppm, regular education, attendance at a smoking cessation clinic, recognition of the need for follow up programs, direct health benefits, weight gain, self-confidence, willpower, drinking, regular exercise, and regular health check-ups had a significant influence on smoking cessation. However, since this research only considers a small sample of students, it will be difficult to extend the results of this study to other analyses, and follow-up studies must be carried out. Therefore, proper guidelines are needed to promote smoking cessation for optimal health. Also, multi-dimensional intervention programs for smoking cessation should be developed.

Acknowledgment
This study was supported by the research program funded by Namseoul University.