Drug and Alcohol Dependence 213 (2020) 108085

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Drug and Alcohol Dependence

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Differential changes in quitting smoking by daily cigarette consumption and T

intention to quit after the introduction of a tobacco tax increase and pictorial
cigarette pack warnings in Korea, 2013–2017
Ikhan Kima,b,*, Young-Ho Khangb,c
a
Department of Health Policy and Management, Jeju National University College of Medicine and Graduate School of Medicine, Jeju, Republic of Korea
b
Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Republic of Korea
c
Institute of Health Policy and Management, Seoul National University Medical Research Center, Seoul, Republic of Korea

A R T I C LE I N FO A B S T R A C T

Keywords: Background: : This study examined whether changes in quitting smoking differed according to smokers’ cigar-
Behavior ettes consumed per day (CPD) and intention to quit (ITQ) after the introduction of two tobacco control measures
Addictive in Korea, a tobacco tax increase in 2015 and pictorial cigarette pack warnings (PCW) in 2016.
Intention Methods: : We utilized data from the Korea Welfare Panel Study from 2013 to 2017, an interval that was divided
Smoking
into four periods (2013–2014, 2014–2015, 2015–2016, and 2016–2017). We examined differential changes in
Smoking cessation
Tobacco
quitting smoking by smokers’ CPD and ITQ using a generalized estimating equation model.
Republic of Korea Results: : Smokers with 1–14 CPD or an ITQ were more likely to quit smoking in each period. However, when
compared to the pre-policy period (2013–2014), smokers with 15 or more CPD and those with an ITQ had a
higher risk ratio of quitting smoking in all study periods. In stratified analyses, when the tobacco excise tax was
increased, the risk ratios of quitting smoking increased in most subgroups, especially smokers with 15 or more
CPD or an ITQ. The increased risk ratio of 15 or more CPD smokers subgroup sustained afterward. However,
after the introduction of PCW, there were no significant changes from the previous period in most subgroups.
Conclusions: : The addictive nature of tobacco and the type of tobacco control policies jointly contributed to
changes in quitting smoking among Korean smokers. Tobacco control policies, particularly substantial tobacco
tax increase, acted as a cue-to-action for quitting smoking among more dependent smokers.

1. Introduction tobacco smoking (Park et al., 2014).

Tobacco use is one of the most critical public health concerns in the
world. Globally, tobacco use accounts for more than 7 million deaths
each year (World Health Organization, 2017; GBD 2017 Risk Factor
Collaborators, 2018). In 2017, tobacco was the second leading risk
factor of all-cause mortality for both sexes combined and the most
harmful risk factor for men (GBD 2017 Risk Factor Collaborators,
2018). Smoking is known to be related to a broad array of diseases,
including cancer, heart disease, and respiratory diseases (Warren et al.,
2014). Korea is no exception to the trend of tobacco being a significant
risk factor for mortality and morbidity. In 2015, smoking was found to
be the risk factor that accounted for the second-highest amount of
disability-adjusted life years for both sexes combined in Korea (GBD
2015 Risk Factors Collaborators, 2016). A previous study estimated that
one-third of all cancer deaths in Korean men could be attributed to
Smoking has an addictive nature, as manifested by patterns of re-
inforcement, tolerance, and withdrawal symptoms (US Department of
Health and Human Services, 1988; Suranovic et al., 1999; Giovino
et al., 1995). The costs of reducing cigarette consumption or quitting
are expected to be especially high for addicted smokers (Suranovic
et al., 1999; Chaloupka and Warner, 2000). When heavy smokers try to
stop smoking, they experience withdrawal symptoms (both physical
and psychological), as well as interference with social interactions with
their peer group (Thompson et al., 2003). Consequently, smoking de-
pendence has shown an inverse relationship with future attempts to
quit and with successfully quitting, and exhibited stronger direct as-
sociations with quitting behavior than smokers’ social and demographic
characteristics (Hyland et al., 2006; Goldberg et al., 1993). According
to a review by Vangeli et al., intention to quit (ITQ) smoking con-
sistently predicted attempts to quit, and dependence on tobacco was

⁎
Corresponding author at: Department of Health Policy and Management, Jeju National University College of Medicine and Graduate School of Medicine, 102
Jejudaehak-ro, Jeju-si, Jeju-do 63243, Republic of Korea.
E-mail address: ikhan.kim@jejunu.ac.kr (I. Kim).

https://doi.org/10.1016/j.drugalcdep.2020.108085
Received 21 January 2020; Received in revised form 27 April 2020; Accepted 9 May 2020
Available online 25 May 2020
0376-8716/ © 2020 Elsevier B.V. All rights reserved.
I. Kim and Y.-H. Khang
inversely related to successfully quitting smoking (Vangeli et al., 2011).
The effects of tobacco control policies also varied depending on smo-
kers’ smoking dependence and motivation to quit (Suranovic et al.,
1999; Willemsen, 2005; Hammond et al., 2003; Ross et al., 2011; Park
et al., 2015; Tabuchi et al., 2017; Nagelhout et al., 2013; Levy et al.,
2007).
The Korean government recently introduced two new national-level
tobacco control policies sequentially. The first policy that was in-
troduced was an increase in the tobacco excise tax. The excise tax for
one pack of cigarettes (20 cigarettes) in Korea increased by 2000 KRW
in January 2015 (equivalent to 1.82 US dollars at the time). As a result,
the price per pack of most brands of cigarettes increased from around
2500 KRW to 4500 KRW (an 80% increase). The next policy, im-
plemented in December 2016, was the application of pictorial cigarette
pack warnings (PCW) on the front and back of cigarette packs. Before
the introduction of this policy, cigarette pack warnings were configured
to cover 30% of cigarette packs and were text-only. However, since the
policy has been introduced, more than 50% of each cigarette pack is
covered with a warning picture (30%) and a warning phrase (20%). The
warning pictures consisted of five pictures related to the specific disease
(lung cancer, larynx cancer, oral cancer, heart disease, and stroke) and
other five pictures not directly related to the specific disease (second-
hand smoke, premature death, skin aging, smoking during pregnancy,
and sexual dysfunction). An example of a warning phrase is “Smoking is
the cause of lung cancer—do you still smoke?” along with information
on a smoking cessation hotline.
Each of the two tobacco control policies was intended to affect
quitting behavior through different mechanisms. Tobacco tax increases
aggravate the economic burden on current smokers, reducing the pre-
sent net utility of current smoking, while PCW initiates a cognitive and
emotional process by providing information about the negative con-
sequences of smoking (Chaloupka and Warner, 2000; Thrasher et al.,
2019; Hammond, 2011; Noar et al., 2016). In this study, we aimed to
analyze differential changes in quitting smoking after the two tobacco
control measures in different subgroups of smokers.
2. Material and methods
2.1. Data
Data from the eighth through 12th surveys of the Korea Welfare
Panel Study (KWPS) were used for analysis. The KWPS is a nationally
representative panel survey that has been conducted annually since
2006. The KWPS survey sampled household panels across the country
using a stratified sampling method and constructed a total of 7072
household panels in 2006. The KWPS originally assigned approximately
50% of the total sample to low-income (less than 60% of median in-
come) participants, taking into account the sample attrition and survey
purposes (Korean Welfare Panel Study, 2020). 1800 new sample
households were replenished at the 7th survey in 2012 due to sample
attrition. The original sample households that were completed the
questionnaire in the 12th survey were 4398 (62.2%) households, and
1500 (83.3%) households were completed among the replenished
households in the 7th survey. The sample retention rate from the 8th to
the 12th survey used in this study was 86.8% (Korean Welfare Panel
Study, 2020). Well-trained interviewers visited each household and
interviewed the subjects face-to-face using a computer-assisted personal
interviewing method. Surveys were conducted between March and
June of each year. The analytic sample was structured as a balanced
panel of participants in the eighth (2013) survey. We initially analyzed
11,449 (79.1%) of the 14,481 participants aged 20 years or older who
participated in the eighth survey and were observed every year. Then,
1239 participants who had any missing information were also excluded
from the analysis. Finally, 10,210 (70.5%) participants were included in
the analytic sample. The excluded sample had a predominance of par-
ticipants who were male, younger, had a low educational level, had
2
Drug and Alcohol Dependence 213 (2020) 108085
never been married, and had a relatively low ITQ and low secondhand
smoke (SHS) exposure. However, the difference in CPD between the
included and excluded samples was not significant (see Supplementary
Table 1). When we set the outcome variable as exclusion from the
analytic sample and conducted a logistic regression analysis, SHS ex-
posure, gender, marital status (never married vs. married or coha-
biting), and self-rated health showed statistically significant differ-
ences, but CPD and ITQ were not significantly different. We conducted
a sensitivity analysis of all the 14,481 participants who participated in
the eighth survey, including a dummy variable that indicated their
exclusion status. More details about the sensitivity analysis are de-
scribed in the statistical analysis section.
2.2. Outcome variables
In this study, the experience of quitting smoking was set as an
outcome variable. Quitting smoking during a certain period was de-
fined as occurring when a person answered ‘yes’ to the question “do you
currently smoke?” on the baseline survey for each period and answered
‘no’ to a question on the next wave survey.
2.3. Smoking dependence and ITQ
Cigarettes per day (CPD) and ITQ were the independent variables of
interest. CPD was measured by the question, “How many cigarettes a
day do you smoke on average?” We classified the responses as 1–14 and
15 or more and set CPD as a categorical variable. This classification has
also been adopted in previous studies to define smokers who are highly
dependent on smoking (Ip et al., 2012; Costa et al., 2010). Supple-
mentary Fig. 1 presents the distribution of current smokers’ daily ci-
garette consumption in 2013. Smokers who consumed half or one pack
a day accounted for the largest proportion. In the sensitivity analysis,
we further divided moderate to heavy smokers into those with 15–24
and 25 + CPD and traced their changes in quitting behavior during the
study period. We defined those who answered that they “currently
[had] no plan to quit smoking,” or planned to quit smoking “not within
six months, but someday” as having no ITQ (Maibach and Cotton, 1995;
Kale et al., 2015). Subjects who replied that they planned to quit
smoking “within a month” or “within six months” were defined as
having ITQ. In the sensitivity analysis, we did not further categorize
these four answers and analyzed the incidence of quitting smoking and
attempting to quit in each period in each of those four groups.
2.4. Other explanatory variables
We selected covariates with reference to the results of previous
studies of predictors of attempts to quit and successfully quitting, as
well as smoking prevalence in Korea (Vangeli et al., 2011; Tabuchi
et al., 2017; Kim et al., 2017). The following nine characteristics of
smokers were used as covariates: SHS exposure, gender, age, education
level, household income, marital status, self-rated health, alcohol con-
sumption, and residence. A detailed description of the explanatory
parameters is given in the Supplementary Material.
2.5. Statistical analysis
Since the tobacco tax increase and PCW were introduced nation-
wide in Korea, all smokers were assumed to be exposed to the newly
introduced tobacco control policies. The entire time interval covered by
the study (from 2013 to 2017) was divided into four periods
(2013–2014, 2014–2015, 2015–2016, and 2016–2017). This study used
a discrete-time design to reflect the dynamic nature of smoking beha-
vior (Singer and Willet, 2003), as has been done to analyze the asso-
ciation between tobacco control policies and quitting behavior in pre-
vious studies (Tabuchi et al., 2017; Nagelhout et al., 2013). The
population at risk for quitting smoking between the kth and (k+1)th
I. Kim and Y.-H. Khang Drug and Alcohol Dependence 213 (2020) 108085

surveys was composed of those who were current smokers at the kth Table 1
baseline survey. Smokers who quit smoking in the previous period were The number of total study subjects during the entire study period and the
not included in the risk set for the following period, but participants number and characteristics of current smokers in the baseline year of each
who relapsed after quitting were included again in the risk set for that period.
period. This research design allowed us to deal with relapse of smoking Variables Baseline year
in the same participants over multiple periods.
We constructed a generalized estimating equation (GEE) log-bino- 2013 2014 2015 2016 2017

mial model without an intercept, taking into account the correlations of Total no. of participants 10,210
the observations (Hubbard et al., 2010; McNutt et al., 2003). The No. of current smokers 1803 1765 1553 1577 1528
reason for no intercept was to show the difference in quitting smoking (%) (17.7) (17.3) (15.2) (15.4) (15.0)
among the smoker subgroup for each discrete period. We added a Characteristics of current smokers
CPD, cigarettes 15.7 15.6 14.6 14.8 14.7
period dummy variable indicating for each period in the model. To
CPD < 15, % 44.7 44.6 49.3 49.3 50.0
calculate the reaction of the subset of smokers in each period, we added 15≤CPD, % 55.4 55.4 50.7 50.7 50.0
interaction terms for all dummy variables in a period and all ex- Having no ITQ, % 93.5 94.3 88.2 92.7 92.7
planatory variables to the model. This model assumes a different out- Plan to quit within a 2.7 1.9 3.8 2.1 2.1
month
come pattern for each period. We used the equation below.
Plan to quit within six 3.8 3.8 8.0 5.2 5.2
4 4 4 4
months
Not within six 41.8 34.5 42.8 37.9 41.4
ln(p) = ∑ αt Dit + ∑ β1t CPDit ∙Dit + ∑ β2t ITQit ∙Dit + ∑ βt Xit ∙Dit months, but someday
t=1 t=1 t=1 t=1
Currently no plans to 51.6 59.8 45.5 54.9 51.3
quit smoking
Where D represents each period within the time interval covered by the SHS, % 41.4 38.1 37.4 38.9 33.1
study; CPD was 0 when the smoker consumed less than 15 cigarettes Female gender, % 10.1 9.4 9.4 10.1 10.2
per day, otherwise 1; ITQ was 0 when the smoker had no intention to Mean age, year (SD) 51.2 51.8 52.0 53.1 53.6
(14.9) (15.0) (14.8) (14.8) (14.8)
quit, otherwise 1; X is a vector for other explanatory variables.
Education, %
We checked our model for multicollinearity using Pearson correla- Middle school or less 28.6 30.0 30.9 30.6 31.4
tion coefficients among all explanatory variables, and tolerance and VIF High school 39.0 39.0 39.6 39.1 39.3
value of each explanatory variable. When we calculated the magnitude College or more 32.4 31.1 29.5 30.3 29.3
of the correlation, we found that none of the variables exceeded the Income, %
More than 60% of 71.4 73.2 74.9 75.5 74.9
0.8–0.9 Pearson correlation coefficient, which is considered as the
median income
threshold at which multicollinearity possibly present (Midi et al., Less than 60% of 28.6 26.8 25.1 24.5 25.1
2013). When we calculated the tolerance and VIF, we found that two median income
variables, the age group of more than 70 (2.75), middle school or less Marital status, %
Married or cohabiting 65.2 65.7 64.3 64.4 64.4
education (2.58), had more than 2.5 of VIF. However, those were more
Divorced, widowed or 17.6 17.7 18.9 19.2 19.6
than 0.3 of the tolerance value. Besides, the variables of our main in- bereaved
terest, 15 or more CPD (1.14) and having no ITQ (1.02), did not in- Never married 17.2 16.6 16.8 16.4 16.0
dicate a potential collinearity problem. Self-rated health, %
The following two analyses were performed to examine whether Very good/Good/ 82.7 84.8 85.6 84.7 83.8
Normal
differences in smoker subgroups were associated with the introduction
Very poor/Poor 17.3 15.2 14.4 15.3 16.2
of tobacco control policies. First, we analyzed the magnitude of the Alcohol consumption, %
interactions of each study period with CPD and ITQ as of 2013–2014 Never drinker 23.2 24.0 26.0 26.0 24.7
using a GEE log-binomial model with an intercept. The regression also 1−4 times per month 33.0 32.7 29.7 30.1 30.0
2−3 times per week 26.3 26.6 27.4 24.9 25.3
contained the set of interaction terms between all the explanatory
4 or more times per 17.4 16.8 17.0 19.0 20.1
variables and the dummy variables for each period. This model ex- week
amined whether the behavioral differences according to CPD and ITQ in Residence, %
each period differed from the behavioral differences according to CPD Metropolitan 43.0 43.2 43.7 42.9 43.5
and ITQ in 2013–2014. Second, we conducted stratified analyses by Urban 38.8 39.1 39.3 39.6 40.1
Rural 18.2 17.7 16.9 17.5 16.5
CPD and ITQ. This model examined whether there were changes in
behavior as of 2013–2014 within each category of CPD and ITQ. All Notes. CPD = Cigarettes consumed per day; ITQ = Intention to quit; SD =
explanatory variables were adjusted. Standard deviation; SHS = Secondhand smoke.
We conducted two sensitivity analyses. The definition of heavy The tobacco tax increase policy was introduced in January 2015, and the PCW
smokers and smokers with an ITQ used in this study was arbitrary was introduced in December 2016.
(Tabuchi et al., 2017; Kale et al., 2015; Dijkstra et al., 1998). Thus, we
plotted the quitting behavior of the heaviest smokers (25 + CPD) 2.6. Ethics statement
during the study period. We also plotted the changes in quitting
smoking for each of the four responses to the ITQ question without This study was reviewed and approved by the Seoul National
further categorization. Second, we constructed a sample containing all University Institutional Review Board (IRB no. 1804-001-932).
2013 survey participants and performed the analysis including a
dummy variable indicating exclusion from the sample. SAS version 9.4
(SAS Institute Inc., Cary, NC, USA) was used for the analysis. The 3. Results
procedure used was PROC GEE, and we assumed an unstructured
covariance structure type as a working correlation matrix. The reason Table 1 shows the number of total observations and current smokers
for using the unstructured covariance structure type was that it had a in the baseline year, and the characteristics of current smokers. A total
unique value on each variance. of 10,210 subjects were followed up for five years. The number of
current smokers in the sample gradually decreased from 1803 in 2013
to 1528 in 2017. CPD declined after the introduction of the tobacco tax
increase (15.6–14.6). However, there was little change in the rest of the

3
I. Kim and Y.-H. Khang
period except the period when tobacco taxes were substantially in-
creased. The proportion of smokers who smoked 15 or more CPD
ranged from 50.0% to 55.4%. The steepest decrease in this proportion,
from 55.4% to 50.7%, was found between 2014 and 2015. The number
of participants with no ITQ decreased in 2015 when the cigarette tax
was significantly increased, and then rose again in 2016 and 2017.
Among current smokers, those with high school-level education, those
who were married or cohabiting, those who consumed alcohol 1–4
times a month, and those living in metropolitan areas accounted for the
highest proportion across the study period. The dynamics of partici-
pants’ smoking and non-smoking status during the entire study period
are shown in < Supplementary Fig. 2 > . Between 2014 and 2015,
when the tobacco tax increased considerably, quitting smoking was
induced with the highest frequency. Between 2016 and 2017, when the
PCW was introduced, the incidence of quitting smoking was similar to
that of 2015–2016.
< Supplementary Table 2 > shows the adjusted risk ratio of quit-
ting smoking after the introduction of tobacco control policies reference
to the previous period of policy introduction for all current smokers.
Quitting smoking increased significantly after the increase in tobacco
tax, whereas no significant change occurred after the introduction of
PCW. We also analyzed the changes in having 15 or more CPD and
having an ITQ for smokers who maintained their smoking after the
introduction of tobacco policies. Smokers with 15 or more CPD de-
creased 0.90 fold (95% confidence interval [CI] (0.86, 0.94)) and with
no ITQ decreased 0.94 fold (95% CI (0.92, 0.95)) after tobacco tax
increased. However, as in the case of quitting smoking, smokers with 15
or more CPD or with no ITQ did not decrease significantly after the
introduction of PCW.
Fig. 1 shows the changes in quitting smoking among current smo-
kers according to CPD and ITQ. All subgroups showed a substantial
increase in quitting smoking after the tobacco tax was increased in
2014–2015. However, only current smokers with 15 or more CPD
(0.2%p) and an ITQ (2.7%p) showed an increase in quitting smoking
after the PCW was introduced compared to the period preceding.
Table 2 presents the risk ratio of quitting smoking by CPD and ITQ
for each period. Gradients by CPD and ITQ in quitting smoking con-
tinued to be present after adjusting for the explanatory variables. The
difference in quitting smoking between smokers with less than 15 CPD
and those with 15 + CPD was relatively small after the tobacco tax was
increased. This result also shows the behavioral affinity of smokers with
an ITQ for quitting after the introduction of new tobacco control po-
licies. < Supplementary Table 3 > present the results of quitting
smoking for each period, including all explanatory variables.
Table 3 shows the results of the interaction of each period with CPD
4
Drug and Alcohol Dependence 213 (2020) 108085
and ITQ. All changes tended to be higher in smokers with more than 15
CPD. Smokers with an ITQ were more likely to stop smoking than in the
2013–2014 period. All the results were not statistically significant, al-
though smokers with 15 + CPD showed marginally more quit smoking
in 2014–2015 than smokers with less than 15 CPD (adjusted risk ratio:
1.40; 95% CI (0.99, 1.98)). As of 2015–2016 period, both smokers with
15 + CPD (adjusted risk ratio: 1.07; 95% CI (0.74, 1.55)) and an ITQ
(adjusted risk ratio: 1.08; 95% CI (0.77, 1.52)) did not show meaningful
interaction with the introduction of PCW.
Fig. 2 shows the stratified analyses by CPD and ITQ subgroups on
quitting. These results present the change in quitting smoking in each
period compared to the 2013–2014 period for each subgroup. In the
results according to CPD, the 15 + CPD subgroup consistently showed a
higher risk ratio of quitting smoking than smokers with less than 15
CPD. In particular, the risk ratio of quitting smoking of 15 or more CPD
subgroups during the 2014–2015 period was significantly higher. For
ITQ, both subgroups also showed the considerably increased risk ratios
of quitting smoking in 2014–2015, but no significant difference from
2013 to 2014 in other periods. < Supplementary Table 4 > shows the
results of the stratified analysis in tabular format.
In < Supplementary Figure 3 > , we further divided moderate to
heavy smokers into two categories (15–24 CPD and 25 + CPD) and
plotted the changes in quitting smoking in these groups. Smoker sub-
group of 25 or more CPD showed similar change patterns as the 15–24
CPD smoker subgroup, although there was a difference in the degree of
change. < Supplementary Fig. 4 > shows yearly changes in quitting
smoking according to smokers’ responses to the question about the ITQ.
Both subgroups of smokers with no ITQ—those who had no plan to quit
smoking and those who stated that they planned to do so, but not
within six months—showed similar patterns in terms of quitting
smoking. The subgroups of smokers who responded that they planned
to quit within a month or six months also demonstrated identical pat-
terns, and they were more likely to quit smoking than other subgroups.
We conducted the sensitivity analysis using a sample containing a
five-year follow-up of all participants in 2013. < Supplementary
Table 5 > presents the results for quitting smoking among all the par-
ticipants who participated in the 2013 survey. Only the point estimates
were slightly different, while the same trends were found as in the re-
sults of the original analytic sample.
4. Discussion
In this study, we examined differential changes in quitting smoking
according to CPD and ITQ after the introduction of two tobacco control
policies in Korea: a tobacco tax increase in 2015 and PCW in 2016. The
Fig. 1. Changes in current smokers’ quitting
smoking by daily cigarette consumption and
intention to quit. (A) Changes in quitting
smoking by daily cigarette consumption. (B)
Changes in quitting smoking by intention to
quit.
Notes. CPD = Cigarettes consumed per day;
ITQ = Intention to quit.
Secondhand smoke, gender, age, education,
income, marital status, self-rated health, al-
cohol consumption, and urbanity of residence
were adjusted in the model.
The tobacco tax increase policy was introduced
in January 2015, and the PCW was introduced
in December 2016.
I. Kim and Y.-H. Khang Drug and Alcohol Dependence 213 (2020) 108085

Table 2
Main effects model: The risk ratio of quitting smoking for each period according to daily cigarette consumption and intention to quit.
Variables 2013–2014 2014–2015 (Tobacco tax increased) 2015–2016 2016–2017 (PCW introduced)

Adjusted RR (95% CI) P-value Adjusted RR (95% CI) P-value Adjusted RR (95% CI) P-value Adjusted RR (95% CI) P-value

CPD
CPD < 15 Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
15≤CPD 0.42 (0.31,0.56) < .001 0.60 (0.49,0.73) < .001 0.56 (0.43,0.73) < .001 0.58 (0.45,0.76) < .001
ITQ
Having no ITQ Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
Having an ITQ 1.38 (0.87,2.18) 0.171 1.82 (1.40,2.36) < .001 1.43 (1.08,1.89) 0.013 1.79 (1.27,2.54) 0.001

Notes. CI = Confidence interval; CPD = Cigarettes consumed per day; ITQ = Intention to quit; PCW = Pictorial cigarette pack warnings; Ref = Reference; RR =
Risk ratio.
Secondhand smoke, gender, age, education, income, marital status, self-rated health, alcohol consumption, and urbanity of residence were adjusted in the model.
The tobacco tax increase policy was introduced in January 2015, and the PCW was introduced in December 2016.

results of the study showed that the tobacco tax increase by 80% was
more strongly associated with quitting smoking than the PCW (covering
an additional 30% of the front and back of each cigarette pack) in al-
most all subgroups of current smokers categorized by CPD and ITQ. We
also found that smokers with less CPD had a greater likelihood of
quitting smoking. However, when compared to the pre-policy period
(2013–2014) in terms of the relative risk ratio, smokers with 15 + CPD
seemed to be more likely to quit smoking after the tobacco tax increase,
and their tendency to quit smoking remained. ITQ was also positively
related to quitting smoking and seemed to be more responsive to the
introduction of tobacco control policies.
Throughout the entire study period, light smokers stopped smoking
more often, and the same tendency was found for smokers with an ITQ. Fig. 2. Stratified analysis by daily cigarette consumption and intention to quit
These results are in line with the results of numerous previous studies for quitting smoking compared with the 2013-2014 period. (A) Risk ratio for
quitting smoking by daily cigarette consumption. (B) Risk ratio for quitting
(Chaloupka and Warner, 2000; Willemsen, 2005; Ross et al., 2011; Park
smoking by intention to quit.
et al., 2015; Nagelhout et al., 2013; Levy et al., 2004, 2005). The
Notes. CPD = Cigarettes consumed per day; ITQ = Intention to quit.
number of cigarettes smoked in a peak period was found to be nega- Secondhand smoke, gender, age, education, income, marital status, self-rated
tively associated with the likelihood of quitting smoking (Douglas, health, alcohol consumption, and urbanity of residence were adjusted in the
1998). Hammond et al. reported that ITQ was positively related to the model.
cognitive processing of PCW among Canadian smokers, and found that The tobacco tax increase policy was introduced in January 2015, and the PCW
those smokers were more likely to engage in quitting behavior pro- was introduced in December 2016.
spectively (Hammond et al., 2003).
Compared to behavioral trends in 2013–2014, the introduction of smoking.
the tobacco control policy seemed to induce a slightly sharper increase Smokers with an ITQ seemed to be more likely to quit smoking
in quitting smoking in smokers with 15 + CPD than in those with less when the new tobacco control policy was introduced. This may have
than 15 CPD. Previous studies have also reported that smokers with a been because tobacco control policies are particularly helpful for ad-
high CPD were responsive to tobacco control efforts (Hughes, 2011; US dicted smokers with an ITQ (Suranovic et al., 1999). This result may
Department of Health and Human Services, 2003; O’Connor et al., also be linked to the mechanisms inherent in tobacco control policies.
2006). Smokers with high CPD generally quit smoking less frequently For example, PCW is likely to promote quitting behavior in smokers
than smokers with low CPD because they are physically, psychologi- with an ITQ by informing smokers about the detrimental health out-
cally, and socially more dependent on smoking. However, they usually comes of smoking (Noar et al., 2015; Hammond et al., 2013). Analyzing
recognize the detrimental effects of smoking on health and tend to seek using the same subjects in this study, after PCW was introduced, at-
assistance for quitting (Thompson et al., 2003). The introduction of a tempts to quit seemed to increase in smoker subgroups with an ITQ
new tobacco control policy may serve to induce heavy smokers to quit compared to 2013–2014 (adjusted risk ratio: 1.18; 95% CI (0.94,

Table 3
Interactions of time periods with CPD and ITQ as of 2013–2014.
Variables 2014–2015 (Tobacco tax increased) 2015–2016 2016–2017 (PCW introduced)

Adjusted RR (95% CI) P-value Adjusted RR (95% CI) P-value Adjusted RR (95% CI) P-value

CPD
CPD < 15 Ref. Ref. Ref. Ref. Ref. Ref.
15≤CPD 1.40 (0.99,1.98) 0.055 1.29 (0.88,1.90) 0.187 1.37 (0.93,2.02) 0.113
ITQ
Having no ITQ Ref. Ref. Ref. Ref. Ref. Ref.
Having an ITQ 1.29 (0.79,2.12) 0.314 1.01 (0.61,1.68) 0.967 1.29 (0.75,2.21) 0.362

Notes. CI = Confidence interval; CPD = Cigarettes consumed per day; ITQ = Intention to quit; PCW = Pictorial cigarette pack warnings; RR = Risk ratio.
Secondhand smoke, gender, age, education, income, marital status, self-rated health, alcohol consumption, and urbanity of residence were adjusted in the model.
The tobacco tax increase policy was introduced in January 2015, and the PCW was introduced in December 2016.

5
I. Kim and Y.-H. Khang
1.49)). An increase in the cigarette tax places an increasing economic
burden on heavy smokers, making them more likely to quit smoking
due to the reduction of the marginal utility of each cigarette (Chaloupka
and Warner, 2000). It is also possible that the effects of the substantial
tobacco tax increase on quitting smoking may have been sustained over
time, and this effect may have impacted the quitting behavior of the
remaining smokers. This result suggests that comprehensive im-
plementation of the tobacco control policy is required. The introduction
of various policies has a complementary impact on various smoker
subgroups, which can lead to more effective results (Noar et al., 2016;
Levy et al., 2004; Task Force on Community Preventive Services, 2001).
The results of this study also provide clues regarding the compara-
tive effects of the two tobacco control policies on quitting behavior.
Since the increase in tobacco excise tax in 2015 was substantial (an
80% increase), the incidence of quitting smoking was much higher than
for other periods in almost all subgroups. This effect remained present
after the introduction of tobacco excise tax increases. In contrast, when
PCW was introduced, a relatively small increase in the incidence of
quitting smoking was observed. This is presumably related to differ-
ences in the type and intensity of these policies, such as the size and
features of warning pictures and phrases (covering 50% of the front and
back of the cigarette pack), compared to the rate of increase (80%) in
cigarette prices. Some previous studies showed that a tobacco tax in-
crease was the most effective policy for lowering the prevalence of
smoking (Levy et al., 2004; Wilson et al., 2012; Levy et al., 2008; Hu
et al., 1995). In another previous study, PCW had an independent effect
on smokers’ quitting attempts, but did not have an impact on the suc-
cess of those attempts (Borland et al., 2009). However, it may also be
the case that the time order of the two tobacco control policies analyzed
in this study mattered. It is possible that smokers would have responded
more actively to PCW if it had been implemented earlier than the
substantial tobacco tax increase.
4.1. Limitations
This study has limitations. First, there were no concurrent control
groups in this study because both tobacco control policies were in-
troduced nationwide in Korea. This study used the previous years (re-
lative to the year when each policy was implemented) as historical
controls (a control period). Furthermore, we mainly explored differ-
ences in smokers’ responses to the tobacco control measures among
smoker subgroups defined by CPD and ITQ, which enabled us to con-
firm the expected differential effects of tobacco control policies.
Second, this study used reported current smoking status from each
survey to determine whether respondents quit smoking over the pre-
vious one-year period. Thus, we were not able to detect how long the
smoking cessation of those who quit smoking was sustained. It is also
possible that heavy smokers reacted to tobacco control policies by
smuggling contraband or becoming electronic cigarette users. However,
a previous study reported that the effects of smuggling could be ne-
glected in terms of magnitude (Levy et al., 2004). Furthermore, the
Ministry of Economy and Finance of Korea confirmed that e-cigarette
sales in Korea started in the second quarter of 2017, and their annual
cumulative proportion of tobacco sales was only 2.2% in 2017 (data are
available upon request). Another limitation regarding the data used was
the relatively small sample size—this induced a wide confidence in-
terval of the estimated parameters, particularly in the analysis related
to ITQ. Thus, the possibility of sampling variation should be cautioned
in the interpretation of the results. Third, some other variables—such as
smoking and quitting history or evaluations of smoking and quit-
ting—may mediate or moderate smoking and quitting behavior. By
using more sophisticated variables about smoking or quitting, it would
be possible to identify the underlying causal mechanism more clearly
and to go beyond empirically tracing the process.
6
Drug and Alcohol Dependence 213 (2020) 108085
5. Conclusions
This study confirmed that the introduction of tobacco control po-
licies in Korea was related to quitting smoking. Light smokers and those
with an ITQ were more likely to quit smoking. However, compared to
the pre-policy period (2013–2014), the quitting smoking of current
smokers with 15 + CPD and those with an ITQ seemed to increase after
the new tobacco control policies were introduced, especially after the
tobacco tax increase. These results suggest that these tobacco control
policies acted as a cue-to-action for moderate to heavy smokers and
smokers who wanted to quit.
Contributors
KIH conceptualized the study. KIH acquired, analyzed, and inter-
preted data. KIH drafted the original version of the manuscript, and
KYH provided critical revisions. All authors have read and approved the
final manuscript.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
The authors have no conflicts of interest to disclose.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.drugalcdep.2020.
108085.
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