Elsevier

Social Science & Medicine

Volume 69, Issue 7, October 2009, Pages 1025-1031
Social Science & Medicine

Adult smokers' perception of the role of religion and religious leadership on smoking and association with quitting: A comparison between Thai Buddhists and Malaysian Muslims

https://doi.org/10.1016/j.socscimed.2009.07.042Get rights and content

Abstract

In recent years, attempts have been made to incorporate religion into tobacco control efforts, especially in countries like Malaysia and Thailand where religion is central to the lives of people. This paper is a prospective examination of the perceived relevance and role of religion and religious authorities in influencing smoking behaviour among Muslims in Malaysia and Buddhists in Thailand. Data were collected from 1482 Muslim Malaysian and 1971 Buddhist Thai adult smokers who completed wave 1 (early 2005) of the International Tobacco Control Southeast Asia Survey (ITC-SEA). Respondents were asked about the role of religion and religious leadership on smoking at Wave 1 and among those recontacted, quitting activity at Wave 2. Results revealed that over 90% of both religious groups reported that their religion guides their day-to-day behaviour at least sometimes, but Malaysian Muslims were more likely to report that this was always the case. The majority (79% Muslims and 88% Buddhists) of both groups believed that their religion discourages smoking. About 61% of the Muslims and 58% of the Buddhists reported that their religious leaders had encouraged them to quit before and a minority (30% and 26%, respectively) said they would be an influential source to motivate them to quit. Logistic regression models suggest that these religious factors had a clear independent association with making quitting attempts in both countries and this translated to success for Malaysian Muslims but not for the Thai Buddhists. Taken together, results from this study indicate that religion and religious authorities are both relevant and important drivers of quitting, but whether this is always enough to guarantee success is less clear. Religion can be a culturally relevant vehicle to complement other tobacco control efforts.

Introduction

The use of religion to improve health is an age-old practice. However, the use of religion and the enlisting of religious authorities in public health campaigns for tobacco control is a relatively recent phenomenon. Previous research indicates that while religion has sometimes influenced success in smoking cessation among adult smokers (Saeed et al., 1996, Swaddiwudhipong et al., 1993), there is little evidence that religious belief or affiliation has a major impact on the general population except for followers of religions with very strong sanctions against tobacco use (Ugen, 2003).

A relevant theoretical framework for understanding how religion can play a role in shaping people's behaviour is reference group theory (Merton & Rossi, 1968). According to this theory, individuals' behaviour is influenced by the groups to which they refer for either an evaluation of their actions or normative guidelines for their behaviour. A group is likely to be used as a reference point when individuals see some similarity in status attributes between themselves and other members, orient themselves to the values of the group, engage in sustained interaction with group members, and define leaders of the group as significant others (Bock et al., 1983, Merton and Rossi, 1968). This theoretical framework has received little attention in relation to how religion might influence smoking behaviour particularly among the adult population.

Historically, tobacco use has been ignored by major religions because it did not exist when their scriptures were written. However, most, including Islam and Buddhism, have religious principles that forbid or discourage the use of addictive substances. For example, Islam declares practices to be forbidden for Muslims (haram) if they are considered to harm health. In recent years, because of the growing evidence of the health risks of smoking, some Islamic scholars have pronounced tobacco use as haram while others have argued that it is merely makruh (advised against) (Ghouri, Atcha, & Sheikh, 2006). At present, the Islamic world is still divided over the religious ramifications of Muslims using tobacco.

Islam is the national religion of Malaysia. Sixty-five percent of the population is Muslim, including virtually all ethnic Malays. In 1995, the national Fatwa Committee for Islamic Affairs in Malaysia ruled that smoking was haram (strictly forbidden). Since then, religious authorities in some states (Selangor, Kedah and Perlis) have declared smoking forbidden while others say it is only ‘makruh’ (advised against) (South China Morning Post, 1995). In 1997, the Federal Government of Malaysia indicated that it would not try to enforce this fatwa since they claimed it would be unenforceable unless all states embraced it.

In late 2004, the Malaysian government launched an anti-smoking campaign during the holy month of Ramadhan to encourage Muslims to quit smoking altogether, taking advantage of the fact that they were already refraining from smoking for more than 12 h each day during fasting. The extent to which this campaign has been effective is not known.

Although Buddhism is not officially the state religion of Thailand, around 90% of the population is Buddhist, the religion of the Thai King. Most learned monks in Thailand see tobacco use as antithetical to Buddhist precepts (World Health Organization, 2002). Two international Buddhist workshops held in Cambodia in 2002 and 2004 declared that tobacco should be classified under the fifth precept, “Suramerayamajjahpamatthana”, as a harmful and addictive substance, that offering tobacco to monks should be considered to be in the third category of wrong offerings “majjadana”, and that monks, who are of the highest moral standing, should be free of nicotine addiction and should also be active in saving lives by preventing tobacco use, establishing smoke-free areas and helping people quit (World Health Organization, 2002). However, religious rulings are typically not as strongly enforced in Buddhism (especially compared with Islam).

A recent study indicated that smoking prevalence among Buddhist monks in Thailand is quite high (24.4%) although lower than the male prevalence rate of 39% (Charoenca et al., 2004). The high smoking rate among monks has led some senior monks to actively conduct anti-smoking activities to educate other monks in their wats/temple and community about the danger of smoking. People were discouraged from offering cigarettes as alms to monks and encouraged to not smoke during Buddhist ceremonies. Findings from the only published study evaluating these efforts, conducted in a rural community in northern Thailand (Swaddiwudhipong et al., 1993), indicated that a greater proportion of people from a village where the monk urged the inhabitants not to smoke were found to have quit smoking for at least a year and to have greater knowledge about the harmful effects of smoking on health. Of those who quit, a greater proportion identified their monk as one important reason for quitting, compared to a control village of similar socio-demographic level. This study suggests that religious leaders can be powerful agents in community-based smoking cessation efforts.

Thailand is a leader in tobacco control in the Southeast Asia region and has had strong tobacco control measures in place for many years. By contrast, Malaysia has only stepped up its tobacco control efforts in more recent years although both of these countries have recently ratified the Framework Convention on Tobacco Control (FCTC) and are obligated to rapidly fulfill the requirements of the FCTC. This paper uses data from the International Tobacco Control Southeast Asia Survey (ITC-SEA), a large population-based cohort study of the impact of tobacco control policies on smoking behaviour to examine the role of religion and religious authorities in tobacco control efforts of these two Southeast Asian countries. For the purpose of this study, we focus on only the dominant religious group in each country: Malaysian Muslims and Thai Buddhists. The specific aims were: (1) to describe and compare the two religious groups' perceptions of the role of their religion and religious authorities on smoking and quitting; and (2) to examine prospectively the association between these religious factors and subsequent quitting activity. We hypothesised that smokers who reported at baseline (wave 1) that they were more influenced by their religion, and who believed their religion disapproves of smoking would be more likely to have an intention to quit (assessed at wave 1) and by the next wave (wave 2), they would be more likely to have tried to quit and among those who tried, they would be more likely to succeed in quitting. We expected that measures of religious leadership influence would have similar pattern of relationship with these quitting-related variables at both waves 1 and 2. We were also interested in exploring whether effects would differ across levels of religiosity and locality (urban-rural).

Section snippets

Sample

Baseline data come from 1482 Muslim Malaysian and 1971 Buddhist Thai adult smokers aged at least 18 years, drawn from a random national sample of 2000 respondents each from Malaysia and Thailand, as part of the ITC-SEA survey via a face-to-face interview conducted between January and March, 2005. Adults with other religious affiliations were not included in this paper because of small numbers. Data for longitudinal analyses consist of 693 Muslim Malaysians and 1539 Thai Buddhists from the

Results

Malaysian Muslim respondents were younger, better educated, and were more likely to be male compared to the Thai Buddhist sample (Table 1). While more than 90% in each country reported that their religious beliefs and values guide their actions at least somewhat, more of Malaysian Muslims (59% vs. 24% of Thai Buddhists) reported that this happens all the time (Table 1) (OR = 5.6, 95% CI: 4.7, 6.8, p < 0.001). This was unaffected by whether respondents were urban or rural residents (p = 0.861).

Discussion

While religion is perceived by nearly all adult smokers of Muslim and Buddhist faiths as being important, far more Muslim Malaysians see it as playing a central role on their day-to-day lives. The more religious smokers in both faith groups are more likely to have an interest in quitting but they do not appear to be more likely to make quit attempts although they may be more likely to succeed when they try (significant for Malaysian Muslims) compared to their less religious counterparts. While

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Cited by (0)

The ITC-SEA Project is supported by grants P50 CA111236 (Roswell Park Transdisciplinary Tobacco Use Research Center) and R01 CA100362 from the National Cancer Institute of the United States, Canadian Institutes of Health Research (79551), Thai Health Promotion Foundation, and the Malaysian Ministry of Health. Rahmat Awang, Wonkyong B Lee, Naowarut Charoenca, and Zarihah M Zain have contributed to the writing of the paper and approved the final version. We would also like to acknowledge the other members of the ITC Project team.

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