Influence of Religious Leaders on Smoking Cessation in a Rural
Population -- Thailand, 1991
Despite substantial increases in smoking and intensified
marketing of tobacco products in developing countries (1), efforts
to prevent tobacco use through community-based approaches have been
limited (2,3). In Thailand, an estimated 9 million children will
become smokers, and more than 2 million will die prematurely as
adults from smoking-related illnesses (1,4). Because of these
risks, the Department of Community and Social Medicine, Mae Sot
General Hospital (MSGH), and the Field Epidemiology Training
Program (FETP) of the Thai Ministry of Public Health recently
assessed the impact of community-based smoking-prevention efforts
initiated by religious leaders. This report describes this program
and summarizes the assessment.
In 1987, a Buddhist abbot in the district of Mae Sot, Tak
Province, implemented health-promotion activities by prohibiting
smoking and posting warning signs with health messages in the
temple area, mandating that all new monks abstain from smoking, and
counseling smokers on the health hazards of smoking. Villagers were
also requested not to smoke during Buddhist ceremonies anywhere in
the village. To evaluate the impact of the monks' smoking-cessation
efforts, the MSGH and the FETP conducted household surveys during
March 1991 in one village (1990 population: 537) inhabited by monks
actively involved in smoking-cessation efforts in their community
(intervention village) and, during March and April 1991, in a
nearby village (1990 population: 914) where no special
smoking-cessation programs had been implemented (reference
village). A questionnaire was developed based on World Health
Organization guidelines for the conduct of tobacco-smoking surveys
among adults (5 ). All villagers aged greater than or equal to 15
years were eligible to be interviewed by trained health-care
workers. To ensure a high response rate, interviews were conducted
in the late afternoon and early evening to reach those who worked
during the day, and households were revisited when eligible persons
were absent at the time of the initial visit. Respondents were
classified by smoking status (current, former, or never smokers)
and duration of quit attempts (3).
A total of 372 (94.7%) of 393 eligible persons in the
intervention village and 664 (95.7%) of 694 in the reference
village participated in the survey. Although not statistically
significant, the prevalence of current cigarette smoking was lower
in the intervention village (155 {41.7%}) than in the reference
village (318 {47.9%}). In the intervention village, 156 (41.9%)
persons had never smoked, and 61 (16.4%) were former smokers: in
the reference village, 260 (39.2%) had never smoked, and 86 (13.0%)
were former smokers.
Of ever smokers in the intervention village, 61 (28.2%) were
former smokers compared with 86 (21.3%) (p=0.06) of those in the
reference village (Table 1). The proportion of former smokers who
previously had quit smoking for greater than 5 years was similar in
both villages (13 {6.0%} in the intervention village and 19 {4.7%}
in the reference village {p=0.5}). In comparison, the proportion of
persons who had stopped smoking for 1-5 years was significantly
greater in the intervention village (19.4% and 11.9%, respectively,
{p=0.01}). The proportion of persons who had stopped smoking for
greater than or equal to 1 year (i.e., former smokers who might be
less likely to relapse) was significantly greater in the
intervention village (25.5%) than that in the reference village
(16.6%) (p=0.01) (Table 1).
Both villages were similar when compared for distributions of
duration of quitting among current smokers and the prevalence of
those who had never considered quitting smoking (Table 1). However,
the proportion of ever smokers who had considered quitting but
never tried was lower in the intervention village (4.6%) than in
the reference village (13.6%) (p=0.001) (Table 1). Therefore, the
overall proportion of ever smokers who had tried to quit smoking
was significantly higher in the intervention village (79.6%) than
in the reference village (72.0%) (p=0.05).
In the intervention village, many (80.3%) of the former
smokers cited the encouragement of a monk as an important reason
for quitting smoking, compared with 25.6% of the reference village
(p
Reported by: W Swaddiwudhipong, MD, C Chaovakiratipong, P
Nguntra, P Khumklam, Mae Sot General Hospital, Bangkok; N Silarug,
MD, Div of Epidemiology, Ministry of Public Health, Thailand. Div
of Field Epidemiology, Epidemiology Program Office; Office on
Smoking and Health, National Center for Chronic Disease Prevention
and Health Promotion, CDC.
Editorial Note
Editorial Note: Although the overall prevalence of smoking among
adults in Thailand decreased from 30.1% in 1976 to 25.0% in 1988
(4), this risk behavior persists as a major problem in that
country. In addition, lung cancer mortality increased from 1.9 per
100,000 in 1977 to 2.6 per 100,000 in 1988. In 1985, health-care
costs and lost future income due to smoking-attributable illnesses
in Thailand were more than $280 million U.S. (4).
In some developing countries, health professionals, educators,
and leaders have been effective in decreasing smoking among
community members (2,3). The findings of this report suggest that
health-education and health-promotion efforts by religious leaders
in one community in Thailand may have contributed to a higher
proportion of quit attempts and maintenance of abstinence in the
intervention village. These efforts also may have increased
awareness of the health consequences of smoking in the village.
Although religious reasons for quitting or not smoking may not be
primary determinants (6,7), this report suggests that religious
leaders may play an important role in community-based smoking
cessation in developing countries such as Thailand.
Smoking-control efforts in Thailand include 1) the formation
of the National Committee for Control of Tobacco Use to administer
a national smoking-control program through policy implementation
and monitoring; 2) implementation of a total ban on cigarette
advertising; 3) use of rotating warning labels on cigarette
packages; and 4) health-education and health-promotion efforts to
inform the public of the health hazards associated with cigarette
smoking (4,8). Involving religious leaders in tobacco-use control,
especially in rural areas, can assist in helping smokers break the
addiction to nicotine through motivation and support of smokers in
their attempts to quit. Such prevention efforts are relatively
inexpensive and appropriate for developing countries and other
settings in which resources are limited (9).
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