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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).


  1. Chapman S, Wong WL. Tobacco control in the third world: a resource atlas. Penang, Malaysia: International Organization of Consumers' Unions, 1990.

  2. World Health Organization. Smoking control strategies in developing countries: report of a WHO expert committee. Geneva: World Health Organization, 1983. (Technical report series no. 695).

  3. CDC. Reducing the health consequences of smoking: 25 years of progress -- a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1989; DHHS publication no. (CDC)89-8411.

  4. Chitanondh H. Tobacco use: an update -- April 1991. Bangkok, Thailand: Ministry of Public Health, Office for Tobacco Consumption Control, National Committee for Control of Tobacco Use, 1991.

  5. World Health Organization. Guidelines for the conduct of tobacco smoking surveys of the general population: report of a WHO meeting held in the general population. In: Report of a WHO meeting held in Helsinki, Finland. Geneva: World Health Organization, 1982; publication no. WHO/SMO/83.4.

  6. Pandey MR, Neupane RP, Gautam A. Epidemiological study of tobacco smoking behavior among adults in a rural community of the hill region of Nepal with special reference to attitude and beliefs. Int J Epidemiol 1988;17:535-41.

  7. Orleans CT, Schoenbach VJ, Salmon MA, et al. A survey of smoking and quitting patterns among black Americans. Am J Public Health 1989;79:176-81.

  8. US General Accounting Office. International trade: advertising and promoting U.S. cigarettes in selected Asian countries. Washington, DC: US General Accounting Office, 1992; report no. GAO/GGD-93-38.

  9. Swaddiwudipong W, Chaovakiratipong C, Nguntra P, Khumklam P, Silarug N. A Thai monk: an agent for smoking reduction in the rural population. Int J Epidemiol (in press).

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