• February 27, 2024

Putting Faith in Cessation

 Putting Faith in Cessation
Image: doidam10

The role of religion in encouraging smoking cessation

By Cheryl K. Olson

The start of a new year is a perennially popular marker for initiating change. This includes fresh attempts to quit smoking. To that end, the U.S. Centers for Disease Control website features a multilingual “New Year, New Possibilities: Start Living a Smokefree Life Today!” advice and resources page.

A study of 2018–2020 social media posts expected to find the Covid-19 pandemic linked to more posts on quitting. Nope. Instead, New Year’s resolutions made a difference.

There’s nothing magic about a new year, of course. But setting some sort of targeted quit date does seem to increase motivation to follow through. A date in the near future—say, a couple of weeks away—seems best. Making a public commitment to quit, and preparing coping aids and skills, may also help.  

The best thing about New Year’s resolutions is that they provide another chance to try. Research suggests that encouraging more quit attempts adds up to more success. Finding ways to do this is especially important for people who aren’t particularly motivated to quit in the near future.

One often-overlooked path to encourage the discouraged or unmotivated to make quit attempts comes from religious observations. Major world religions have days every year where smoking is discouraged or forbidden.

 “Jews don’t smoke for 25 hours on Yom Kippur,” says Derek Yach, a physician who focused on smoking cessation at the World Health Organization and the Foundation for a Smoke-Free World. “Muslims refrain during daylight for the month of Ramadan. Some Christians stop during Lent.”

“This raises the question of how people who smoke can continue quitting post the fast,” Yach adds. “How could you build on that?”

The role of religion in encouraging smoking cessation deserves a closer look. And what, if anything, do we know about how major religions feel about tobacco harm reduction, including vaping?

Religion and Smoking: The Basics

“Systematic evidence of religious affiliation differences in tobacco use is surprisingly limited,” says a recent paper on religion’s role in smoking and vaping. One problem is distinguishing between the effects of religious affiliation, general religiosity and specific beliefs. Overall, studies show that people with no religious affiliation are more prone to smoking. Faiths with clear anti-tobacco positions, such as Seventh-day Adventists and Latter-day Saints, are less likely to smoke.

Things get murky beyond that. Regular church attendance is often linked to lower smoking, for example. People more engaged with religion may have more nonsmokers in their social networks. Religious doctrines feed into social norms that affect smoking behavior.

Of course, the texts of most major religions were written before tobacco spread across the globe. This means that religious scholars have had to interpret those texts and issue decrees regarding how smoking (and more recently, vaping) fits or clashes with their doctrines.

Islam is one example. Until the early 20th century, according to an article in the BMJ, most Muslim jurists did not believe that smoking had any negative health effects. Some thought it might even aid digestion or reduce stress. As evidence of health risks increased, smoking became discouraged (mukrooh). Some scholars and institutions went further and declared smoking to be prohibited (haram). 

Smoking is not explicitly banned by Christianity, Judaism, Hinduism or Buddhism. But religious values that promote avoiding deliberate harm to the body, and disapprove of addiction, mitigate against smoking.

At times, religion has been a smoking promoter. The website of the U.S. Conference of Catholic Bishops notes that the Catholic Church played a major role in bringing tobacco to Italy and spreading its use. In 2017, Pope Francis, stating that “No profit can be legitimate if it puts lives at risk,” announced plans to ban Vatican cigarette sales. The Vatican City State reportedly earned €10 million ($10.97 million) per year in profit from smokes sold (sans Italian taxes) through duty-free shops to its citizens and employees, who could purchase 50 or more discounted packs a month.

Yach has long been intrigued about the potential of religious organizations to combat smoking. “In 1999, when I was at WHO, I convened a meeting through the World Council of Churches,” he recalls. Despite the name, the council represented a range of major religions. The meeting focused on what religions say about tobacco control and smoking.

“What were the commonalities that suggested they supported tobacco control?” he wondered at the time. “We found there were three: Thou shalt not kill; thou shalt not kill others; and you should tell the truth.”

Yach has recently returned to studying the issue of faith and health, with a new emphasis on tobacco harm reduction. Religious doctrines are still unsettled on that point. However, Yach notes that in most religions, “to save a life” is the highest value and ought to be supportive of harm reduction.

In most religions, “to save a life” is the highest value and ought to be supportive of harm reduction.

Derek Yach, global health expert

Hitting Pause

A review of studies on religiosity and smoking cessation found that few actually focused on quitting. There are a handful of published studies on smoking and Ramadan. In most Muslim-majority nations, religion and culture discourage smoking during the daytime fast, both in public and at home. Many Muslims perceived quitting smoking to be easier during Ramadan.

One Malaysian study of 61 men who smoked found decreased Fagerstrom nicotine dependence scores during and shortly after Ramadan. The Ramadan environment, with most Muslims abstaining from smoking, was credited with helping men to reduce the number of cigarettes smoked or to stop smoking completely. The authors suggested that cessation support from health professionals might boost this effect.

During Ramadan in 2015, a cessation effort targeted Malay men working in public offices who smoked. The intervention group got a booklet educating on smoking-related health effects and religious rulings as well as practical and motivational tips and religious encouragements. All participants had reduced nicotine dependence scores and saliva cotinine levels during Ramadan, and these remained significant for the intervention group after Ramadan.

A study in Croatia focused on the first day of Lent, which some Christian groups observe for roughly six weeks leading up to the Easter holiday. Lent is a period of self-denial, which might involve fasting or giving up favored activities. A television and radio campaign for this “smoke out day” led to high awareness, and a quarter of people in the study abstained from smoking for 24 hours. People with lower levels of education were more likely to participate. 

Religion Meets Technology

Religion-based smoking cessation efforts could potentially reach groups that conventional methods have failed to help. In the U.S., older adults are more likely to attend religious services, and their smoking rates have been stagnant for the past two decades. The combination of faith communities and new technologies is particularly intriguing.

One recent study sent twice-daily text messages (half religiously tailored) to 50 Somali Muslim men in Minnesota during Ramadan. Research participants saw the messages as appropriate and encouraging, and they smoked fewer cigarettes per day. Seven quit smoking.

A published protocol for a new study describes a “Christian faith-based Facebook intervention for smoking cessation in rural communities.” Researchers plan to create and test a private moderated online group that uses peer and pastoral support, accessible to people who lack access to city resources.

Ideally, we will eventually see studies that add harm reduction innovations, such as e-cigarettes, reduced-risk shisha and heated-tobacco products, to this mix of faith and tech.

Religion and Harm Reduction

Religious perceptions regarding reduced-harm nicotine options, such as vaping, are still evolving. Research on vaping and religion is extremely limited. Several studies found that religiosity bears no relationship to e-cigarette use among teens and young adults.

The Malaysian study that looked at ways to encourage smoking cessation during Ramadan in 2015 was disrupted by the “vaping phenomenon,” with some subjects in both study groups starting to vape. Because vaping was not part of the protocol, it was ignored. A 2023 paper on e-cigarettes in Malaysia grouped “e-cigs, electronic shisha and shisha pens” as haram, along with cigarette smoking, due to perceived health risks.

Perceptions of effects on health may be important. For example, a 2019 article on Judaism and e-cigarettes gives multiple perceived reasons for prohibiting their use, including that e-cigarettes are dangerous, are a gateway to smoking and are addictive. Further, “even if medical literature has not firmly and definitively established the long-term dangers of e-cigarette use independent of combustible cigarettes, the suspicion that these products are dangerous is sufficient to prohibit their use.”

Clearly, strong evidence that reduced-harm nicotine products are a positive for health would be needed to overcome these concerns. Spreading credible information, such as the Cochrane review showing that vaping can successfully promote smoking cessation, might show that reduced-risk alternatives can fit with religious doctrines.

Encouragingly, two recent studies (with the same lead author) looked favorably at e-cigarette use during Ramadan. One looked at vaping preferences and reasons for using e-cigarettes in the United Arab Emirates. A majority reported starting vaping to quit smoking. Over half reported no withdrawal symptoms during the Ramadan fasting time. The second study had a similar focus and findings but took place in Jordan. It noted that “Ramadan offers a good opportunity for smokers to quit, as the reported physical and psychological e-cig withdrawal symptoms were found to be relatively weak.” In both studies, e-cigarettes were accurately perceived as less risky than smoking.

Faith-Based Harm Reduction

The challenge now, as Yach sees it, is to think through how to explain harm reduction in clear and meaningful ways to faith-based groups. “People say, well, we don’t want to get into religion. But health is not merely the absence of disease. And the word ‘spiritual’ should be included alongside mental, physical and social well-being.”

As a parallel, Yach points to the success of faith-based HIV/AIDS programs run through churches: “What’s at the core of an AIDS program? Harm reduction.” Given the billions of people who identify with religious groups, he says, the potential benefit could be huge.