Randomized controlled trial on the effect of Al-Quran recitation vs counseling on smoking intensity among Muslim men who are trying to quit smoking

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1 Rndomized controlled tril on the effect of Al-Qurn recittion vs counseling on smoking intensity mong Muslim men who re trying to quit smoking Aid Mzih Z, Imrn A, Azlin I, Hrmy MY Aid Mzih Z, Imrn A, Azlin I, et l. Rndomized controlled tril on the effect of Al-Qurn recittion vs counseling on smoking intensity mong Muslim men who re trying to quit smoking. Mlys Fm Physicin. 2018;13(2); Keywords: - Authors: Aid Mzih Zinudin (Corresponding uthor) MD, MMed Fmily Medicine Deprtment of Phrmcology School of Medicl Sciences Universiti Sins Mlysi Kubng Kerin, Kelntn Mlysi. Imrn Ahmd MD, MMed Fmily Medicine Deprtment of Fmily Medicine School of Medicl Sciences Universiti Sins Mlysi Kubng Kerin, Kelntn Mlysi. Abstrct Introduction: Nicotine crvings nd withdrwl symptoms re ssocited with higher rtes of relpse. It hs been shown tht combining behviorl therpy nd phrmcotherpy leds to higher long-term bstinence rte in those who quit smoking. Al-Qurn recittion hs been proven to reduce nxiety mong thletes before tournments nd pulse nd hert rtes mong ptients witing crdic opertions. As most of the ptients who wish to stop smoking experience highnxiety sttes, we postulte tht Al-Qurn recittion will lso ble to reduce crving mong smokers ttempting to quit smoking. Methods: Fifty smokers from n outptient clinic were rndomly ssigned to control nd intervention groups. They were tught different wys of coping with smoking urges, i.e., counseling using the 12 M method (control group) versus Al-Qurn recittion (intervention group). They met for four consecutive weeks of counselling nd to fill out withdrwl scle. Crbon monoxide (CO) levels were tested t bseline nd t week 4. At week 12, the number of cigrettes smoked ws mesured gin. The decrese in the number of cigrettes considered to be cliniclly significnt for the clcultion of smple size ws bsed on expert opinion Results: The reduction in the number of cigrettes smoked ws 7 cigrettes in the counselling group nd 9 cigrettes in Al-Qurn recittion group over 12 weeks durtion. There ws sttisticlly significnt difference in the number of cigrettes smoked between the groups. There ws lso sttisticlly significnt difference in the chnge in crvings between the groups t week 4 (p-vlue= 0.005). However, the difference in the chnges in CO levels between the two groups ws not sttisticlly significnt. Conclusion: Al-Qurn recittion produced sttisticlly significnt reduction in the number of cigrettes smoked t week 12 nd significnt chnge in crvings t week 4 mong smokers ttempting to quit. Difference in smoking bstinence rtes ws not mesured in this study. Azlin Ishk MBBS, MMed Fmily Medicine Deprtment of Fmily Medicine School of Medicl Sciences Universiti Sins Mlysi Kubng Kerin, Kelntn Mlysi. Hrmy Mohd Yusoff MD, MMed Fmily Medicine Fculty of Medicine, Universiti Sultn Zinl Abidin, Kul Terenggnu, Terenggnu Mlysi. Introduction It is estimted tht there re currently five million smokers in Mlysi. The prevlence of smoking mong Mlysins ged 18 nd over is 22.6%. 1 There re pproximtely 10,000 smoking-relted deths ech yer in Mlysi, nd this totl is estimted to increse to 30,000 per yer by 2030 if the current smoking trends continue. 2 However, quitting smoking is not n esy tsk. The chnce of success in single, unided ttempt to quit smoking is pproximtely 1 in 100, nd 98% of smokers relpse within yer. 2 The relpse rte is high due to the ddictive nture of nicotine. Withdrwl symptoms occur when the nicotine level in the blood declines. Phrmcologicl gents proven to improve the chnces of successfully quitting smoking include nicotine replcement therpy, vrenicline, bupropion, cysticine, nd nortriptyline. 3 It hs been shown tht combining phrmcologicl gent with behviorl therpy is more beneficil thn the phrmcologicl therpy lone in helping those who re trying to quit smoking. 3 At present, ptients ttending clinics for smoking cesstion in helth cre fcilities re given counseling on how to stop smoking. This includes setting up dte to quit nd getting rid of cigrettes, shtrys, nd other items tht induce smoking. Counselling on the 12 M method is given to control smoking urges. 12 M stnds for Melengh-lenghkn 19

2 (dely), Menrik nfs dlm-dlm (tke deep breth), Minum ir (drink some wter), Membut sesutu (do something), Mengunyh sesutu (chew something), Mndi (tke shower), Membsuh tngn (wsh your hnds), Melkukn senmn regngn (do stretching exercises), Membc do (sy pryer), Menjuhkn diri (void), nd Meditsi (medittion). 2 The 12 M method, in conjunction with phrmcotherpy, hs been shown to be beneficil. The cesstion rte for this combintion (6 month s bstinence) rnges from 31.8% 4 to 52.5%. 5 There is no vilble dt for 12 M used s single therpy. A study mong Muslims in Mlysi nd Buddhists in Thilnd suggests tht religious fctor is independently ssocited with successful ttempts to quit smoking in both countries; over 90% of prticipnts reported tht their religion guides their dy-to-dy behvior, in which smoking is discourged. A logistic regression model suggests tht the religious fctor hd cler independent ssocition with ttempts to quit nd trnslted into success for Mlysin Muslims. 6 A few studies hve shown tht Al-Qurn recittion cn reduce nxiety nd improve vitl signs. A study in Irn showed significntly reduced level of nxiety mong thletes who recited the Al-Qurn before tournments. 7 It lso reduced nxiety in women witing cesren section 8 nd significntly reduced the pulse nd respirtory rtes of ptients before hert surgery. 9 Another study showed reduced nxiety, blood pressure, nd pulse rtes mong ptients witing bdominl surgery. 10 These studies provide evidence tht Al-Qurn recittion hs relxtion effects nd brings clmness to the reciter. Tking into ccount tht prcticlity is n importnt fctor in dherence, four short chpters in the Al-Qurn were chosen for this study becuse they re memorized by lmost ll Muslims nd esily recited nd reproduced. Till now, there hs been no vilble dt on the effect of Al-Qurn recittion on smoking cesstion or withdrwl symptoms. Therefore, in this study, the reserchers tested the effects of Al-Qurn recittion nd 12 M counseling on smoking intensity mong Muslim smokers. The study lso collected withdrwl symptoms scores nd crbon monoxide levels from the prticipnts to test for ny chnges tht occurred s the result of the interventions. Methods A rndomized controlled tril ws conducted mong 50 smokers between June 2013 nd June 2014 t the Outptient Clinic, Universiti Sins Mlysi (USM) Hospitl, tertiry teching hospitl in Mlysi. This study ws pproved by the Humn Reserch Ethics Committee of USM on the 29th of November, Its FWA registrtion number is , nd its IRB registrtion number is Current smokers, i.e., those smokers smoking 10 cigrettes per dy, more thn 18 yers old, Muslims ble to recite the Al-Qurn, nd intending to quit smoking, were included. Fmilirity with Al-Qurn recittion ws necessry s those unfmilir with the recittion would find it difficult nd be unble to comply with the protocol. Those who hd difficulty ttending interventions, were prticipting in other interventions, or using phrmcotherpy to quit smoking were excluded. The investigtor ensured the eligibility of the prticipnts. A computergenerted rndomiztion list of prticipnts ws obtined. The investigtor rndomized the ptients ccording to the list into either the counselling group or Al-Qurn recittion group. Potentil prticipnts were screened t visit 1 (V1). The smokers who fulfilled the inclusion criteri were given n explntion concerning the study, nd those who greed to prticipte gve their informed consent. The prticipnts were then llocted into two groups bsed on the rndomiztion list. The prticipnts were lso sked to set dte to quit. They were scheduled to mke visit 2 (V2) one dy prior to their quit dte. A week before V2, ll prticipnts were clled s reminder of their quit dte. At V2, the prticipnts were required to fill out questionnire which contined three prts: demogrphic informtion, smoking chrcteristics (including Fgerstrom score), nd religiosity scle. The bseline religiosity score ws obtined in order to see if direct reltionship could be found between the piousness of the prticipnt nd the likelihood of success in quitting smoking. The score ws obtined through the use of vlidted scle, the Muslim Religiosity-Personlity Inventory. 11 The bseline number of cigrettes smoked ws recorded, nd ech prticipnt s crbon monoxide (CO) level ws tested using crbon monoxide nlyzer, microco monitor 20

3 model 36-MC02-STK. The vlidity of the tool ws checked by the supplier month prior to the strt of the study. The sme nlyzer ws used for ll prticipnts. Prticipnts were tught techniques to quit smoking, which included setting dte to quit, getting rid of cigrettes nd shtrys, nd telling fmily nd friends bout their ttempt to quit. They were lso coched on wys to cope with smoking urges. The counselling group ws tught the 12 M method, nd the Al-Qurn recittion group ws tught to recite four chpters of the Qurn while concentrting on the mening of the verses. The four chpters used were: Al-Ftihh, An-Ns, Al-Flq, nd Al-Ikhls. The sme investigtor delivered the content for ech group, guided by PowerPoint slides. A question nd nswer session ws held during ech group meeting or visit. Prticipnts were sked to prctice the methods nd record their prctices in diry. Prticipnts were seen t visits 3 (week 1), 4 (week 2), 5 (week 3), nd 6 (week 4). At ech visit, counseling nd Al-Qurn recittion were emphsized, depending on the group prticipnts were ssigned to, nd the Mly version of the Wisconsin Smoking Withdrwl Score (WSWS) (12) ws filled out by the prticipnts. At week 4, CO levels were ssessed. At visit 7 (week 12), the number of cigrettes still being smoked per dy ws obtined vi phone cll. The primry outcome for this study ws smoking intensity in term of the reduction in the number of cigrettes smoked per dy t the end of study period, i.e., the difference in cigrettes smoked per dy between week 1 nd week 12. The secondry outcomes were the chnges in withdrwl symptoms scores bsed on the WSWS nd chnges in CO levels from week 1 to week 4. The WSWS hs 28 items, which re rted on 5-point scle with 0 being totlly disgree nd 4 being totlly gree. Low score signifies low withdrwl symptoms nd high scores signifies high withdrwl symptoms. It contins seven domins, which re nger, nxiety, concentrtion, crving, hunger, sdness, nd sleep. For nlysis, the withdrwl symptoms score ws clculted ccording to domin. The totl score for ech domin ws then entered into the SPSS. The nger domin ws covered by questions 13, 15 nd 18; the nxiety domin by questions 3, 6, 8 nd 10; the concentrtion domin by questions 4, 23 nd 27; the crving domin by questions 9, 11, 20 nd 26; the hunger domin by questions 1, 14, 16, 21 nd 28; the sdness domin by questions 7, 12, 19 nd 24; nd the sleep domin by questions 2, 5, 17, 22 nd 25. Questions 1, 2, 4, 10, 17, 22, nd 24 hd reverse scoring. The higher the totl scores signifies the higher symptoms experienced by the ptient. The smple size ws clculted using the Power nd Smple Size Clcultion (PSSC) softwre. The first objective ws to compre the chnge in withdrwl symptoms score mong group t 4 weeks intervention. The stndrd devition (SD) vlue for crving for cigrette now ws dpted from study conducted by Shhb et l. 14 The second objective ws to compre the chnge in crbon monoxide level mong groups t 4 weeks intervention. The third objective ws to compre the chnge in number of cigrette smoked mong the intervention group compred to control group t 12 weeks intervention. The SDs for the CO level nd number of cigrettes smoked were dpted from Lee et l. 13 The detectble men ws bsed on expert opinion. Bsed on the smple size clcultions for ech objective, the lrgest smple size required ws 21 (for objective 3). After fctoring in 20% drop out rte, the smple size clculted ws 25 per group. Figure 1. Study overview nd design Al-Qurn recittion (n=25) Study end (n=24) Screening (n=56) Rndomiztion (n=50) Exclusion (n=6) Counseling (n=25) V3, V4,V5,V6 V3, V4,V5,V6 Withdrwl from study (n=1) 4 weeks Study end (n=24) Lost to follow-up (n=1) 21

4 Dt ws nlyzed using SPSS for Windows Non-prmetric tests were used due to skewed distributions on boxplots chrting (not shown). Independent t-tests were used for comprison of bseline chrcteristics, differences in withdrwl scores from bseline, differences in CO levels from bseline, nd difference in the number of cigrettes smoked between groups. The pired t-test ws used to nlyze the differences in withdrwl scores from bseline to endpoint in the sme group. Dt re reported s medins + Interqurtile Rnge (IqR) unless otherwise stted, nd p-vlue of less thn 0.05 ws used to indicte significnt difference. Results A totl of 56 potentil prticipnts were screened. Of these, 50 met the inclusion criteri nd were rndomized to the counseling group (n=25) nd Al-Qurn recittion group (n=25). One prticipnt from Al-Qurn recittion group withdrew from the study t V4 since he could not comply with the Al- Qurn recittion when he hd smoking urges. In ddition, one prticipnt in the counseling group ws lost to follow-up in V4-V6. Thus, 48 prticipnts completed the study (response rte of 96%). Complince with the counseling sessions nd Al-Qurn recittion sessions ws 100%. All prticipnts returned their diries nd chieved more thn 70% complince with the protocol (prcticing 70% or more of the methods tught for coping with smoking urges s ttested to in their diry). Bseline chrcteristics There were no sttisticlly significnt differences in bseline chrcteristics in terms of mritl sttus, employment, income, eduction level, helth sttus nd religiosity between the two groups (results not shown). Bseline smoking chrcteristics re shown in Tble 1. Tble 1: Smoking chrcteristics of prticipnts t bseline Vribles Al-Qurn recittion Control group p-vlue Smoking chrcteristics Number of cigrettes per dy 14.5 (6) 12.5 (8) Smoking durtion (yers) 22.5(21) 26.5 (15) Fgerstrom score 4.00 (5) 4.00 (4) Crbon monoxide level 10.0 (5) 8.5 (6) History of ttempts to quit Yes 22 (91.7) n (%) 21 (87.5) n (%) b No 2 (8.3) n (%) 3 (12.5) n (%) Religiosity score 124 (24) 120 (26) Medin (IQR) for numericl vrible, n (%) for ctegoricl vrible, Mnn-Whitney Test b Fisher s Exct Test Chnge in the number of cigrettes per dy t week 12 nd crbon monoxide levels t week 4. There ws sttisticlly significnt difference in the reduction in the number of cigrettes smoked t 12 weeks between the two groups, s shown in Tble 2. There ws no sttisticlly significnt difference in the chnge in CO levels between the groups. Tble 2: Chnge in the number of cigrettes smoked t 12 weeks nd CO levels mesured t week 4 Group Z-stt p-vlue Al-Qurn Vrible recittion Counseling Number of cigrettes - 9 (5.75) - 7 (4) * CO level - 5 (4) - 3 (3) Mnn-Whitney Test 22

5 Group effect: withdrwl symptoms score between counselling nd Al-Qurn recittion groups There ws sttisticlly significnt difference in the chnge in crving between the counseling nd Al-Qurn recittion groups t week 4, s shown in Tble 3. Chnges in other domins were not sttisticlly significnt. Tble 3: Chnges in withdrwl symptoms scores by domin t week 4 Group Z-stt p-vlue Al-Qurn Domin recittion Counseling Anger 5(3) 5 (3) Anxiety 6 (1) 6 (5) Crving 6 (2) 7 (1) * Concentrtion 7 (3) 8 (2) Hunger 7 (2) 7 (1) Sdness/ depressed 5 (3) 5 (3) Sleep 5 (2) 5 (3) Mnn-Whitney Test Time effect: withdrwl symptoms scores within groups Within group nlysis showed tht there were sttisticlly significnt chnges in nger, nxiety, nd crvings t week 4 in the Al-Qurn recittion group. However, in the counseling group, significnt chnge ws seen only in the nxiety domin. Results re depicted in Tble 4. Tble 4: Chnges in withdrwl symptoms scores within group t week 4 Prmeters Week1 Al-Qurn recittion group Medin (IqR) Week4 Chnge (CI) p-vlue Week1 Control Group Medin (IqR) Week4 Chnge (CI) p-vlue Anger 5(2) 5(3) * 5 (4) 5 (3) Anxiety 7 (3) 6 (1) * 8 (3) 6 (5) * Crving 8 (2) 6 (2) * 7 (1) 7 (1) Concentrtion 7 (2) 7 (3) (4) 8 (2) Hunger 8 (3) 7 (2) (2) 7 (1) Sdness/ depressed 6 (1) 5 (3) (3) 5(3) Sleep 5 (3) 5 (2) (2) 5 (3) Wilcoxon Signed Rnks Test Discussion Abstining from smoking for more thn three months is predictor of success in quitting. It is suggested tht self-reported cesstion for more thn three months should be considered n intermedite criterion for success in the evlution of community interventions. 14 Therefore, we clled prticipnts to determine the number of cigrettes smoked t 12 weeks. Our results showed sttisticlly significnt difference in the number of cigrettes smoked t week 12 in the Al-Qurn recittion group compred to the counseling group. An lterntive outcome mesure is the bstinence rte, which mesures the proportion of ptients who totlly quit smoking. However, this rte is usully computed t lest 6 months fter the end of the intervention. It ws not possible to follow these prticipnts for this length of time s the resercher hd time restriction. When chronic tobcco consumers bstin from tobcco, they develop withdrwl symptoms. Tobcco withdrwl symptoms include crvings, hunger, nger, nxiety, depression, difficulty concentrting, imptience, insomni, nd restlessness. These symptoms pek within 23

6 the first week nd lst for two to four weeks. 15 Therefore, in this study, withdrwl score ws tken t four weeks post intervention. Our results showed sttisticlly significnt difference in only the chnge in crving scores t week 4 in the Al-Qurn recittion group in comprison to the counseling group; differences in the chnges in other withdrwl symptoms were not sttisticlly significnt. In this study, prticipnts were instructed to recite four short Al-Qurn chpters, nmely Al-Ftihh, An-Ns, Al-Flq, nd Al-Ikhls. These chpters comprise few long verses ech tht required the prticipnts to tke deep breth in order to recite the verse completely. When reciting these verses, they were unintentionlly prcticing deep brething. Our results re consistent with using yogic brething exercises 16 nd controlled deep brething. 17 A study by Shhb 16 investigted the effect of brething exercises on crvings nd withdrwl symptoms nd reveled sttisticlly significnt reduction in smoking urges but not for ny other withdrwl symptoms. Reciting Qurnic phrses hs been proven to reduce nxiety mong thletes nd women witing cesren sections nd lso reduces the pulse rte mong ptients witing open hert nd bdominl surgery. These physiologicl chnges could reduce the crvings mong those who recite the Al-Qurn. CO levels were exmined t bseline nd four weeks post intervention. There ws no significnt difference in the chnges noted between the two groups. This non-significnt difference cn be explined by few fctors. First, number of ptients exhibited poor exhltion technique. At bseline, there were lredy redings of less thn 10ppm, which did not correlte with their smoking sttus. In prticulr, this occurred mong ptients who hd sthm nd/or hert disese, explining their poor efforts to exhle completely, which cuses lower CO levels to be recorded. Another fctor ws high vribility in smoking technique. Some of the smokers inhled the cigrette smoke more deeply thn others. The prticipnts who inhled lightly hd lower crbon monoxide levels, ccording to the CO nlyzer. Another possible reson ws tht ptients hd reduced cigrette smoking dy before the orienttion dy, s the resercher informed them of the dte hed of time. This would result in lower CO redings. Therefore, when compred to levels t week 4, there ws no significnt chnge. From this study, it ws discovered tht Al-Qurn recittion led to significnt difference in the chnge in the number of cigrettes smoked t 12 weeks compred to counseling with the 12 M method. This finding suggests tht the Al-Qurn recittion pproch is potentil method with which to improve smoking cesstion efforts. This is due, in prticulr, to its bility to reduce crvings, s higher degree of crving is ssocited with relpse. Becuse Al- Qurn recittion is shown to reduce stress, it cn reduce crvings, nd this is reflected in the lower number of cigrettes smoked. This study ws limited by the smll smple size. It my not be ble to represent ll Muslim men who re trying to quit smoking. The sme investigtor delivered the content to both groups to reduce systemtic bis. Idelly, the counseling nd Al- Qurn recittion groups would hve different counselors. It is lso importnt to note tht selfreported mesures of withdrwl symptoms re more vulnerble to differentil misclssifiction bis, which cn mke interpreting the results difficult. Acknowledgements We would like to cknowledge the coopertion of ll the prticipnts nd stff involved in this project. We would lso like to cknowledge the questionnire s uthors Steven Eric Kruss nd Ahmed Awisu for giving us permission to use the questionnire. How does this pper mke difference to generl prctice? Al-Qurn recittion hd been shown to reduce nxiety mong thletes before tournments nd pulse nd hert rtes mong ptients witing crdic opertions. There is no prior study which hs ssessed the influence of Al-Qurn recittion on reducing nicotine withdrwl symptoms nd smoking intensity. Our study reveled tht Al-Qurn recittion exerted moderte effect on smoking intensity. Our study lso reveled significnt difference in the chnge in crvings in the Al-Qurn recittion group compred to the counseling group. This study did not demonstrte difference in smoking bstinence rtes which ws not mesured. 24

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