CIGARETTE SMOKING AMONG THAI BUDDHIST MONKS, CENTRAL AND EASTERN THAILAND

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1 CIGARETTE SMOKING AMONG THAI BUDDHIST MONKS, CENTRAL AND EASTERN THAILAND Wisit Chveepojnkmjorn nd Nthporn Pihinrong Deprtment of Epidemiology, Fulty of Publi Helth, Mhidol University, Bngkok, Thilnd Abstrt. A ross-setionl study ws onduted from June to Deember, 2003 mong Thi Buddhist monks in 4 provines of the entrl region (Nonthburi, Pthum Thni, Srburi nd Chi Nt) nd in 4 provines of the estern region (Chhoengso, Ryong, Trt, nd S Keo) of Thilnd. Dt were olleted using fe to fe interviews, questionnires, nd physil exmintion reports (weight, height, hert rte, blood pressure, et) s the reserh tools. This study foused on soiodemogrphis, history of illness, nd smoking behvior. The proportion of the igrette smoking ws 47.6% of the totl of 920 Buddhist monks. The ge group yers, Mh Niky setion nd Publi temple were the mjority of the study subjets. Multivrite nlysis reveled tht only four ftors were relted to smoking onsumption: dhrm edution, Nkthrm To (grde 2) (OR=0.6, 95%CI: ), Nkthrm Aek (grde 3) or bove (OR=0.4, 95%CI: ); Ly edution, seondry shool (OR=0.7, 95%CI: ), bhelor degree or bove (OR=0.4, 95%CI: ); systoli blood pressure >140 mmhg (OR=1.8, 95%CI: ) nd history of respirtory illness (OR=3.2, 95%CI: ). As result, dhrm edution nd well eduted persons were the ruil ftors whih led to suess in deresing igrette smoking. Smoking esstion mpigns nd edution of the onsequenes of smoking re strongly reommended mong risk groups. INTRODUCTION Smoking is mjor preventble use of deth nd disbility. It is mintined by dependene on niotine (Hll, 2002). A lrge number of epidemiologil studies hve linked smoking to ner, oronry hert disese, emphysem, hroni bronhitis, reprodutive-relted problems, nd other onditions (The Surgeon Generl, 1982, 1983, 1984, 1989; WHO, 1983). The onsumption of igrettes nd other tobo produts nd exposure to tobo smoke re the world s leding preventble uses of deth, responsible for bout 5 million deths yer, mostly in poor ountries nd poor popultions (WHO, 2003). In the 1990s, the number of smokers in the world ws estimted t 1.3 billion, it is expeted to rise to 1.7 billion by 2023 if the globl prevlene of tobo use remins unhnged (Guindon nd Boislir, 2003). The epidemi of tobo ddition, disese nd Correspondene: Wisit Chveepojnkmjorn, Deprtment of Epidemiology, Fulty of Publi Helth, 420/1 Rjvithi Rod, Bngkok 10400, Thilnd. Tel: +66 (0) ; Fx: +66 (0) E-mil: phwv@mhidol..th deth is ontinuing to shift rpidly to developing nd trnsitionl mrket ountries (Murry nd Lopez, 1996). An lrming 23.4% of This over 11 yers of ge ontinue to smoke (Ntionl Sttistil Offie, 2001). Among Thi dults, mles smoke more thn femles (38% of mles, 2% of femles) (Beyer nd Brigden, 2003). However, the mle smoking prevlene hs fllen signifintly from 49% in 1996 to 38% in 1999 (Vteestokit et l, 2000). Buddhism is the ntionl religion of Thilnd, where nerly 95% of the popultion is Buddhist. Monks hve powerful influene through the modeling of non-smoking s desirble nd meningful tion. However, This offer mnuftured igrettes to monks s lms with other ommon food nd personl items, even though some believe tht offering igrettes to monks is sin. Hlf the ountry s 300,000 monks re smokers, but erlier inititives to get them to hnge their hbits hve lrgely been unsuessful (Ingrm, 2002). Smoking is mjor use of morbidity nd mortlity mong Thi monks. Smoking-relted diseses, espeilly in the irultory nd respirtory system mong Thi monks, hve been rpidly inresing over the Vol 36 No. 2 Mrh

2 SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH pst dede (Priest Hospitl, 2003,b). The outptient proportions of diseses of the irultory system nd the respirtory system were bout 16% nd 13%, respetively in , nd were mong the ten leding uses of illness t the Priest Hospitl (Priest Hospitl, 2001, 2003,b). This hospitl is the only one in the ountry tht just trets leris. A better understnding of the smoking ptterns in monks ould led to proper solutions for smoking ontrol. The im of this study ws to determine the possible ftors for igrette smoking mong Thi monks in 8 provines (entrl nd estern regions). The study foused on soio-demogrphis, helth sttus, history of illnesses nd smoking behviors of Thi monks. MATERIALS AND METHODS Study design nd popultion A ross-setionl study ws onduted from June to Deember, 2003 in order to determine the risk ftors tht ontribute to smoke mong some Buddhist monks in 8 provines (entrl region: Nonthburi, Pthum Thni, Srburi, nd Chi Nt; estern region: Chhoengso, Ryong, Trt, nd S Keo). The trget popultion ws the Buddhist monks who lived in temples t lest one yer, ge 20 yers. The totl study subjets numbered 920. They were ll willing to prtiipte in the present study. All urrently smoking monks were lssified s urrent smokers nd non-smoking monks were lssified s non-smokers. A totl of 438 urrent smokers nd 482 non-smokers were reruited. Fe to fe interviews, nd weight, height, blood pressure nd hert rte mesurements were performed by well trined provinil helth stff in eight provines. The questionnires onsisted of 4 prts: soio-demogrphi, history of illness, history of smoking nd mesurement vribles. The detils of the study were explined nd informed onsent ws obtined by signture or thumb print from ll the prtiipnts. Soio-demogrphis, history of illness, nd smoking behviors re displyed by perentge, men, stndrd devition, medin, nd qurtile devition. The Mnn-Whitney U test ws performed to ompre the mens for weight, height, body mss index, hert rte, nd systoli nd distoli blood pressure. Chi-squre tests were utilized to differentite proportionl exposures between the urrent smokers nd the non-smokers for tegoril vribles whih were employed in order to find out the suitble vribles. Multiple logisti regression ws used to estimte the umultive odds rtios (OR) nd their 95%CI s mesures of ssoitions inluding identifition nd djustment for onfounding vribles. Assessment of the sttistil signifine of eh independent vrible ws done using the Likelihood Rtio Test (LRT) t the p-vlue of 0.05 by two-til tests. Smple size The smple size ws lulted using the following formul (Lwng nd Lemeshow, 1991) Z 2 1-α/2 P(1-P) n= d 2 Where n=minimum number of subjets tht were inluded, P=proportion of urrent smokers in the Thi-mle popultion=0.43 (Ntionl Sttistil Offie, 2001), Z 1-α/2 =1.96 t α=0.05, d=bsolute preision=0.04. The lulted smple size ws t lest 589. RESULTS The proportion of igrette smokers ws 47.6% of the totl of 920 Buddhist Thi monks. The mjority of the study subjets were ged yers (49.3% of urrent smokers, 51.4% of non-smokers). The verge ge of the urrent smokers ws 37.9 yers, slightly lower thn the non-smokers, whih ws 38.7 yers. The proportion of smokers delined with inresing ge for the urrent smokers. For Dhrm edution, most of the urrent smokers (36.5%) hd no shooling; 38.4% of the non-smokers hd Nkthrm Aek (grde 3) or bove. For ly edution, the urrent smokers hd higher proportion of primry shool edution (46.1%), while the non-smokers hd higher proportion of seondry shool edution (41.2%). The provine with the most urrent smokers ws Srburi Provine (34.7%) (19.9% of the nonsmokers). The seond rnk ws Ryong Prov- 506 Vol 36 No. 2 Mrh 2005

3 Tble 1 Comprison of seleted soio-demogrphi hrteristis between urrent smokers nd the non-smokers. Current smokers Chrteristis Yes No p-vlue No. % No. % Age (yr) (N=920) < > Men ± SD 37.9 ± ± 15.7 Medin ± QD 35.0 ± ± 12.5 Dhrm edution (N=899) No shooling Nkthrm Tri (grde 1) Nkthrm To (grde 2) Nkthrm Aek (grde 3) or bove Edution (N=920) Primry shool Seondry shool Votionl shool Bhelor degree or bove Provine (N=920) Nonthburi Pthum Thni Srburi Chi Nt Chhoengso Ryong Trt S Keo Former ouption (N=920) b Agriulture Employee Student Governmentl offier/ stte enterprise offier Others Type of temple (N=920) Arm Lung (Royl) Rsdorn (Publi) Type of ordintion (N=920) Dhmmyut Niky Mh Niky Position (N=920) Abbot Others Durtion of monkhood (yr) (N=920) < > Men ± SD 6.0 ± ± 10.8 Medin ± QD 3.0 ± ± 5.0 History of illness within 1 yer Respirtory trt (N=920) Yes No Gstrointestinl trt (N=920) Yes No = not signifint t α = 0.05; 0.01 < p < 0.05; b < p < 0.01; p < by Person hi-squre Vol 36 No. 2 Mrh

4 SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH Tble 2 History of smoking mong urrent smoking Buddhist monks. Chrters No. % Strt of smoking (N=437) Before monkhood During monkhood Age t strt of smoking (yr) (N=429) < > Men ± SD 17.2 ± 4.3 Medin ± QD 17.0 ± 2.0 Current ge of smoker (yr) (N=429) < > Men ± SD 19.7 ± 6.7 Medin ± QD 19.0 ± 2.5 Durtion of smoking (yr) (N=429) > Men ± SD 17.8 ± 14.1 Medin ± QD 14.0 ± 10.3 Number of igrettes per week (N=417) < > Men ± SD 94.8 ± 66.9 Medin ± QD 70.0 ± 45.5 Number of igrettes per dy (N=427) < > Men ± SD 13.9 ± 9.4 Medin ± QD 10.0 ± 5.5 Smoking hbits (N=436) Every dy Often (sometimes in week) Osionl (one in week) ine (21.0% urrent smokers, 16.6% non-smokers). The highest two former ouptions mong the urrent smokers were griulturl workers (36.5%) nd employees (48.6%) whih were similr to the non-smokers, griulturl workers (42.9%) nd employees (37.8%). Both groups hd high proportion of publi temple monks (93.4% for urrent smokers, 92.3% for nonsmokers), nd high proportion in the Mh Niky setion (95.4% for urrent smokers, 93.4% for non-smokers). The durtion of monkhood in both groups delined with inresing number of yers (<5, 5-9, nd yers), but it inresed gin fter 14 yers. The verge durtion of monkhood in the urrent smokers ws 6 yers shorter thn the non-smokers, whih ws 9.2 yers. A history of respirtory illness within one yer in the urrent smokers nd the non-smokers were 82.6% nd 71.8%, respetively. Some of the vribles ssoited with urrent smoking, were Dhrm edution, residentil provine, durtion of monkhood, former ouption, ly edution, nd history of respirtory illness within 1 yer (Tble 1). Most of the urrent smokers begn smoking before beoming monks (95.2%). The most ommon ges to strt smoking were yers (54.5%) nd bove 19 yers (24.2%). The min ge group of urrent smokers ws yers (43.8%), followed by yers (32.2%). The durtion of urrent smokers ws minly 1-9 yers (36.6%), nd >34 yers (17.9%). Most smoked less thn 80 igrettes per week (52.1%) or more thn 119 igrettes per week (34.5%). In ddition, the min proportion of igrettes smoked per dy ws igrettes (40.7%). Most smoked every dy (86.9%) (Tble 2). The verge hert rte (per minute) in the urrent smokers ws 81.7, slightly higher thn the non-smokers ws The urrent smokers hd n verge systoli blood pressure (128.0 mmhg) higher thn the non-smokers (124.1 mmhg). The distoli blood pressure in the urrent smokers (80.6 mmhg) ws slightly higher thn the non-smokers (78.8 mmhg). Some of the vribles ssoited with urrent smoking were hert rte, systoli blood pressure, nd distoli blood pressure (Tble 3). 508 Vol 36 No. 2 Mrh 2005

5 Tble 3 Weight, height nd hert rte of urrent smokers nd the non-smokers. Current smokers Chrteristis Yes No p-vlue Men ± SD Men ± SD Weight (kg) (N=903) 61.4 ± ± 10.9 Height (m) (N=906) ± ± 9.4 Body mss index (kg/m 2 ) (N=902) 22.4 ± ± 6.3 Hert rte (per minute) (N=820) 81.7 ± ± 7.8 *** Systoli blood pressure (mmhg) (N=808) *** b > < ± ± 15.2 *** Distoli blood pressure (mmhg) (N=871) ** b > < ± ± 9.7 ** = not signifint t α = 0.05 ** < p < 0.01; *** p < p-vlue by Mnn-Whitney U test, b p-vlue by Person hi-squre test There were 8 different ftors inluded in the model: edution, history of respirtory illness, former ouption, Dhrm edution, provine, durtion of monkhood, hert rte, nd systoli blood pressure (p<0.05). The vribles whih were not sttistilly signifint re exluded. To evlute the effet of risk or protetive ftors nd djust for onfounding vribles, ll potentil vribles were inluded in the finl model. The reson why we seleted only systoli blood pressure ws tht the systoli blood pressure nd distoli blood pressure were found to hve ollinerity. Upon djusting for potentil onfounders, only four vribles were signifintly ssoited with urrent smoking. Subjets who studied to Nkthm To (grde 2) nd Nkthm Aek (grde 3) were 0.6 nd 0.4 times, respetively, less t risk thn those with no shooling (95%CI= , ). Subjets who finished seondry shool, bhelor degree or bove hd higher protetive ftors for smoking thn those with primry shool edution (OR=0.7, 95%CI= ; OR=0.4, 95%CI= ). Subjets who hd history of respirtory illness were 3.2 times more t risk for smoking thn those who hd none (95%CI= ). Subjets who hd systoli blood pressure >140 mmhg were 1.8 times more t risk for smoking thn those with systoli blood pressure <140 mmhg (95%CI= ), s shown in Tble 4. DISCUSSION The mjority of study subjets were in the Mh Niky setion (type of ordintion), ge yers, worked in griulture or s employees before being monks, lived in publi temple, nd hd no Dhrm edution. The proportion of igrette smoking ws 47.6%. These findings re similr to previous report (Ingrm, 2002) whih found tht bout 50% of monks were smokers. They strted smoking before monkhood (95.2%), were youth ged yers (43.8%), hd durtion of smoking 1-9 yers (36.6%), smoked igrettes per dy (40.7%), nd smoked everydy (86.9%). A poor soio-eonomi sitution ws ritil ftor whih led them to beome monk. Temples were their shools nd temporry homes nd they lived on lms donted by the publi. The verge length of being monk ws 6 yers. A solution to the smoking problem is needed both before nd fter being monk s well s while being monk. There is no religious edit bnning monks from smoking. Even senior leris n some- Vol 36 No. 2 Mrh

6 SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH Tble 4 Risk ftors for urrent smoking mong Buddhist monks by multiple logisti regression. Vrible OR 95 % CI p-vlue Age (yr) < > Dhrm edution No shooling 1 Nkthm Tri (grde 1) Nkthrm To (grde 2) Nkthrm Aek (grde 3) or bove Edution Primry shool 1 Seondry shool Votionl shool Bhelor degree or bove b Former ouption Agriulture 1 Employee Student Government offier/stte enterprise offier Others Durtion of monkhood (yr) < > Systoli blood pressure (mmhg) < History of illness within 1 yer Respirtory trt No 1 Yes b, not signifint t α= <p<0.05; b 0.001<p<0.01; p<0.001 by Likelihood Rtio Test. times be seen smoking. Smoking goes ginst the morl vlues of Buddhism, sine monks re the spiritul leders of the ly people, Thi monks n lso be ruil gents for smoking redution in the rurl popultion (Swddiwudhipong, 1993). Tobo, whether smoked or hewed, is now widely onsidered n dditive nd dngerous drug. However, s its impt on onsiousness is slight, most Buddhists do not onsider smoking to be breking the fifth preept. In Mynmr nd Jpn, smoking by monks is s ommon s it is in Thilnd mongst monks of the Mh Niky setion. In Sri Lnk nd mongst Tibetns nd Chinese, smoking monks re looked down upon nd they usully refrin from it. From the Buddhist perspetive, smoking my well be unwise but it does not hve morl dimension. Smoking mong monks is relted to respirtory illness nd high systoli blood pressures. Tems of helth personnel should edute s to the impt nd disdvntges of smoking, nd should ounsel to stop smoking. 510 Vol 36 No. 2 Mrh 2005

7 However, government offiils will hve to be espeilly vigilnt to see tht this new legisltion is respeted. Enforement offiils from severl government deprtments re responsible for ensuring tht the new restritions on tobo dvertising nd mrketing, nd on smoking in publi ples, re respeted. If they re suessful, Thilnd my soon begin to enjoy the publi helth benefits tht flow from delining tobo onsumption (WHO, 1997). Our study found tht the more edution (Dhrm nd ly edution), the less monks smoke. This finding is similr to previous studies (Hnn et l, 1995; WHO, 1997). Edutionl promotion nd intensive nti-smoking mpigns through the medi re importnt mesures for smoking esstion. ACKNOWLEDGEMENTS The uthors would like to express sinere thnks for the prtil support given by the stff of the provinil helth offie in eight provines. We would lso like to express our respet nd mny thnks to the prtiipting monks who provided useful informtion for this study. We lso wnt to thnk those whom we did not mention for their kindness nd enourgement. REFERENCES Beyer JD, Brigden LW. Overview. In: Beyer JD, Brigden LW, eds. Tobo ontrol poliy: strtegies, suesses nd setbks. Wshington, DC: World Bnk nd RITC, Guindon GE, Boislir D. Pst, urrent nd future trends in tobo use. Wshington, DC: World Bnk, Hll W. The prospets for immunotherpy in smoking esstion. Lnet 2002; 360: Hnn N, Asghr A, Owen W, Asel N. Smoking: high hzrds in high shool. J Okl Stte Med Asso 1995; 88: Ingrm S.Thi monks urged to quit smoking. 1 April BBC New [ASIA-PACIFIC] [Online]. [Aessed 2004 Aug 5]. Avilble from URL: news.bb.o.uk/2hi/si-pifi/ stm Lwng SK, Lemeshow S. Smple size determintion in helth studies: prtil mnul. Genev: WHO, 1991: 25. Murry CL, Lopez AD. Alterntive projetions of mortlity nd disbility by use : globl burdens of disese study. Lnet 1997; 349: Ntionl Sttistil Offie. Report of the igrette smoking nd loholi drinking behviour survey Bngkok: Sttistil foresting bureu, 2001: 55 (in Thi). Priest Hospitl, Deprtment of Medil Servies, Ministry of Publi Helth. Sttistil report Bngkok: Priest Hospitl, 2002 (in Thi). Priest Hospitl, Deprtment of Medil Servies, Ministry of Publi Helth, Thilnd Sttistil report Bngkok: Priest Hospitl, 2003 (in Thi). Priest Hospitl, Deprtment of Medil Servies, Ministry of Publi Helth, Thilnd Sttistil report 2003b. (in Thi). Swddiwudhipong W, Chovkirtipong C, Nguntr P, Khumklm P, Silrug N. A Thi monk: n gent for smoking redution in rurl popultion. Int J Epidemiol 1993; 22: The Surgeon Generl. The helth onsequenes of smoking: ner. Wshington, DC: DHHS. 1982; DHHS publition no. (PHS) The Surgeon Generl. The helth onsequenes of smoking: rdiovsulr disese. Wshington, DC: DHHS. 1983; DHHS publition no. (PHS) The Surgeon Generl. The helth onsequenes of smoking: hroni obstrutive lung disese. Wshington, DC: DHHS. 1984; DHHS publition no. (PHS) The Surgeon Generl. Reduing the helth onsequenes of smoking: 25 yers of progress. Wshington, DC: DHHS. 1989; DHHS publition no. (CDC) Vteestokit P, Hughes B, Ritthphkdee B. Thilnd: winning bttles, but the wr s fr from over. Tob Control 2000; 9: World Helth Orgniztion. Smoking ontrol strtegies in developing ountries report of WHO Expert Committee. WHO Teh Rep Ser 1983; 695. World Helth Orgniztion. Tobo or helth: globl sttus report. Genev: World Helth Orgniztion, World Helth Orgniztion. The world helth report 2003: shping the future. Genev: World Helth Orgniztion, Vol 36 No. 2 Mrh