Religiosity, tobacco use, and poverty.

Abstract: A study was conducted to examine the relationship between religion and tobacco use among low-income persons living in the South. The study findings revealed significant differences between tobacco users and nonusers in attending religious services: while about 40% of nonusers were attending church services more than once a week, less than 30% of tobacco users attended church services. Study results also show that about 45% of Baptist reported tobacco use. Overall, participant's religiosity was found to be very strong. Other implications for the study are discussed.

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Religiosity is an important predictor of psychological functioning as well as behavior. Numerous studies document that religiosity is associated with lower rates of premarital sexual behavior, substance abuse including alcohol and tobacco, and other risky behaviors (Brega & Coleman, 1999; Cochran, 1992; Engs & Mullen, 1999; Kandel, Adler, & Sudit, 1981; Koenig, George, Cohen, Hays, Larson, & Blazer, 1998; Thorne, Nickerson, & Gemmel, 1996; Wallace & Bachman, 1993). Studies have shown that there is an association between tobacco use and the belief in God and religiosity (Brega & Coleman, 1999; Engs & Mullen, 1999; Sutherland & Shepherd, 2001). Those who take part in church-related activities are less likely to smoke (Thorne, Nickerson, & Gemmel, 1996). Research has found an inverse relationship between the belief in God and substance use. In Sutherland and Shepherd's (2001) study among 11-16 year olds, of those who did and did not believe in God, 13.7% and 24.8% used tobacco, 50.2% and 73.7% used alcohol, and 9.6% and 21.1% used illicit drugs, respectively. The present study examines how a religion is associated with tobacco use among low-income individuals in the South.

CHURCH ATTENDANCE

Research suggests that church attendance is linked to tobacco use as well as alcohol and drug use (Koenig et al., 1998; Merrill & Thygerson, 2001; Moore, Laflin & Williams, 1996; Strawbridge, Cohen, Shema, & Kaplan, 1997; Sutherland & Shepherd, 2001). According to Moore and Laflin (1996), infrequent church attendance is related more to higher use of tobacco more than moderate church attendance. In the same respect, an increase in tobacco use is found more among moderate church attendance than frequent church attendance. In a study of 11-16 year olds (n = 4,516) led by Sutherland and Shepherd (2001), it was found that among those who attended church, 10.7% smoked, while 21.0% of those who did not go to church used tobacco. Alcohol use was 31.5% and 68.3% among those who did and did not attend church, respectively. For those attending church, 7.1% used illicit drugs and 17.0% of those not attending reported illicit drug use. Koenig and colleagues (1998) conducted a study of 3,968 people 65 years or over and found that those who frequently attended religious services were significantly less likely to smoke cigarettes and/or ever start smoking. They also found that among frequent church attenders that did smoke, they smoked fewer cigarettes than those who did not attend church. In a study (n = 6,188) conducted by Merrill and Thygerson (2001), members of the Church of Jesus Christ of Latter-clay Saints (LDS) who attended church less than once a week were at a higher risk of tobacco use. Smokers and heavy drinkers were less likely to be frequent attenders. Research by Strawbridge et al. (1997) that found those who were frequent church attenders, that is, attending any denominational religious services once a week or more, had lower rates of smoking and alcohol use. Frequent attenders who did smoke or drink heavily were more likely to quit than infrequent attenders. This study suggests that frequent attenders have supportive social connections, stable marriages and "adopt better health practices."

DENOMINATIONAL AFFILIATION

Denominational affiliation is a significant factor related to tobacco, alcohol, and drug use (Ahmed & Brown, 1994; Engs & Mullen, 1999; Koenig, George, Cohen, Hays, Larson, & Blazer, 1998; Koenig, Moberg, & Kvale, 1988; Merrill & Thygerson, 2001; Miller, Davies, & Greenwald, 2000; Mullen, Williams, & Hunt, 1996; Strawbridge, Cohen, Shema, & Kaplan, 1997). Among a sample of 676 adolescents, Miller et al. (2000) found an inverse relationship between more fundamentalist religious denominations and substance use, abuse, or dependence.

People with no religious preference are more likely to be smokers than those with a religious preference. A study by Merrill and Thygerson (2001) found lower smoking levels among members of the Church of Jesus Christ of Latter-day Saints (LDS) in Utah compared to Non-Latter-day Saints and those who have no religious preference. A reported 0.4% of active LDS members were current smokers while 8.3% Non-LDS were currently smoking. Among those with no religious preference, 28.1% currently smoked. Research has found that among African American women of child bearing age (18-44 years old), women of Pentecostal denominations were less likely to smoke and more likely to quit than women who identified themselves as Baptists or non-Pentecostal. Ahmed and Brown (1994) reported that 40.4% of the Baptist women currently smoked, 23.3% currently smoked who answered with "other" or "no" religious affiliation, and 16.7% of Pentecostal women smoked. In the Engs and Mullen (1999) study of post secondary students in Scotland, females identifying themselves as Roman Catholic reported higher usage of tobacco than those of the Church of Scotland, who had the lowest proportion. Male students had a higher percentage of tobacco use among those with "other" or "no" religious background. Similar to females, the lowest percentage was those of the Church of Scotland. Mullen and colleagues (1996) studied an Irish population to examine the relationship between religion and tobacco and alcohol use. Catholics reported higher rates of smoking and alcohol use than any other group. Among men who were born Catholic, 36% used tobacco, compared to 31% of the rest of the population. Catholic women reported a tobacco use percentage of 47%, while 44% of the rest of the population used tobacco. Born Catholics were 1.4 times more likely to be heavy to moderate smokers than the rest. When comparing tobacco use among Protestants, Catholics, and those with no religion, Catholics were more likely to be heavy smokers than the others. Fewer Protestant men smoked (24%) than both Catholics (40%) and those with no religion (37%). A similar pattern for women was discovered (36% of Protestants, 49% of Catholics and 55% of non-religious used tobacco). More Catholic men (13%) were heavy daily smokers (21 + cigarettes per day) than Protestants (8%) and non-religious (9%) (Mullen, Williams, & Hunt, 1996). In a study by Amey et al. (1996), White Catholics were the most likely to have taken a drink or used tobacco, when compared to African Americans and other denominations. One possible explanation of the trends mentioned is that the Protestant church prohibits alcohol and tobacco use. And the Presbyterian theology promotes the sacredness of a body, a temple of the Holy Spirit. The Catholic Church neither prohibits nor promotes drinking and smoking (Amey, Albrecht, & Miller, 1996; Mullen, Williams, & Hunt, 1996). Stricter denominations, such as Mormons and Seventh Day Adventists, as well as other Christian religions, report higher rates of healthy behavior, such as restricting tobacco and alcohol use (Koenig, George, Cohen, Hays, Larson, & Blazer, 1998; Levin, 1994a & b). These findings concerning denomination and smoking should be used to develop smoking-cessation programs (Ahmed & Brown, 1994).

SOCIOECONOMIC FACTORS

Numerous studies document that tobacco use increases among individuals with economic, educational, and social disadvantages (CDC, 2001; Rogers, Man, & Hummer, 1995; Thorne, Nickerson, & Gemmel, 1996; Zang & Wynder, 1998). For example, a Centers for Disease Control and Prevention (CDC) report (2001) reveals that tobacco use was higher among adults living below the poverty level (33.1%) compared to those living at or above the poverty level (23.4%). The number of persons disadvantaged is the highest in urban areas (CDC, 1995). Residents of public housing have been found to be at high risk for smoking (Dubrow & Gabarino, 1989; Epstein, Williams, Botvin, Diaz, & Ifill-Williams, 1999; Feigelman, Li, & Stanton, 1995; Flint & Novotny, 1997; Newman, 1975; Normoyle & Foley, 1988). A study conducted by Epstein et al. (1999), they examined 624 adolescents living in low-income public housing developments in New York City. Due to their exposure to poverty and its related factors, this population is at higher risk for tobacco use. Poverty issues related to geographic location can often influence tobacco use as well. According to a study conducted by King et al. (1999) of 16,738 African Americans, approximately 57% resided in a central city and about 56% lived in the South. Generally, African Americans living within a central city demonstrated higher rates of smoking. For example, 32.1% living in a central city currently smoked while 27.0% living in a non-central city area smoked. Southern black women demonstrated the lowest level of smoking. This may be because of religious restrictions, social norms and sanctions, and alternative coping skills (King et al., 1999). Also, those living in the South with lower incomes had higher rates of smoking. For example, 36.3% of those making less than $15,000 currently smoked compared to 27.6% smoking who had an income between $20-49,999. The current trends of tobacco use among various ethnicity religions shows a need to monitor smoking patterns by sociodemographic factors. They can then be used to create effective public health projects, including faith-based interventions, which aim to reduce smoking and smoking-related diseases. These programs must be focused on demographic, social, cultural, religious, and other forces that influence tobacco use (Zang & Wynder, 1998). As stated earlier, religion plays a role in the use of tobacco and other drugs. Religion provides a support system and beliefs and attitudes that contribute to lower levels of tobacco use. The use of faith-based interventions can be effective since religion is a significant factor in smoking.

More research is needed to examine the effects of faith-based programs on minority populations in lowering tobacco use. Religion is an important factor in the South and the church may be an effective route to decreasing tobacco use. The purpose of this study is to examine the possible role religion can play in tobacco use prevention and cessation among indigent populations.

METHODS

PARTICIPANTS

A total of 400 low-income individuals were sampled from August 2001 to July 2002 in Columbus, Georgia. The city of Columbus is located 100 miles southwest from Atlanta and had a population of about 190,000 in 2001. Participants were recruited through a door-to-door survey from two Housing Authority complexes. All participants in this study signed a consent form after trained field staff explained the purpose of the study. Participation was voluntary and information collected remained completely confidential. Protocol and questionnaire were approved by the Columbus State University Institutional Review Board.

To be eligible for the study, participants had to be residents of Columbus Housing Authority and at least 10 years of age. In the case of youth participants below the age of 18, the custodial parents signed an informed consent form. A monetary incentive was provided for their time. The survey instrument was developed to measure the relation between tobacco use and religious factors. The survey questions included information about sociodemographic background, tobacco use, and several religious items. This survey instrument was pilot tested on a sample of twenty eligible low-income individuals during June and July of 2001. A few changes in the instrument and recruitment methods were made after the pilot test. The interview took about one hour to complete.

MEASURES AND ANALYSIS

First, study participants were asked about their current tobacco use (yes or no). For purpose of the study, current tobacco use was defined as the self-reported current use of tobacco products including chewing tobacco, cigarette, cigar, and pipe. Each participant was also asked about the following religion-related items: the type of religion and their denomination affiliations, strength of belief in God (4 point-scale from 'very strong' to 'not at all'), a frequency of church attendance, attending church with someone else (yes or no), church offering any counseling or support services (yes or no), and attending social functions at their church (yes or no). Descriptive analyses were performed to examine sociodemographic profiles and religious factors between tobacco users and nonusers. Independent Samples T-test was conducted for interval variables and chi-square tests were performed for categorical variables.

RESULTS

Demographic characteristics of tobacco users and nonusers are shown in Table 1. The mean age of the sample was 33.1 (from 10 to 82); the majority of the sample was female (77.7%) and African American (97%). Sixty-five percent of the respondents had never been married before, and relatively few were currently married. The majority (54.3%) did not graduate high school, and mean grades of education completed among respondents were below 11 (10.51). About 54% of the sample had no access to transportation. Tobacco users tended to be older than nonusers (p <. 001) and tended not to get married (p < .02).

Table 2 shows the type of religions and denominations by tobacco use. The majority of the participants (86.6%) were Christian with a denomination of Baptist (68.8%), but the difference by tobacco use was not significant. Of those Christians, around 44% were tobacco users (150/342). Results also document that 45% (117/263) of Baptists and about the same percentage of Methodists (14/31) reported current tobacco use. Although numbers are small, results indicate higher prevalence of tobacco use among Catholics. About 84% of them reported tobacco use (5/6) which is much higher than other denomination affiliations in the study.

Tobacco users and non-users were compared in terms of how strong their beliefs is in their religion (Table 3). Overall participant's confidence was very high: 75% of respondents, regardless of tobacco use status, reported their strong belief in their religion. It was statistically significant that tobacco using participants were less likely to believe in their religion than the comparisons (p < .03).

Table 4 shows the religious comparisons of tobacco users and non-users. The study result documents a significant finding that current tobacco users were less likely than nonusers to attend church services. About 40% of nonusers reported attending church services more than once a week, compared to 30.6% of those tobacco users (p < .01). Although the differences were not statistically significant, there was a tendency for tobacco users to attend less church with someone else and have less counseling or support services available at church than non-tobacco users. There was also a tendency for tobacco users to engage in fewer social functions at church than non-users.

DISCUSSION

The goal of this study is to examine the relationship between religious factors and tobacco use among low-income populations. In particular, this study compared tobacco users and non-tobacco users and documented different characteristics of their religious factors. Various studies examined the relations between religiosity and substance abuse among general populations, but there have been few studies documenting possible links between tobacco use and religiosity among a low-income population. The study findings revealed significant differences between tobacco users and nonusers in attending religious services: while about 40% of nonusers were attending church services more than once a week, less than 30% of tobacco users attended their church services (p < .01). Findings in our study are consistent with other studies (Merrill & Thygerson, 2001; Moore & Laflin, 1996; Sutherland & Shepherd, 2001; Strawbridge, Cohen, Shema, & Kaplan, 1997; Whooley, Boyd, Gardin, & Williams, 2002), suggesting that those frequent church attenders are less likely than those infrequent church attenders to associate with tobacco use. With regard to denominational affiliation, our study findings are also similar to a 1994 study by Ahmed and Brown that more than 40% of Baptists reported tobacco use. Results show the higher prevalence of tobacco use among Catholics, which is consistent with a study by Mullen, Williams, and Hunt (1996). In our study, overall participant's religiosity was found to be very strong. More than 75% of participants, regardless of tobacco use status, claimed that they strongly believed in God. Our study did not ask how often they were involved in their religious activities such as practicing prayer and their use of religious media programs (radio or TV programs), but we asked their church attendance to measure their level of religiosity. This high level of religiosity among sampled participants may be explained by Southern culture where hospitality and conservatism are commonly practiced. Also, several studies suggest that African Americans are more religious than others and have a positive attitude toward the church they attend (Amey, Albrecht, & Miller, 1996; Brega & Coleman, 1999). This result implies that faith-based tobacco prevention and treatment interventions may generate effective outcomes when targeting the Southern populations living under the poverty level.

Limitations of this study need to be noted. Since the study sample predominantly includes female low-income African Americans in Southern Georgia, one needs to be careful when generalizing study results to other populations or geographical areas. Also, data are collected using a convenient sampling, thus, study results may not reprensent the general population. Randomization was not possible because of safety reasons in the community. Lastly, tobacco use status was based on self-report.

Despite the study liminations, our findings are important enough to support the view that the faith-based interventions can play an important role in preventing and treating tobacco use among low-income individuals. In summary, our findings report that tobacco-using low-income participants were less likely to attend Sunday church services, have low religiosity, have low counseling or support services available at their church than the comparisons, but their overall religiosity was strong and they were confident in their god.

CHES AREAS

Responsibility I--Assessing Individual and Community Needs for Health Education

Competency A--Obtain health related data about social and cultural environments, growth and development factors, needs, and interests

Competency B--Distinguish between behaviors that foster and those that hinder well-being

Support for this research was provided by Georgia Department of Human Resources (GDHR) West Central Health District. The authors would like to thank Tiffany Beaumont for help in the preparation of this manuscript.

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Doohee Lee, PhD, MPH is an Assistant Professor at Cleveland State University. David C. Bell, PhD is a professor of Sociology at Indiana University Purdue University Indianapolis (IUPUI). Chantelle Moon, DPT is currently affiliated with Benchmark Family Services in Watertown, NY. Address all correspondence to Dr. Doohee Lee, PhD, Assistant Professor, Cleveland State University, Health Care Administration and Public Health Program, College of Business Building, Room 438, Cleveland, OH 44114; PHONE: [phone]; FAX: [phone]; E-mail: [e-mail]

Table 1. Characteristics of Sample (%)

                                   Total        Tobacco Users
                                                   (n=172)

Gender
  Male                            90   (22.5)      50   (29.1)
  Female                         310   (77.5)     122   (70.9)
Race
  African-American               388   (97.0)     168   (97.7)
  Anglo                            3    (0.8)       2    (1.2)
  Hispanic                         2    (0.5)       0
Age (Mean)                     33.06            35.65
  10-18                           53   (13.3)      12    (7.0)
  19-25                          121   (30.3)      48   (27.9)
  26-37                           90   (22.5)      37   (21.5)
  38+                            136   (34.0)      75   (43.6)
Marital status
  Never married                  257   (64.6)     100   (58.5)
  Married/living as married       29    (7.3)      12    (7.0)
  Divorced/widowed/separated     102   (25.1)      59   (34.5)
Education
  Less than high school          216   (54.4)      94   (54.7)
  High school graduate           181   (45.6)      78   (45.3)
Currently working                126   (31.8)      51   (30.2)
Access to Transportation         185   (46.4)      89   (51.7)
Welfare recipient                181   (45.5)      70   (40.7)

                                 Non-users      P-value
                                  (n=228)

Gender
  Male                            40   (17.5)
  Female                         188   (82.5)      .006
Race
  African-American               220   (96.5)
  Anglo                            1    (0.4)
  Hispanic                         2    (0.9)      .588
Age (Mean)                     31.09
  10-18                           41     (18)
  19-25                           73     (32)
  26-37                           53   (23.2)
  38+                             61   (26.8)     -.001
Marital status
  Never married                  157   (69.2)
  Married/living as married       17    (7.4)
  Divorced/widowed/separated     102   (23.4)      .016
Education
  Less than high school          122   (54.2)
  High school graduate           103   (45.8)      .932
Currently working                 75   (33.0)      .545
Access to Transportation          96   (42.3)      .061
Welfare recipient                111   (49.1)      .158

Note: test on frequencies are by Pearson chi-square; tests
on means are by independent samples t-test.

Table 2. Types of Religion and Denomination by Tobacco Use

                                    Tobacco Users
                        Total          (n=172)

Types of religion
  Christian         342   (86.6%)   150   (88.8%)
  Jewish              2   (0.5%)      1   (0.6%)
  Buddhist            2   (0.5%)      1   (0.6%)
  Hindu               0               0
  Muslim              0               0
  Other              11   (2.8%)      3   (1.8%)
  None               38   (9.6%)     14   (8.3%)

Denomination
  Baptist           263   (66.6%)   117   (68.8%)
  Methodist          31   (7.8%)     14   (8.2%)
  Catholic            6   (1.5%)      5   (2.9%)
  Unification         1   (0.3%)      0
  Presbyterian        8   (2.0%)      2   (1.2%)
  Other              72   (18.2)     27   (15.9%)

                      Non-users
                       (n=228)      P-value

Types of religion
  Christian         192   (85%)
  Jewish              1   (0.4%)
  Buddhist            1   (0.4%)
  Hindu               0
  Muslim              0
  Other               8   (3.5%)
  None               24   (10.6%)      .759

Denomination
  Baptist           146   (64.9%)
  Methodist          17   (7.6%)
  Catholic            1   (0.4%)
  Unification         1   (0.4%)
  Presbyterian        6   (2.7%)
  Other              45   (20.0%)      .296

Table 3. Level of Religiosity by Tobacco Use

                                 Total        Tobacco
                                               Users
                                              (n=172)

How strongly do you believe
    in your religion?
  Very strong                 297 (75.2%)   117 (69.2%)
  Somewhat strong              40 (10.1%)    25 (14.8%)
  Neutral                      33 (8.4%)     17 (10.1%)
  A little and not at all      25 (6.3%)     10 (5.9%)

                               Non-users    P-value
                                (n=228)

How strongly do you believe
    in your religion?                        .031
  Very strong                 180 (79.6%)
  Somewhat strong              15 (6.6%)
  Neutral                      16 (7.1%)
  A little and not at all       6 (6.6%)

Table 4. Religious Activities by Tobacco Use

                                    Total        Tobacco
                                                  Users
                                                 (n=172)

Frequency of church attendance
  Once or more a week            142 (35.6%)    52 (30.6%)
  1-3 times per month             88 (22.1%)     9 (20.0%)
  Less than once per month       105 (26.4%)    58 (34.1%)
  Never                           63 (15.8%)    26 (15.3%)
Attending church with
  someone else                   296 (74.9%)   125 (74%)
Counseling or support services
  available at their churches    279 (71.5%)   119 (70.8%)
Attending social functions
  at church                      178 (45.4%)    75 (44.6%)

                                  Non-users    P-value
                                   (n=228)

Frequency of church attendance
  Once or more a week             90 (39.5%)
  1-3 times per month             29 (23.7%)
  Less than once per month        47 (20.6%)
  Never                           37 (16.2%)     .011
Attending church with
  someone else                   171 (75.7%)     .700
Counseling or support services
  available at their churches    160 (72.1%)     .788
Attending social functions
  at church                      103 (46.0%)     .792