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Religious Involvement and Cigarette Smoking in Young Adults
The CARDIA Study
Mary A. Whooley, MD;
Alisa L. Boyd, MPH;
Julius M. Gardin, MD;
David R. Williams, PhD, MPH
Arch Intern Med. 2002;162:1604-1610.
ABSTRACT
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Background Results of previous studies have suggested that involvement in religious
activities may be associated with lower rates of smoking. We sought to determine
whether frequent attendance at religious services is associated with less
smoking among young adults.
Methods This prospective cohort study of 4569 adults aged 20 to 32 years included
approximately equal numbers of blacks and whites and men and women from 4
cities in the United States who attended the 1987/1988 examination of the
Coronary Artery Risk Development in Young Adults (CARDIA) study. Frequency
of attendance at religious services and denominational affiliation were determined
by self-report questionnaire in 1987/1988. Cigarette smoking was determined
by interview at this time and again 3 years later.
Results Of 4544 participants who completed the tobacco questionnaire in 1987/1988,
34% (891/2598) who attended religious services less than once per month or
never and 23% (451/1946) who attended religious services at least once per
month reported current smoking (odds ratio [OR], 1.7; 95% confidence interval
[CI], 1.5-2.0; P<.001). This association between
less frequent attendance at religious services and current smoking was found
in most denominations and remained significant after adjusting for potential
confounding variables (OR, 1.5; 95% CI, 1.3-1.8; P<.001).
During 3-year follow-up, nonsmokers who reported little or no religious involvement
had an increased risk of smoking initiation (adjusted OR, 1.9; 95% CI, 1.3-2.7; P<.001).
Conclusions Young adults who attend religious services have lower rates of current
and subsequent cigarette smoking. The potential health benefits associated
with religious involvement deserve further study.
INTRODUCTION
CIGARETTE SMOKING ranks as the primary cause of premature death in industrialized
countries throughout the world.1-2
Despite an ongoing decline in smoking among older adults,1, 3
the recent increase in smoking among youths (from 28% in 1991 to 36% in 1997)4 is alarming. Because the negative health effects of
cigarette smoking are cumulative, the risk of developing a smoking-attributable
disease increases the earlier that smoking begins.4
Previous studies2, 5-16
have suggested that involvement in religious activities may affect smoking
behavior. However, most studies were cross-sectional, limiting inferences
about cause and effect2, 5-7,9-14,16;
many did not examine whether employment, education, or social network might
confound the association between smoking and religion5, 9, 11-12;
and the results of others may not be generalizable.2, 13-14
We analyze the association between religious involvement and cigarette
smoking and describe the distribution of religious affiliation among young
men and women and black and white participants enrolled in the Coronary Artery
Risk Development in Young Adults (CARDIA) study. We examined whether frequent
attendance at religious services was associated with smoking prevalence and
whether it predicted subsequent smoking 3 years later.
PARTICIPANTS AND METHODS
PARTICIPANTS
The CARDIA study is a multicenter prospective cohort study designed
to describe the evolution of coronary heart disease risk factors in young
adults and to identify associated habits, behaviors, and lifestyles. The study
design and baseline characteristics of the participants have been described
previously.17 Between March 1985 and June 1986,
we recruited 5115 participants, aged 18 to 30 years, including approximately
equal numbers of black and white participants and men and women, from 4 American
cities (Birmingham, Ala; Chicago, Ill; Minneapolis, Minn; and Oakland, Calif).
Participants were recruited primarily through telephone contact, except in
Oakland, where a health plan membership roster was used. The appropriate institutional
review boards approved the study, and all participants provided written informed
consent.
MEASUREMENTS
From May 1987 to July 1988, 4569 participants completed the following
self-report question: "How often do you attend religious services such as
those at a church or synagogue?" The 7 response categories were every day,
more than once a week, once a week, 2 or 3 times a month, once a month, less
than once a month, and never. We defined high-frequency attendees as those
attending religious services at least once per week; moderate-frequency attendees
as attending 1, 2, or 3 times per month; and low-frequency attendees as attending
less than once per month or never.
We also asked participants: "What is your religion? Please specify a
religious denomination." We coded denominations using 25 categories: Baptist,
Roman Catholic, Methodist, Lutheran, Pentecostal, Presbyterian, Jewish, Episcopal,
Christian Church or Church of Christ, Seventh Day Adventist, Congregational
or United Church of Christ, Orthodox, Reformed, Muslim, Mormon, Buddhist,
Christian Scientist, Quaker, Mennonite, Hindu, Moravian, atheist, agnostic,
other, or none/don't know/unable to code. For this study, we collapsed participants
into 11 denominational groups, including 1 for each of the 9 groups with at
least 50 participants, 1 for other, and 1 for agnostic, atheist, or none/don't
know/unable to code.
Smoking status was determined in 1987/1988 and in 1990/1991 based on
responses to 3 interview-administered questions:
1. Have you ever used any tobacco product, such as cigarettes, cigars,
tobacco pipe, chewing tobacco, snuff, or nicotine chewing gum?
2. If yes to number 1, have you ever smoked cigarettes regularly for
at least 3 months? By "regularly," we mean at least 5 cigarettes per week,
almost every week.
3. If yes to number 2, do you still smoke cigarettes regularly?
Participants were defined as current smokers if they responded "yes"
to all 3 questions. All other participants were considered nonsmokers. In
1987/1988, we asked current smokers the following yes/no question: "Have you
tried to stop smoking cigarettes in the past 2 years?" We also ascertained
the number of cigarettes smoked by asking, "How many cigarettes do you smoke
per day on the average?"
In 1987/1988, we determined age, sex, ethnicity, marital status, years
of education, employment status, family history of myocardial infarction (MI),
presence of hypertension, presence of diabetes mellitus, body mass index,
alcohol use, level of physical activity, social network, and whether participants
belonged to any organizations or clubs. The physical activity score was defined
as the sum of the total number of months (weighted by frequency and intensity)
during which each of 13 activities was performed during the previous year.18-19
Social network adequacy was measured using a 4-item scale (How often
do you [1] feel lonely, [2] find yourself wishing someone would comfort you,
[3] feel that other people really care for you [reverse scored], and [4] wish
that you had more close friends?). Each question had 4 response categories
(4 indicates frequently; 3, occasionally; 2, rarely; and 1, never), with higher
scores indicating a better social network. For participants who completed
only 2 or 3 of the 4 items (n = 4), we assigned the mean value of nonmissing
responses to the other items. Participants who answered fewer than 2 of the
questions did not receive a score. As an additional measure of social activity,
we asked participants the following yes/no question: "Do you belong to any
organizations or clubs (such as political groups, athletic teams, or regular
groups you play sports with)?"
STATISTICAL ANALYSIS
For the primary analysis, we decided a priori to compare cigarette smoking
in participants who reported attending religious services at least once per
month (high- or moderate-frequency attendees) with those who reported attending
religious services less than once per month or never (low-frequency attendees).
Differences in characteristics between groups were compared using  2 tests for dichotomous variables and 2-tailed t
tests for continuous variables. We used backwards elimination logistic regression
for a cross-sectional analysis examining the risk of current smoking in participants
who were less frequent attendees of religious services compared with those
who attended religious services more frequently. We added any variables that
were associated with smoking (at P<.05) to multivariate
models that included frequency of attendance at religious services. Tests
of P for trend were calculated using the 2 test for trend in proportions.
We examined the association between frequency of attendance at religious
services in 1987/1988 and subsequent smoking in 1990/1991 using analyses stratified
by initial smoking status. Among participants who were not smoking in 1987/1988,
we examined the association between frequency of attendance at religious services
in 1987/1988 and starting to smoke by 1990/1991. Among participants who reported
current smoking in 1987/1988, we examined the association between frequency
of attendance at religious services in 1987/1988 and smoking cessation by
1990/1991. For these analyses, we reported odds ratios (ORs) and 95% confidence
intervals (CIs). Analyses were performed using statistical software (SAS version
6.12; SAS Institute Inc, Cary, NC).
RESULTS
CHARACTERISTICS OF PARTICIPANTS
Table 1 lists the distribution
of participants by religious denomination. Almost half of the participants
were either Baptist or Roman Catholic. Most Baptists were black, and most
Roman Catholics were white. Of the 4569 participants, 1953 (43%) reported
attending religious services at least once per month in 1987/1988 (Table 2). Compared with those who attended
religious services at least once per month, participants attending less than
once per month or never were slightly older; were more likely to be male,
white, and unmarried; and reported greater alcohol consumption (Table 2). Less frequent attendees were also more physically active,
were more likely to belong to an organization or club, and had a lower body
mass index. However, these participants had poorer social network scores than
those who attended religious services more frequently. Geographic location
was strongly associated with attending religious services, but there were
no differences in education, employment, family history of MI, presence of
diabetes mellitus, or presence of hypertension by frequency of attendance.
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Table 1. Distribution of 4569 Participants by Religious Denomination
and Proportion Who Reported Current Smoking in 1987/1988
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Table 2. Characteristics of 4569 Participants by Religious Service
Attendance
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Current Smoking
Greater frequency of attendance at religious services was associated
with less current smoking. High-frequency attendees ( 1/wk) had the lowest
prevalence (17%) (Figure 1). Of
the 4544 participants who completed the tobacco questionnaire in 1987/1988,
34% (891/2598) who attended religious services less than once per month or
never reported current smoking compared with 23% (451/1946) who attended religious
services at least once per month (OR, 1.7; 95% CI, 1.5-2.0; P<.001). This association was diminished but still significant after
adjusting for potential confounding variables (OR, 1.5; 95% CI, 1.3-1.8; P<.001) (Table 3).
Among smokers (n = 1342), less frequent attendees reported smoking a greater
mean number of cigarettes per day than more frequent attendees (14 ±
10 vs 12 ± 9; P<.001). In subgroup analyses,
less frequent attendance at religious services was associated with current
smoking in all race-sex subgroups except black men (Table 4).
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Figure 1. Participants reporting current
smoking by frequency of attendance at religious services. Low indicates less
than once per month or never; moderate, 1, 2, or 3 times per month; and high,
at least once per week.
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Table 3. Univariate and Multivariate Predictors of Current Smoking
(Among All Participants) and Smoking Initiation (Among Nonsmokers)*
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Table 4. Adjusted Risk of Current and Incident Smoking Associated With
Attending Religious Services Less Than Once per Month or Never by Race-Sex
Subgroups*
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Among participants who attended religious services 1 to 3 times per
month (moderate-frequency attendees), 30% (267/890) reported current smoking
compared with 17% (184/1056) of those who attended religious services once
per week or more (OR, 2.0; 95% CI, 1.6-2.5; P<.001).
This association remained significant after adjusting for age, ethnicity,
marital status, education, employment status, alcohol use, belonging to an
organization, and geographic location (OR, 1.9; 95% CI, 1.5-2.4; P<.001).
Religious Denomination
The prevalence of smoking ranged from 12% among Jewish participants
to 36% among Baptists (Table 1).
Overall, Baptists and Pentecostals who attended religious services less than
once a month or never had the greatest prevalence of smoking (Table 5). Jewish and Presbyterian participants had the lowest prevalence
of smoking, regardless of how frequently they attended religious services.
Participants in the "other" category who reported attending religious services
at least once per month also had a low prevalence of smoking.
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Table 5. Risk of Current Smoking Associated With Attending Religious
Services Less Than Once a Month or Never vs Once or More per Month by Religious
Denomination
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Less frequent attendees of religious services had a greater prevalence
of smoking than did more frequent attendees across all denomination categories,
with the exception of Presbyterians, who had a relatively low prevalence of
smoking regardless of frequency of attendance at religious services (Table 5). However, in multivariate analyses,
these associations were statistically significant at the P<.05 level in the Baptist, Pentecostal, and "other" denominational
categories only.
Smoking Incidence
Of the 4569 study participants, 4072 (89%) had follow-up smoking data
in 1990/1991. Of these, 1741 (43%) attended religious services at least once
per month in 1987/1988 compared with 212 (43%) of the 497 participants who
were lost to follow-up (P = .97).
A total of 2913 of 3202 participants (91%) who were nonsmokers in 1987/1988
completed the follow-up tobacco questionnaire in 1990/1991. Greater frequency
of attendance at religious services was associated with less smoking initiation,
with high-frequency attendees (1/wk) having the lowest incidence (3%)
(Figure 2). A total of 7% (109/1571)
of nonsmokers who attended religious services less than once per month or
never started smoking cigarettes during 3-year follow-up compared with 4%
(54/1342) of those attending religious services at least once per month (OR,
1.8; 95% CI, 1.3-2.5; P<.001).
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Figure 2. Nonsmokers reporting smoking initiation
at 3-year follow-up by frequency of attendance at religious services. Low
indicates less than once per month; moderate, 1, 2, or 3 times per month;
and high, at least once per week.
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In multivariate analyses, participants attending religious services
less frequently in 1987/1988 had a 90% increased risk of starting to smoke
during 3-year follow-up compared with participants attending religious services
at least once per month (adjusted OR, 1.9; 95% CI, 1.3-2.7; P<.001) (Table 3). The
independent association between less frequent attendance at religious services
and starting to smoke seemed to be present in all race-sex subgroups except
black men (Table 4).
Among nonsmokers who attended religious services 1 to 3 times per month
(moderate-frequency attendees), 5% (29/554) started to smoke during 3-year
follow-up compared with 3% (25/788) of those who attended services once per
week or more (OR, 1.7; 95% CI, 1.0-2.9; P = .06).
This association remained present but not statistically significant after
adjusting for ethnicity, education, alcohol use, and geographic location (OR,
1.6; 95% CI, 0.9-2.8; P = .11).
Smoking Cessation
In 1987/1988, 57% of the 891 smokers who attended religious services
less than once per month or never reported efforts to quit in the previous
2 years compared with 67% of the 451 smokers who attended religious services
at least once per month (adjusted OR, 0.7; 95% CI, 0.6-0.9; P = .005). However, of the 1159 participants (86%) who were smokers
in 1987/1988 and who completed the follow-up tobacco questionnaire in 1990/1991,
only 15% (117/760) of the less frequent attendees reported that they were
no longer smoking compared with 17% (69/399) of those attending religious
services at least once per month (OR, 0.9; 95% CI, 0.6-1.2; P = .4). Multivariate analysis that adjusted for potential confounding
variables produced similar results (OR, 0.8; 95% CI, 0.6-1.1; P = .2).
COMMENT
Compared with participants who attended religious services frequently,
less frequent attendees were more likely to report current smoking and to
start smoking during 3-year follow-up. This association was particularly evident
for the Baptist, Pentecostal, and "other" (Seventh Day Adventist, Congregational/United
Church of Christ, Orthodox, Reformed, Muslim, Mormon, Buddhist, Christian
Scientist, Quaker, Mennonite, Hindu, or Moravian) denominations and was present
in all race-sex subgroups except black men. Other independent predictors of
current smoking included age; being black, unmarried, less educated, or unemployed;
consuming more alcohol; and belonging to a club or organization. Other independent
predictors of smoking initiation included being black or less educated and
consuming more alcohol. Living in Minneapolis was associated with current
and incident smoking.
As with any observational study, we cannot eliminate the possibility
of confounding because the character traits leading to religious involvement
may also result in avoidance of smoking. Likewise, we cannot exclude the possibility
that smokers may have chosen not to attend religious services owing to concerns
about social pressures against smoking. However, given the low probability
values, it is unlikely that the strength of the observed association between
religious involvement and smoking is due to chance. It is also unlikely that
biased ascertainment of smoking (eg, underreporting by those who attend religious
services) is responsible for this finding given the high validity of self-reported
smoking in CARDIA study participants.20
If attending religious services does affect cigarette smoking, what
are the potential reasons for this association? Although some denominations,
such as Mormon,21 prohibit substance use, most
do not have explicit proscriptions against smoking. Religious beliefs may
provide coping mechanisms that reduce the impact of stressful circumstances
that would otherwise precipitate cigarette smoking.22
Faith-based coping strategies have been related to improved well-being,23 and religious behaviors are useful in managing stressful
life changes.24 Women seem to derive particular
support from religious activities15 and are
more likely than men to use religion as a coping mechanism for stress.24 This could explain the stronger association between
attendance at religious services and less frequent smoking initiation among
women in our study.
Another causal possibility is that frequent attendance at religious
services may provide an educational and supportive social environment. Religious
involvement offers a sense of belonging to a group with shared values,7 and this environment may promote healthy behaviors.25 Religious adherents may be more likely to adopt healthy
practices because many religions emphasize respect for the body26
and discourage risk-taking behavior.27
Two other cohort studies have examined the association between religious
involvement and cigarette smoking, but we are unaware of any studies demonstrating
an association between attending religious services and not starting to smoke.
One study2 found that participation in private
religious activity predicted less subsequent smoking in the elderly, but attendance
at religious services was not associated with subsequent smoking. Another
study15 of adults aged 16 to 94 years found
that attendance at religious services was associated with smoking cessation,
but its effects on smoking prevalence or incidence were not examined. Other
studies5-7,9-14
of religious involvement and smoking have used only cross-sectional analyses
or lacked appropriate multivariate adjustments.
It is unclear why we observed an association between religious attendance
and cigarette smoking in all race-sex groups except black men. This apparent
interaction likely is not due to chance because it was present for both current
and incident smoking. It is possible that black men attend religious services
for different reasons than do women or white men. Perhaps black men are more
likely to attend services to accommodate other family members, less likely
to adopt coping strategies associated with religious involvement, or less
likely to derive support from the social and educational environment of a
church because of more stressful life circumstances.
Although our categories of religious denomination may not have captured
the considerable variation within distinct denominational subgroups,28-29 they reveal some interesting findings.
We observed substantial differences in the distribution of participants across
religious denominations. Black participants were more likely than white participants
to be Baptist or Pentecostal and less likely to be Roman Catholic, Lutheran,
Presbyterian, Jewish, or Episcopal. We also observed a wide range of smoking
prevalences across denominational categories. Jewish and Presbyterian participants
were less likely to smoke than were members of any other denomination, regardless
of their frequency of attendance at religious services. Baptist and Pentecostal
participants who attended religious services fewer than 1 time per month or
never had a greater prevalence of smoking than members of any other denomination.
Although differences in ethnicity and socioeconomic status may account for
some of these discrepancies, it is possible that some religions but not others
espouse themes that promote healthier behaviors and lifestyle.
Our study has 2 major limitations. First, although frequency of attendance
at religious services is a commonly used measure, it does not represent all
aspects of religious involvement.22, 28
Second, the health effects of involvement in religious activities may not
differ from those associated with participation in other community organizations.28 However, even after adjusting for the CARDIA study's
measure of social network and for belonging to organizations or clubs, the
association between attendance at religious services and smoking behavior
was unchanged.
In summary, frequent attendance at religious services is associated
with a decreased risk of current smoking and smoking initiation in white men,
white women, and black women, but not in black men. Whether less smoking may
explain part of the association between religious involvement and decreased
mortality15, 30 is unknown. Further
studies are needed to clarify the role that religious involvement may play
in disease prevention through its effect on cigarette smoking and other behaviors.
AUTHOR INFORMATION
Accepted for publication November 29, 2001.
This study was supported by a Research Career Development Award from
the Department of Veterans Affairs Health Services Research and Development
Service (Dr Whooley); the Robert Wood Johnson Generalist Physician Faculty
Scholars Program (Dr Whooley); and contracts NO1-HC-48047, N01-HC-48048, N01-HC-48049,
and N01-HC-48050 from the National Heart, Lung, and Blood Institute, National
Institutes of Health, Bethesda, Md (the CARDIA study).
We thank Stephen Hulley, MD, MPH, for his comments on the manuscript
and Li-Yung Lily Lui, MA, MS, and Michael Shino, BA, for their assistance
with data analysis.
Corresponding author and reprints: Mary A. Whooley, MD, Department
of Veterans Affairs Medical Center (111A1), 4150 Clement St, San Francisco,
CA 94121 (e-mail: whooley{at}itsa.ucsf.edu).
From the Department of Veterans Affairs Medical Center, San Francisco,
Calif (Dr Whooley and Ms Boyd); the Departments of Medicine, Epidemiology,
and Biostatistics, University of California, San Francisco (Dr Whooley); the
Division of Cardiology, St John Hospital and Medical Center, Detroit, Mich
(Dr Gardin); and the Survey Research Center, Institute for Social Research,
University of Michigan, Ann Arbor (Dr Williams).
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