Smoking prevalence among Monks in Thailand

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Smoking Prevalence Among Monks in Thailand

Nipapun Kungskulniti

¹

, Naowarut Charoenca

¹

, Tharadol Kengganpanich

¹

, Wilai Kusolwisitkul

¹

, Natchaporn Pichainarong

¹

,

Patcharaporn Kerdmongkol

¹

,

Phimpan Silapasuwan

¹

, Stephen L. Hamann

²

, and Thalida Em Arpawong

³

Abstract

Previous studies among Buddhist monks in Thailand have reported smoking rates to be as high as 55%. Because 95% of Thais are Buddhist, monks are highly influential in establishing normative behavioral patterns. As the first population-based study on smoking among Buddhist monks in Thailand, this study aims to determine the smoking prevalence in six regions of the country, and to examine smoking knowledge, risk perceptions, behaviors, and

1Faculty of Public Health, Mahidol University, Bangkok, Thailand

2College of Medicine, Rangsit University, Bangkok, Thailand

3Keck School of Medicine, University of Southern California, Los Angeles, CA, USA Corresponding Authors:

Naowarut Charoenca, Mahidol University, Faculty of Public Health, 420/1 Rajvithi Road, Raj- thewee, Bangkok 10400, Thailand

Email: [email protected]

Thalida Em Arpawong, University of Southern California, Institute for Health Promotion and Disease Prevention Research, Soto Street Building, SSB 2001 N. Soto Street, MC 9239, Los Angeles, CA 90089, USA

Email: [email protected]

Reprints and permission:

sagepub.com/journalsPermissions.nav DOI: 10.1177/0163278711426424 http://ehp.sagepub.com

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associated demographics among full-fledged and novice monks (n¼6,213).

Results demonstrated that the overall prevalence for current smoking monks is 24.4% (95% confidence interval [24.453, 24.464]), with regional differences ranging from 14.6% (North) to 40.5% (East). Findings suggest that integrating prevention and cessation programming into religious courses may be one avenue for reaching many incoming monks. Further, involving monks in tobacco control education and setting a nonsmoking standard among them is vital to the success of reducing smoking rates among the general population in Thailand.

Keywords

smoking prevalence, monks, Thailand, tobacco control, Buddhist

Tobacco use causes over 5 million deaths globally each year with a pro- jected increase to 8 million deaths annually by 2030 (Global Adult Tobacco Survey [GATS], 2009). In Thailand, adult daily and occasional tobacco smoking prevalence was reported at 45.6%for males and 3.1%for females, or 23.7%overall equaling 12.5 million adults (GATS, 2009). Thailand has achieved a substantial decline in smoking prevalence over the span of 18 years, from a 32.0%adult prevalence in 1991 (National Statistical Office, 2001). However, to maintain a downward trend in smoking prevalence in Thailand, it is crucial to identify key targets of the population for which to implement prevention and cessation programming.

Buddhist monks play a central role in setting normative patterns for approximately 95% of the general Thai population, that is, Buddhist (Central Intelligence Agency [CIA], 2011). For Thai Buddhists, daily life revolves around religious and community events that take place at temples (called Wats) and through ceremonies involving Buddhist monks. Because Buddhist monks garner such strong influence among Thais, the smoking practices among monks may serve as an important indicator of smoking trends in Thailand as a whole.

Tobacco use, and use of any other drugs (e.g., alcohol, psychoactive substances), violates the fifth precept in which monks commit to upon entering the monkhood. The precept prohibits the use of intoxicating substances. However, due to aggressive efforts of transnational tobacco companies and promotion of their products within the country (Chantornvong & McCargo, 2001; Sarntisart, Supakankunti, Teerachaisa- kul, Chuensukkasemkul, & Kaluntakaphan, 2003; Vateesatokit, Hughes, &

Ritthphakdee, 2000), the use of tobacco by Thai people began to rise

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dramatically in the late 1980s. As such, tobacco use by monks followed and gained gradual acceptance over time by the general population. Many Thais even offer manufactured cigarettes to monks as alms with other items offered daily such as food and personal items.

Numerous consistent and widespread efforts have been made by both the Thai Ministry of Public Health and the nonprofit organizations to maintain control on tobacco consumption in general and among monks. In 1986, one nongovernmental organization called Action on Smoking and Health (ASH) Thailand launched a national campaign attempting to alter social norms and the public’s practice by declaring that offering cigarettes to monks was a sin.

Despite tobacco control efforts, several studies have reported very high rates of smoking among Buddhist monks in Thailand. In 1985, one study among monks living in Bangkok (BKK) reported an alarming 53.6%

prevalence rate (Bowonwatananuwongs et al., 1987). Three years later, a study among monks in Chonburi province reported the smoking rate to be 54.8%(Charoenca, 2003). Following that, a larger-scale study conducted in 1993 reported a 55.0%smoking prevalence rate among Buddhist monks (Srinual, Imamee, Vateesatokit, & Suwan, 1993). These studies indicated that smoking was even more common among monks than in the general male population around the same time (43.2%in 1993; National Statistical Office, 1999). However, the largest study included 678 monks from 48 temples in Rajburi province, in the central region of Thailand. Thus, all of the previous studies were limited to one province or city in Thailand and preceded a major decline in male smoking. While smoking rates purported to drop between 1991 and 2001, no national studies among monks have been conducted to confirm this.

In reaction to the high prevalence rates being reported, in 2001, a meeting was convened among representatives from The Monk Association of Thailand, theological institutions for monks, and the health field to examine data from the Monk Hospital in BKK, established specifically to care for ailing monks and novices. Hospital records for the year 2000 revealed that 34.9% of the 53,000 monks that had made outpatient visits to the hospital for health and medical services were smokers (Monks’ Hospital, Department of Medical Services, Ministry of Public Health, 2002). Further, hospital mortality data showed that smoking- related illnesses were the number one cause of death for Thai monks (Monks’

Hospital, Department of Medical Services, Ministry of Public Health, 2002).

In descending order, monks were dying from lung cancer, chronic obstructive pulmonary disease, lung infections, cardiovascular problems, liver cancer, lung tuberculosis, oesophageal cancer, stroke, and cirrhosis.

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Thus, tobacco use has already manifested significant consequences in morbidity and mortality for the Buddhist monks.

More than 10 years after the last study, results from a survey were released, conducted among Buddhist monks in four provinces from each of the Central and Eastern regions of Thailand in 2003. The study collected data on demographics, smoking history, as well as history of illness among monks.

Surveying 920 monks, the study reported a smoking prevalence rate of 47.6%among monks, slightly lower than prior studies (Chaveepojnkamjorn

& Pichainarong, 2005). Some variables associated with current smoking among monks were Dharma education, residential province, duration of monkhood, former occupation, level of education, and history of respiratory illness within the past year. However, through final analysis of the data, authors reported that only four factors remained as significant correlates of cigarette smoking among monks in the eight provinces: relatively lower lay education, less Dharma education, higher systolic blood pressure of 140 mmHg or greater, and history of respiratory illness. Although this study did document lower levels of smoking among monks, it represented cigarette use within two regions of the country only.

A national prevalence study of cigarette smoking among Thai monks is crucial to the development of appropriate interventions aimed at both reducing rates of smoking among monks and among Thais in general. Thus, the present article serves as the first and only population-based prevalence study on the smoking status among Buddhist monks in Thailand.

This study had three aims. The first aim was to determine the smoking prevalence among monks in multiple regions of Thailand. The second aim was to assess monks’ knowledge, risk perceptions, and practices concerning smoking and its effects. The third aim was to describe characteristics among monks who smoke (e.g., rank, education, and age), where monks smoke (e.g., at our outside temple grounds), and patterns of when and how much monks smoke (e.g., time of day, frequency, and duration).

Method Procedure

We conducted a methodologically rigorous, population-based cross-sectional study to determine the smoking prevalence and patterns among monks throughout Thailand. A stratified cluster four-stage sampling design was implemented with data for the sampling design gathered for each stage from four sources. First, the number of monks/novices, temples, and denominations

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by region and province was derived from the ‘‘Report on Religion B.E. 2542,’’

Ministry of Education. Second, the names and addresses of temples by type and denomination for each province were obtained from the Ministry of Education.¹Third, the name of each district (khet) by population density was gathered from the BKK Metropolitan Administration.² Fourth, a list of smoke-free temples was obtained from ASH Thailand, from their

‘‘Smoke-free Wats’’ project. From these data sources, it was determined that 31,044 temples with 365,140 total monks/novices existed within the 75 provinces of Thailand. The sample size needed for this population- based study was calculated to be at least 6,022 monks/novices.

The sampling plan was implemented in two parts: Part 1 for the BKK metropolitan area and Part 2 for the six regions of Thailand (East, West, North, Northeast, South, and Central excluding BKK) due to the large variation in population density, concentration of wats, types of wats, and monks/novices residing in BKK versus the rest of Thailand.

Part 1: Sampling plan for the BKK.It was determined that 440 wats existed in the BKK, an area divided into five zones, based on population density.

Two districts were randomly sampled from each zone, yielding a total of 10 districts. Simple random sampling was employed to select one wat from each district. Two of the 10 sampled wats were part of the ‘‘Smoke-free Wat’’ program. From the 18,533 monks/novices in BKK, the calculated sample size of at least 306 was needed. Data were collected from all monks/novices meeting the inclusion criteria in each sampled wat, resulting in a sample size of 421 monks/novices from BKK.

Part 2: Sampling plan for each of the six regions.First, four provinces were selected from each of the six regions by an unequal probability sampling method, using the ratio of monk/novices to Wat as auxiliary variables.

Second, a systematic sampling method was used select 25%of all districts in each province. Third, the systematic sampling method was applied to wats to determine the numbers of each denomination (Mahanikai and Thammayut) and type (royal and public) per district. The number of wats required for sampling was calculated based on the ratio of monks/novices to wats such that the number of wats corresponded to that of the district, adjusted by the method of sampling with probability proportional to size. Therefore, the number of monks/novices surveyed in each region is proportional to the size of each region.

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Participants

Investigators initiated contact of selected wats by sending a letter or calling the temple abbot. None of the abbots declined participation. Study staff visited wats to inform monks/novices of the significance of the study, to relay the confidentiality of the collected data, and to gather signed consent forms before monks/novices completed the self-administered questionnaires. For participants who had difficulty reading and/or writing, research assistants completed the questionnaires through interview.

Data collection occurred during Buddhist lent (when monks stay in their temples) between June and October 2003. Inclusion criteria for participation were having been in monkhood as monks or novices (individuals who are in monkhood and are of age 20 or younger) for at least 1 year and being between the ages of 12 and 65. Data were collected from a total of 6,213 monks/novices, creating the analytical sample for this study. All procedures were approved by the Institutional Review Board at Mahidol University.

Measures

Demographic characteristics.Demographic variables were captured through questions on age, denomination (Thammayut/Teravadha or Mahanikai), type of wat served (public or private), status (monk or novice), rank and administrative role, duration of monkhood, educational level (from primary to professional schooling), and theological (Dharma) education.

Smoking knowledge, perceptions, and history. The smoking portion of the questionnaire was organized into three parts, covering topics of smoking knowledge, perceptions/attitudes about smoking, and smoking history. Smoking knowledge was assessed through five questions that inquired about knowledge about the temple’s smoking rules, the law banning smoking in religious places, quitting smoking reduces health risks, smoking being a major morbidity/mortality risk, and secondhand smoke causes disease. Perceptions of smoking was assessed through 7 items that asked about an opinion on offering cigarettes to monks, social norms regarding monk/novice smoking and refusing offered cigarettes, smoking campaigns, and smoking cessation programs. All knowledge and perception questions were answered by multiple choice format (e.g., yes/no/don’t know, true/false/don’t know, agree/disagree/not sure, should/

shouldn’t). Smoking history was assessed through questions on years of smoking, number of cigarettes smoked per day, how cigarettes are obtained, quit attempts, and other smoking characteristics. Questions were pilot tested with 39 monks/novices to assess difficulty and clarity of items. Items were reviewed

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for difficulty, face, and content validity by a researcher from ASH Thailand, the Thai Ministry of Public Health, and a monk from Wat Chonprathan.

Data Analysis Plan

Descriptive statistics were calculated with monks/novices categorized as smokers and nonsmokers. Knowledge and attitude responses were examined with monks/novices categorized into current and former smokers (as defined by the Behavioral Risk Factor Surveillance System and Smoking Cessation in Black Americans study; Brownson et al., 1992; Remington et al., 1988).

Current smoking defined as persons who had smoked100 cigarettes in their lifetime and who smoked everyday or some days at the time of the interview.

Former smokers were defined as those who had smoked100 cigarettes in their lifetime but did not smoke at the time of the interview. Chi-square tests were used to evaluate differences in responses by smoking status.

Prevalence of smoking among monks/novices in Thailand was estimated using a poststratification estimation of proportions procedure and the following formula:

^ p¼

PL h¼1N_h^^p_h

N

V^ð^pÞ ¼ 1 N²

X^L

h¼1

N_h² nh

N_h

Nh1p^_hð1p^_hÞ N_hn_h Nh

^cvð^pÞ ¼ ffiffiffiffiffiffiffiffiffiffi V^ð^pÞ q

^

p 100%

Wherep^¼estimated prevalence of smoking among monks;p^_h¼estimated prevalence of smoking among monks in stratumh¼Qnh

i¼1xhi

nh;Xhi¼number of monks who smoke in templeith stratumh;Nh¼stratum size;nh¼sample size in stratum h; V^ð^pÞ¼variance of the estimate;^cvð^pÞ ¼coefficient of variation of the estimate.

Results

Demographic Characteristics and Smoking Prevalence

Monks in Thailand were sampled in proportion to their distribution by region (BKK, Central, East, West, North, Northeast, and South), as reported

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by the Monks Association of Thailand.³From a total of 365,140 monks/

novices from 31,044 wats in 76 provinces in Thailand, a sample of 6,213 monks/novices from 528 wats in 59 provinces completed surveys. The highest concentration of monks was sampled from the North and Northeast regions comprising 60% of the participants. Of the sample, 24.4% of monks/novices were current smokers (95% confidence interval [24.453, 24.464]), with smoking rates ranging from 14.6%in the North, 20.4%in the Northeast, 22.8%in the West, 29.7%in BKK, 33.5%in the South, 40.2%in the Central, and 40.5%in the East region.

Table 1 compares demographic characteristics of monks by current smoking status. More than half of the participants had been in monkhood for more than 1 year (58.5%). The majority of monks and novices resided in public wats (88.8%) and belonged to the less strict Mahanikai discipline of Buddhism (88.8%). Fifty percent of monks/novices were under age 24 and most did not hold hierarchical ranking (94.5%) or a leadership position such as abbot (90.9%). Most monks/novices received a high school education (61.1%) and religious schooling (70.0%) with those who were current smokers beings less likely to have received religious education and more likely to reside in BKK. Forty-five percent of current smokers tended to be between the ages of 25 and 44, and in monkhood for 1–4 years. Slightly more than a third of full-fledged monks were current smokers compared to junior monks, or novices (37.2%vs. 6.2%, respectively).

Factors Related to Smoking

Status as a monk, not as a novice, was related to smoking (Cramer’sV¼.475, p< .001). Primarily, this was due to 84.5%of novices being never smokers with 6.2%being current smokers compared to 37.2%of monks being current smokers. Monks/novices based in public wats versus royal wats were more likely to be smokers, though monks based in royal wats made up only 11%of all monks, therefore the association was weak (Cramer’sV¼.108, p< .001). Other characteristics weakly but significantly correlated to smoking were belonging to the Thammayut Buddhist denomination (Cramer’s V¼.035,p¼.023), higher rank as a monk (Cramer’sV¼.101,p< .001), administrative position as an abbot (Cramer’sV¼.165,p< .001), lower educational level (Cramer’sV¼.066,p< .001), religious education (Cramer’sV

¼.066,p< .001), and duration in monkhood (Cramer’sV¼.205,p< .001).

Older age was more strongly correlated with smoking (Cramer’sV¼.331, p< .001).

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Table 1.Comparison of Selected Demographic Characteristics Between Monks/

Novices Who Are Current Smokers and Nonsmokers

Smoker Nonsmoker

Characteristics N % N % p value

Status (6,213) <.001***

Monk 1,351 37.2 2,283 62.8

Novice 160 6.2 2,419 93.8

Type of wat <.001***

Public 1,412 25.6 4,108 74.4

Royal 99 14.3 594 85.7

Denomination .023*

Thammayut 190 27.4 503 72.6

Mahanikai 1,321 23.9 4,199 76.1

Age <.001***

10–24 years 344 11.1 2,761 88.9

25–44 years 683 35.0 1,270 65.0

45–65 years 484 42.1 666 57.9

Duration of monkhood <.001***

1–4 years 680 19.8 2,761 80.2

5–14 years 458 27.7 1,197 72.3

15 years 367 35.3 673 64.7

Hierarchical ranking <.001***

Yes 86 25.3 254 74.7

No 1,425 24.3 4,448 75.8

Administrative position <.001***

Abbot/administrator 142 25.9 405 74.1

Monk/novice 1,344 24.6 4,116 75.4

Education level <.001***

None/primary 404 31.7 872 68.3

Secondary/high school 781 20.7 2,987 79.3 Vocational/advanced voc 139 32.4 290 67.6 Bachelors degree and above 176 25.2 521 74.8

Religious education <.001***

Yes 945 23.9 3,010 76.1

No 507 29.9 1,187 70.1

Region <.001***

Bangkok 125 29.7 296 70.3

All other regions 1,386 23.9 4,406 76.1

Note. Chi-square test between the variable and smoking status

*p< .05. ***p< .001.

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Knowledge and Risk Perceptions

Regarding knowledge and attitudes of monks/novices, less than half of monks/novices sampled knew the rules on smoking in their wat (42.5%).

Among those who knew the smoking rules, there was a significant difference between those who were nonsmokers (63.5%) versus current or former smokers (both 18%;p< .05). Only one third of the sample knew there was a law banning smoking in religious places in Thailand; of those that knew the law, there was a significant difference between those who were smokers (25.3%) versus nonsmokers (56.3%; p < .05). Eighty-eight percent of monks/novices knew quitting smoking would reduce health risks although only 60% knew smoking is a major morbidity/mortality risk. Ninety-four percent of monks/novices knew that secondhand smoke causes disease.

Though knowledge level regarding health risks from smoking and secondhand smoke was high, a significant difference existed between the monks/

novices who knew these risks and were current smokers (approximately 25%) or were nonsmokers (more than half).

Attitudes and Opinions Regarding Smoking

Of the monks/novices who agreed with each of the opinion questions, there was a significant difference by smoking status with more than half being nonsmokers and less than one quarter being current smokers or another quarter being former smokers (p< .05). Eighty-two percent of monks felt that people should be told not to offer cigarettes to monks, while 57%

believe that monks should refuse cigarettes when offered. A little more than half of the monks thought people have more respect for monks who do not smoke (58%) and slightly more than half thought monks who smoke are not accepted by the public (53%). Ninety-one percent agreed that there should be a cessation program for monks who smoke. Although 79% of monks supported a campaign to educate the public to not offer cigarettes, 60%

of monks said they accepted smoking among fellow monks.

Patterns Among Monks/Novices Who Currently Smoke

Table 2 presents the smoking history of 1,511 monks/novices who were defined as current smokers. Ninety-one percent of these monks began smoking before entering the monkhood. Seventy-five percent of monks initiated smoking by age 19 and 62% were regular smokers by that age.

Of monks reporting length of time as a regular smoker, 32.4%had smoked

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Table 2.Smoking History and Behaviors Among Monks and Novices Who Are Current Smokers

Current Smokers (n¼1,511) NorM(SD) %

Smoking initiation

Before monkhood 1,374 90.9

During monkhood 137 9.1

Age of smoking initiation 17.0 (4.28)

15 years 381 25.6

15–19 years 735 49.4

20–24 years 294 19.8

25 years 78 5.2 Average cigarettes per day 10.5 (7.41)

1–5 cigarettes 430 29.2

41 cigarettes 4 0.3 First cigarette of the day, how long after getting up

15 min. 369 24.4

Within 15–30 min 239 15.8

Within 30–60 min 291 19.3

60 min 612 40.5 Want to quit smoking

Yes 1,076 72.5

No 409 27.5

Tried to quit smoking within the past year

Yes 783 51.8

No 728 48.2

Methods used to quit smoking^a

Cold turkey 419 53.5

Drug therapy 24 3.1

Weaning 396 50.6

Others 30 3.8

Why you cannot quit smoking?^a

Don’t know how 396 27.3

Don’t want to 488 33.6

No advice 240 16.5

Others 327 22.5

Note.^aResponses were reported in nonexclusive categories, thus percentages total to greater than 100.

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25 years or more, another third smoked less than 10 years, and a third smoked between 10 and 25 years. Seventy-five percent of monks smoked daily, with most monks reporting smoking 6–10 cigarettes per day (44%) or 1–5 cigarettes per day (29%).

An indicator of tobacco dependency among monks was relatively high with nearly 40%having their first cigarette of the day within 30 min of getting up in the morning. Smoking occurred most frequently in the residence (51.6%), and/or temple grounds (41.3%), with smoking elsewhere being uncommon. Ninety-five percent of monks purchased their own cigarettes with only small percentages of monks getting cigarettes by asking other monks (20%), or being offered (17%). Overall, 45.5%of monks reported having symptomatic health problems due to smoking.

The majority of monks reported wanting to quit smoking (72.5%) with half reporting having tried to quit in the past year (51.8%). At least half of those who tried to quit attempted to stop using entirely by themselves (cold turkey), while the other half attempted to reduce their smoking gradually over time (weaning). At least 61% of monks had been advised to quit smoking, most often by lay people (48%), other monks (44%), a health professional (40%), or media (29%). One third of monks said they could not quit because they really did not want to, while 27.3%and 16.5%reported they could not quit because they did not know how or received no advice on quitting, respectively.

Former Smokers

Of the monks surveyed, 1,173 monks were defined as former smokers (data on former smokers not shown). Sixty-one percent quit smoking while in monkhood and 39%prior to monkhood. Most had quit less than 5 years ago (57%), while 26%quit more than 10 years ago. Similar to current smokers, most of the former smokers had smoked 6–10 cigarettes per day (48%) and 30%had smoked 5 or fewer cigarettes per day. Of those who had quit, 62.9%, 20.5%, and 16.6%had made 1–2, 3–4, or 5 or more quit attempts, respectively. As with current smokers, about two thirds (68.6%) of the former smokers had been advised to quit; also, advice to quit came from three primary sources: other monks (48.6%), lay persons (44.7%), and/or health professionals (41.4%).

Discussion

This study represents the first and only nationally conducted examination of smoking rates among Buddhist monks in Thailand. The results on smoking

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behavior and related knowledge, opinions, and perceptions among monks provides a broad picture of the smoking problem extant in Thailand as well as some indication of the effectiveness of prevention and cessation efforts implemented thus far. Although past smoking prevalence rates among monks for the country as a whole are not available for comparison, estimates reported by previous studies at the province-level provide some indication of past smoking rates. Monks surveyed for this study were between the ages of 12 and 65 years old and included both full-fledged monks and novices.

We found the overall prevalence of current smoking to be 24.4%among Buddhist monks in Thailand with another 18.9% being former smokers.

If earlier studies aforementioned are an indication of past smoking rates among monks (up to 55%), this rate may reflect the relative success in smoking prevention and cessation efforts implemented by nongovernmental organizations, the Thai Ministry of Health, as well as the government itself.

This study demonstrates that both personal and contextual factors influ- enced smoking among monks. Comparisons between smoking and nonsmoking monks reveal significantly different personal factors contributing to smoking status, including status as a monk or novice, type of wat at which the monks/novices reside, increasing age, duration in monkhood, educational level, and formal theological education. Contextually, the overall smoking prevalence varied by region, with nearly 15%in the north, 40%in the central, and 41%in the east regions. Closer examination of smoking history and demographic characteristics revealed no clear explanation for these specific regional differences with such patterns being inconsistent with male smoking rates in those respective areas. However, since smoking was significantly associated with older age and duration in monkhood overall, with the majority (61%) of current monk smokers reporting that they initiated smoking prior to entering the monkhood, implementing intervention measures aimed toward novices in high prevalence areas upon entry into the monkhood may be one strategy for encouraging cessation and thus reducing smoking rates among monks overall.

The finding that monks with secondary education or some college have lower smoking rates than those with only primary or vocational levels of education is consistent with smoking prevalence among the general male population in Thailand (GATS, 2009). Also, monks with formal theological training were less likely to smoke than those without religious schooling.

In Thailand, Dharma education provided to monks and novices is publicly available by most large temples and does not require tuition. Therefore, it is common for families in the countryside that may have limited income to

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ordain their sons so that they may receive some formal schooling despite not being of standard academic program. Although theological education is not required for monks and novices, most of them (70%) choose to enter some religious training along with regular public schooling. Therefore, integrating some prevention and cessation intervention programming with the temples’ religious courses may be one avenue for reaching the majority of incoming monks and novices. Monks could be encouraged, if not sanctioned, to adapt a smoke-free lifestyle as it would align with their acceptance of the fifth precept of Buddhism of abstaining from indulging in intoxicating substances.

Regarding cessation, three quarters of current monk smokers said that they wanted to quit and half made attempts to quit within the last 12 months.

Several reasons monks gave for being unsuccessful at quitting were not having a true desire to quit, lack of knowledge of cessation methods, as well as absence of effective quit advice. Nonetheless, the majority of former smoking monks was able to successfully quit after just one or two quit attempts (63%) and most had quit during monkhood (61%). Former smokers attested that the majority had received advice to quit (69%) with highest influence attributable to other monks, lay people, or a health professional.

This suggests that advice from other monks may have slightly more salience to quit successfully compared to advice from other sources.

Evidence from this study suggests that efforts by the country’s leading antismoking advocates, such as ASH Thailand, as well as the Thai government have had some success in curbing tobacco use with at least one third of monks/novices being aware of nonsmoking policies. However, continuing to enforce the policy of smoke-free wats could further facilitate quitting among the 72%of monks/novice who reported wanting to quit (despite frequently smoking on temple grounds), while discouraging initiation by new monks/novices. Further, increased education within the wats could help to reinforce the health, social, and religious benefits of remaining abstinent.

Also, as Buddhist monks play such a central important role in establishing normative patterns among Thais, adhering to the no-smoking policy among monks in and outside of the wats is essential for the success in reducing male smoking in the general population. Several articles have documen- ted the achievements that Buddhist monks have attained in helping to reduce smoking in parts of the country (e.g., Ingram, 2002; Swaddiwudhi- pong, Chaovakiratipong, Nguntra, Khumklam, & Silarug, 1993) including a Morbidity and Mortality Weekly Report, published by the United States Centers for Disease Control (CDC, 1993). The CDC report emphasized that former smokers in the intervention village—where a higher proportion made

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quit attempts and maintained abstinence from smoking occurred compared to the referent village—cited the encouragement of a monk as an important reason for quitting smoking.

Further, this study finds broader applicability to other countries in which there are high percentages of Buddhists. Prior studies have begun to document the levels of smoking among Buddhist monks in other countries such as Lao and Cambodia (Smith, Umenai, & Iida, 2000; Vanphanom, Phengsa- vanh, Hansana, Menorath, & Tomson, 2009). In addition, several articles have been published investigating the usefulness of Buddhist-based interventions and the consistency between Buddhism and addiction recovery programs in general (Chen, 2010; Groves & Farmer, 1994; Yong, Hamann, Borland, Fong, & Omar, 2009).

Although the present study on smoking prevalence includes the largest sample of Buddhist monks ever surveyed in Thailand, there are limitations.

Unanticipated difficulties with data collection at the wats were encountered such that some monks selected for sampling were unavailable. Also, the Buddhist monk population in Thailand is not stagnant as monks constantly enter and leave the monkhood. This suggests that periodic surveying of monks maybe important in order to track changes over time. Nonetheless, this study serves as a baseline with which to compare future national studies of smoking behaviors and beliefs among Buddhist monks in Thailand. Finally, rates of smoking may have changed within the 8 years of conducting this population-based survey. However, to our knowledge, this remains the most recent population-based data available on smoking among monks in Thailand.

In summary, high rates of smoking among those who maintain strong influence over 95%of the members in Thai society, such as monks, are significant when considering the implementation of tobacco control measures.

Efforts to understand the reasons behind smoking among monks will ame- liorate programmatic efforts to achieve a reduction in smoking. Buddhist monks realize they are able to set social norms within the country. Thus, public health practitioners and health professionals targeting smoking may consider involving monks in tobacco control education, not only in Thailand but also in other countries with a large proportion of Buddhists (e.g., Lao, Cambodia).

Further, developing and enforcing policies that set a nonsmoking standard among monks is vital to the success of reducing smoking rates among the general population. For individuals involved in tobacco control, this study estab- lishes a national baseline prevalence for smoking among monks in Thailand.

Ongoing monitoring and evaluation of smoking practices among monks will be a valuable yardstick for smoking trends within the country and will be important for ensuring continued reduction in smoking rates overall.

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Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research project from The Rockefeller Foundation.

Notes

1. Ministry of Education website: www.moe.go.th.

2. BKK Metropolitan Area Administration website: www.bangkok.go.th (formerly www.bma.go.th).

3. BKK includes the region of the Bangkok metropolitan area only. Central includes provinces Pathumthani, Saraburi, Nonthaburi, Chainat. East includes provinces Trad, Srakaew, and Chachoengsao, Rayong. West includes provinces Nakhon Pathom, Samut Songkhram, Prajuabkhirikhan, Rachaburi. North includes provinces Lampoon, Phayao, Sukhothai, Nakhonsawan. Northeast includes provinces Sakon Nakhon, Mahasarakham, Mukdaharn, Chaiyapum. South includes provinces Nakhosithammarat, Chumporm, Trang, Pattani.

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