FACTORS RELATED TO TOBACCO USE AMONG MONKS IN … Use among Monks i… · AND LUANG PRABANG...

Vanphanom Sychareun, MD, PhDAlongkon Phengsavanh, MD, PhD

Visanou Hansana, MD, MCTMSing Menorath, MD, PhD

Angkham Ounavong, MD, MPH

The Collaborative Funding Program for Southeast Asia Tobacco Control Research

FACTORS RELATED TO TOBACCO USE

AMONG MONKS IN VIENTIANE CAPITAL CITY

AND LUANG PRABANG PROVINCE, LAO PDR

Financial support from

World Health Organization (WHO Lao PDR) The Rockefeller Foundation

Research for International Tobacco Control (RITC)

Factors Related to Tobacco Use among Monks in Vientiane Capital City and

Luang Prabang Province, Lao PDR

by Vanphanom Sychareun, MD, PhD; Alongkon Phengsavanh, MD, PhD;

Visanou Hansana, MD, MCTM; Sing Menorath, MD, PhD and Angkham Ounavong, MD, MPH

Postgraduate Studies and Research Department

Faculty of Medical Sciences National University of Lao

Vientianne, Lao PDR

Supported by World Health Organization (WHO Lao PDR) and

Southeast Asia Tobacco Control Alliance (SEATCA) Under the Collaborative Funding Program for Tobacco Control Research

Financial support from World Health Organization (WHO Lao PDR)

The Rockefeller Foundation and Research for International Tobacco Control (RITC)

May, 2008

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ACKNOWLEDGEMENTS

The authors would like to thank the World Health Organization (WHO) and Southeast Asia tobacco Control Alliance (SEATCA) for the financial support provided for this study. In particular, the authors wish to express their gratitude to the Dean of the Faculty of Medical Sciences - Assoc. Prof. Som Ock Kingsada for the support of our study and the Vice Dean – Assoc. Prof. Sing Menorath, who is responsible for the Postgraduate Studies and Research, Faculty of Medical Sciences for his invaluable support to the research team.

I would also like to acknowledge several other people, namely my research teams - Dr. Ketkesone Prasisombath, Dr. Soudavanh Soysouvanh, Dr. Khonesuda Banuvong, Dr. Vatsana Thammavongsa, Dr. Vatsana Somphet, Dr. Oua Phimmasane, Mr. Kongmany Chaleunvong and Mr. Johnly who have helped me complete this study. I would like to extend our gratitude to Buddhism Association at the Central level and Luangprabang province for recognizing the importance of this study and thus gave their approval to this study and subsequently in helping us make contact with the abbots of the temples. I also would like to thank the Lao National Construction Front in Vientiane, and Luang Prabang in helping us obtain the list of monks/novices. I would like extend my appreciation to the abbots for taking time off from their busy schedule to be interviewed. Finally, I would like to give my heart felt thank to the monks and novices for providing invaluable information which is crucial to this study.

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ABSTRACT Smoking is the most serious risk factor for morbidity and mortality worldwide and the efforts of monks are needed to confront this epidemic. The valuable contributions of monks in particular should be recognized due to their role as main religious practitioners in Laos and are considered to be the role model concerning smoking behaviors. The aim of this study is to assess the prevalence of smoking among monks, the predisposing, enabling and reinforcing factors related to smoking among them and the prevalence of offering cigarettes to monks. This is a cross-sectional study on the smoking prevalence among monks, their smoking pattern and knowledge, attitudes concerning tobacco use by using quantitative and qualitative data collected between March and September 2006 from among 390 monks/novices. Questions about smoking history and current smoking patterns were based on the World Health Organization (WHO) and a current review paper. Variables assessed included known predictors of smoking in adult populations: age and sex, smoking history (duration, frequency, previous quit attempts), socio-economic status (education), other smoking variables (the presence or absence of other smokers in the family and temple, whether friends and fellow monks smoked), predisposing factors (knowledge, attitudes and beliefs), enabling factors (accessibility, availability, regulations and policies related to smoking), reinforcing factors (family and peer influences) and intention to quit smoking. The results from this study revealed that the prevalence of daily smoking among monks was 11.8% and there is a little variation between Vientiane (11.7%) and Luang Prabang provinces (12.2%). The prevalence of offering cigarettes to monks was 57.3% which is similar to the qualitative data. The predisposing factors such as Knowledge, Attitudes, and Practices related to smoking among monks entailed a high level of knowledge on addiction of nicotine and passive smoking which increased risk of heart diseases; however, approximately 50% were aware that smoking was just as fatal as taking illegal drugs, AIDS and car accidents. Slightly less than half (43.8%) knew about smoking rules in religious places. The majority of monks supported the opinions not to smoke in all enclosed public places including temple area (91%); respect monk’s smoking (89.8%); and advised people to quit smoking (93.1%) and campaign not to offer cigarettes to monks (86%); however, they were less likely to agree with the prohibition on the offering of tobacco to monks (23.8%) and that monks should refuse cigarettes offered to them (9.2%). Among current practices; the majority of monks and novices started smoking on a regular basis at the age between 15-20 years. The reason for starting smoking among monks and novices were peer influence (48.7%), followed by release stress (17.6%), intimate adults (9.2%), getting free (6.7%). The availability of cigarettes offered by the public is one factor contributing to smoking among monks. The reinforcing factors related to smoking among monks are smoking among family members. Factors related to smoking among monks are age, ethnic group,

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monk’s status, age at entering monk hood, duration of religious education and level of knowledge of the harmful effects of smoking on health; however, after controlling for confounders, none of the factors were statistically significantly associated with smoking status of monks. Based on the findings from this study, there is a need to organize health education programs on smoking regularly for monks and provide information, education and communication (IEC) materials such as stickers, posters, brochures and leaflets on the harmful effects of smoking. At the same time, smoking cessation programs should be started by providing skills on how to quit smoking. There should be a campaign to encourage the public not to offer cigarettes to monks or not to afford cigarettes to monks due to the negative effects of smoking on health. Monks should be the health educators and role models together with the health staff in providing health education to monks and the public.

The Monk’s Association should set up regulations that prohibit smoking on temple grounds and impose strict regulations on monks and novices to discourage smoking. Monks should serve as “role models’ for not smoking because the majority of Lao people believe in Buddhism and the role of Buddhism in daily life is crucial for the general public.

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TABLE OF CONTENTS Pages ACKNOWLEDGEMENTS…………………………………………....................

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ABSTRACT…………………………………………………………….............

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LIST OF TABLES………………………………………………………………. vii 1.INTRODUCTION AND BACKGROUND 1 1.1. Research Questions…………………………………………………………. 2 1.2. General Objective…………………………………………………………. 3 1.3. Specific Objectives………………………………………………………... 3 1.4. Theory Applied: Precede Theory………………………………………….. 3 2. LITERATURE REVIEW 4 2.1. Prevalence of Smoking Among General Population……………………… 4 2.2. Prevalence of Smoking Among Monks 4 2.3. Factors related to Knowledge and Attitudes Towards Smoking Among Monks……………………………………………………………………….

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2.3.1. Predisposing Factors ……………………………………………… 5 2.3.2. Enabling Factors …………………………………………………… 5 2.3.3. Reinforcing Factors ………………………………………………… 6 2.4. Intervention to Reduce Smoking Among Monks 7 3. RESEARCH METHODOLOGY 8 3.1. Project Sites ……………………………………………………................... 8 3.2. Target Population.......................................................................................... 8 3.3 Sample Size..................................................................................................... 8 3.4. Sampling........................................................................................................ 9 3.5. Variables Assessed......................................................................................... 10 3.6. Instrument Tools ........................................................................................... 11 3.7. Data Analysis ............................................................................................... 11 3. 8. Data Collection ............................................................................................ 12 3.9. Ethical Consideration..................................................................................... 12 3.9.1. Approval by a Relevant Ethical Review Board in Lao PDR.............. 12 3.9.2. Research Material to be Obtained....................................................... 13 3.9.3. Privacy & Confidentiality Protections................................................ 13 4. RESULTS 14 4.1. Characteristics of the Study Population......................................................... 14 4.2. Smoking Status of Monks and Novices......................................................... 16 4.3. Ex-smokers................................................................................................... 16 4.4. Current Smokers............................................................................................ 18 4.5. Smoking Cessation......................................................................................... 21 4.6. Predisposing Factors...................................................................................... 23 4.6.1. Understanding of the Health Effects of Smoking................................ 23 4.6.2. Attitudes Regarding Smoking Among Monks.................................... 26 4.7. Enabling Factors (Accessibility, Availability, and Policy)............................ 30 4.8. Reinforcing Factors....................................................................................... 33

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4.8.1. Family Members Who Smoke.............................................................. 33 4.9. Intention to Participate in Tobacco Control Programs................................... 34 4.10. Factors Related to Smoking Among Monks................................................ 37 4.10.1. Multiple Regressions......................................................................... 39 4.11. Prevalence of Offering Cigarettes to Monks............................................... 40 4.12. Abbots’ Opinion Towards Smoking............................................................ 42 4.12.1. Opinion about Smoking Among Monk............................................... 42 4.12.2. Acceptance of Smoking Among

Monks......................................................... 42

4.12.3. Monks as Role Models........................................................................ 43 4.12.4. Offering Cigarettes to Monks by the Public....................................... 43

4.12.5. Regulation or Law Related to Smoking in the Temples..................... 43 4.12.6. Influences on Monk’s Smoking Practices........................................... 44

4.12.7. Integrate Lessons of Smoking in the Training Curriculum.............. 44 4.12.8. Preaching about the Effects of Smoking to People 44

5. DISCUSSION 46 5.1. Prevalence of Smoking Among Monks....................................................... 46 5.1.1. Prevalence of Offering Cigarettes to Monks.......................................... 46 5.2. Predisposing Factors..................................................................................... 46 5.3. Enabling Factors........................................................................................... 47 5.4. Reinforcing Factors....................................................................................... 47 5.5. Factors Related to Smoking........................................................................... 47 5.6. Limitations..................................................................................................... 48 6. CONCLUSION 49 7. RECOMMENDATIONS 50 7.1. Develop Intervention Program for Tobacco Control................................... 50 REFERENCES 52 APPENDIX Questionnaire Survey of KAP Towards Smoking Among Monks...........................

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Guidelines for In-depth Interview with Key Buddhist Leaders................................ 62 Questionnaire for Nuns/elderly on the Offering of Tobacco to Monks.................... 63

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LIST OF TABLES

Pages

Table 1: Smoking rate in South East Asia by country................................. 4 Table 2: Distribution of sample size by region................................................. 9 Table 3: Number of monks and novices in the provinces/ regions and number of sample size by region, province and district..................

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Table 4: Distribution of sample size of nuns/elderly by province...................... 10 Table 5: Characteristics of monks and novices by region................................ 14 Table 6: Smoking status of monks and novices by province........................... 16 Table 7: Smoking status of monks and novices who are ex-smokers by province............................................................................................

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Table 8: Distribution of monks and novices who are current smokers by province...........................................................................................

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Table 9: Percentage distribution of smoking cessation among monks and novices.................................................................................................

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Table 10: Monk’s and novice knowledge about health effect of smoking by smoking status.........................................................................

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Table 11: Knowledge about the health effects of smoking among monks and novices by smoking status.................................................................

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Table 12: Monk's and novice's attitudes towards tobacco use by provinces 27 Table 13: Monk's and novice's attitudes towards tobacco use by region and smoking status....................................................................................

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Table 14: Monk's and novice's practice at temple by region.............................. 31 Table 15: Monk's and novice's practice at temple by smoking status.................. 32 Table 16: Family members who smoke by provinces.................................. 34 Table 17: Percentage distribution of monk’s and novice’s intention to participate in Tobacco Control by province......................................

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Table 18: Percentage distribution of monk’s and novice’s intention to participate in Tobacco Control by smoking status...............................

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Table19: Factors related to smoking status among monks................................... 37 Table 20: Mean and SD of knowledge and attitudes towards smoking associated with smoking status............................................................

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Table 21: Odds ratios for logistic regression analysis for respondents reporting smoking..............................................................................

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Table 22: Characteristics of nuns and elderly offering cigarettes to monks by province.........................................................................................

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Table 23: Prevalence of offering cigarettes to monks.......................................... 41

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1. INTRODUCTION AND BACKGROUND Lao People’s Democratic Republic is a country with more than 85% of the population is believers in Buddhism, which therefore has a strong influence on the lifestyle of the local people (National Statistical Center, 2005). The temple is a source of education and Buddhist monks are very influential in teaching people to do good things. The religious homogeneity in Lao has resulted in a strong relation between religious identity and ethnic identity. Buddhism shapes religious, ethnic, and cultural identity in Laos (Laos Religion, 2007). Whether or not there is a Buddhist temple in the community, Buddhism provides guidelines for behavior through its five precepts for the laity: refrain from taking life, from stealing, from illicit sexual activity, from speaking falsely, and from consuming inebriating substances. As with other Theravada Buddhists, the Lao gain merit by presenting gifts of food, including cigarettes and money to the temple and by having their sons ordained as monks for varying periods of time. A large majority of Lao men become monks for some part of their lives. Ideally, ordination takes place when the man is twenty years old. Becoming a monk has been an avenue of advancement for many men from rural Laos (Wikipedia, 2007).

Monks are the main religious practitioners among Lao, and most young men are expected to become a monk for a short period to prepare them for marriage. This practice is also crucial for the transfer of merit from son to mother and is the source of a special bond between them. Most men enter the temple for not more than a month. Young men who stay longer are from poor families and are there to receive an education; some, however, stay for life. Older men sometimes retreat into the temple, as do a few older women. The monks not only are in charge of Buddhist religious ceremonies but function as dream interpreters, traditional medical practitioners, and counselors. Other religious practitioners include spirit mediums and shamans, most of whom are women. Shamans and mediums also are found among all the minorities (Culture of Laos, 2007).

Tobacco is listed as the third most important agricultural crop in Lao People's Democratic Republic. In 1997, it was reported that 7,500 hectares of arable land were devoted to tobacco, producing 1,600 tones of tobacco leaf. Currently, there is only one tobacco/cigarette manufacturer in Lao People's Democratic Republic. The factory obtains its raw material from approximately 1,000 villages along the Mekong and reportedly produced 49.3 million packs of cigarettes in 1996, and 47.8 million packs in 1997. The value of tobacco and tobacco products exported annually is estimated at US$800,000 each year. In addition to the local manufacturer, there are three importing tobacco companies that have extended their sales operations to the whole country. A total of 742 individuals were employed full-time by the tobacco industry in 1995. In 1996, import costs amounted to US$1,532,842. Government tax on tobacco is more than 8.5 billion Kip (US$2 million) each year. In 1999, the cost of a local pack of 20 cigarettes ranged from 2000-4000 kip (US$27-55 cents), while imported cigarettes were selling at 7000-9000 kip (US$0.95-1.23) per pack, roughly equivalent to the cost of one meal. Recently in 2006, the cost of local cigarettes was about 4000 to 5000 Kips (WHO, 2000).

Laos is a tobacco growing country where the use of cigarettes among men is more accepted by the general population. In particular, tobaccos are offered to the monks

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during ceremonies or ‘Sukhouan’, and this gradually increased the use of tobacco among monks.

Cigarettes are by far the most popular type of tobacco product consumed. Pipe tobacco is used by 2-3% of consumers. No national prevalence surveys have yet to be conducted. The Ministry of Health estimated that 25% of urban males and 60% of rural males smoke, while the rates are believed to be 1.5% among urban women and 30% among rural women. However, smoking prevalence could be as high as 70-90% among certain minority groups in certain rural areas. Data is available from several smaller surveys (MOH, 2005). The World Health Survey (2006) showed that among the 4,889 adults who smoke, the prevalence of tobacco use was 40.3%, whereby the percentage of males who smoked was higher than females (67.7% versus 16%, respectively). The tobacco epidemic is one of the greatest public health challenges in the Western Pacific and South East Asia Region. Every eight seconds, someone in the world dies of a smoking-related disease. Every year, four million people die from the effects of tobacco use (Nicotine Laser Center, 2007). One in four of these deaths occur in our region. The hazards to health from smoking are well known. In countries where smoking is a long-established habit, about 90% of lung cancer cases, 30% of all cancer deaths, 20-25% of coronary heart diseases and strokes, and over 80% of chronic bronchitis and emphysema cases are attributed to tobacco use. Smoking can cause chronic lung disease, coronary heart disease, and stroke, as well as cancer of the lungs, larynx, esophagus, mouth, and bladder. In addition, smoking contributes to cancer of the cervix, pancreas, and kidneys (WHO, 2000).

Thus, the Asia-Pacific Cohort Studies Collaboration (APCSC) investigated the association between smoking and mortality in the Asia-Pacific Region from meta-analysis of individual participant data from 44 cohort studies in the Asia-Pacific region. For this analysis, 512,676 people were included from 34 cohort studies: 25 in Asian countries and 9 in Australia or New Zealand (ANZ). In the Asian countries, 59% of men and 3% of women were current smokers. Cardiovascular disease was the leading cause of death in Asian women. However in Asia, smoking was significantly associated with total mortality, cancer mortality, cardiovascular mortality, respiratory mortality, but not with injury mortality. The fractions (%) of mortality attributable to current smoking ranged from 9% to 25% in men, and from 1% to 23% in women. The fractions (%) of cause-specific mortality attributable to current smoking were different by countries and sex (Hyeon C. K., et. al., 2007).

There are no studies assessing the prevalence of smoking among monks and the factors related to smoking among them. The evidence from the neighboring countries showed the higher prevalence of smoking among monks and that there is a need to develop intervention programs on smoking prevention and cessation among monks with tobacco control organizations that are concern with smoking-relating diseases. 1.1. Research Questions

1. What is the prevalence of smoking among monks in the Vientiane capital city and Luang Prabang of the Lao PDR?

2. What are the predisposing, reinforcing and enabling factors related to smoking among monks?

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3. What is the prevalence of people offering cigarettes to monks? 1.2. General Objective

To study the factors related to tobacco use among monks. 1.3. Specific Objectives

To study the prevalence of smoking among monks in Vientiane Capital City and Luang Prabang provinces of the Lao PDR.

To examine the prevalence of offering cigarettes to monks. To examine the predisposing factors such as Knowledge, Attitudes, and

Practices related to smoking among monks. To study the enabling factors such as availability, accessibility, regulations

and policies related to smoking among monks. To study the reinforcing factors (peers and family influences) related to

smoking among monks. To identify factors that influence tobacco use and acquiring information for the

development of effective smoking prevention and cessation strategies.

1.4. Theory Applied: Precede Theory The Precede theory will apply to assess the risk factor influencing smoking behavior among monks. The PRECEDE conceptual framework was utilized for categorizing major themes. According to this framework, major determinants of behavior can be classified into Predisposing, Reinforcing, and Enabling factors. PRECEDE assumes that behavior is largely determined by culture and that individual variables affecting behavior may differ depending on the population subgroup to which an individual belongs (Green, & Kreuter, 1991).

• Predisposing Factors - any characteristics of a person or population that motivates behavior prior to the occurrence of that behavior. For examples:

o Knowledge, beliefs, values, and attitudes • Enablers - characteristic of the emotional/psychological and physical

environment that facilitate action and any skill or resource required to attain specific behavior such as

o Accessibility, availability, regulations and policy. • Reinforces - rewards or punishments following or anticipated as a

consequence of a behavior. They serve to strengthen the motivation for behavior.

o Family and peers.

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2. LITERATURE REVIEW 2.1. Prevalence of Smoking Among General Population Table 1 shows that about 38% of Lao PDR’s total population are tobacco smokers; smoking rate of the male population is more than two times higher than females (41% among males and 15% among females). 6,700 hectares or 0.87% of land is grown with tobacco and 33,400 tonnes of tobacco produced is made in Lao PDR. Lao has the highest cigarette smoking rate in Southeast Asia (Mackay & Eriksen, 2002). There is currently no analysis done neither on who the cigarette smokers are nor about smoking among monks. Table 1: Smoking rate in Southeast Asia by country

Smoking rate (%) Country Total Male Female

Lao PDR 38 41 15 Cambodia 37 66 8 Myanmar 32 43.5 22.3 Thailand 23.4 44.1 2.6 Malaysia 26.4 49.2 3.5 Indonesia 31.4 59 3.7 Philippines 32.4 53.8 11 Singapore 15 26.9 3.1 Brunei 27 40 14 Vietnam 27.1 50.7 3.5

(Source: Mackay & Eriksen. The Demographics of Tobacco. The Tobacco Atlas. World Health Organization (2002. p 96; 104).

In 2003, a Global Youth Tobacco Survey was done in Vientiane which involved 2404 students. About 16.9% of them had ever smoked cigarettes, 16.5% currently use any tobacco product with a rate of 24.6% among males and 4.9% among females (CDC, 2003). 2.2. Prevalence of Smoking Among Monks A study carried out in Central Part of Thailand, Chonbury (1988) found that the prevalence rate of smoking among 678 monks from 48 temples was 54.8%; followed by teachers and health professionals. Similar study in Rachbury (1994) also found that about 56% of monks smoked. Navarath et al. (2006) suggested that the prevalence of smoking among monks in the whole country has reduced to 24.4% and vary by geographic areas with 14.6% in the North; 40.5% in the East; 40.2% in the Central, 33.5% in the South, and 14.6% in Bangkok; while the West, Northeast and North has the prevalence of 22.8%; 20.4% and 14.6%, respectively. The prevalence of current smokers among Buddhist monks in Cambodia is 44%, in comparison to the smoking prevalence among the general male population in Phnom Penh which is almost 65% (1994) and among Buddhist monks in Thailand at 56% (1990).

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2.3. Factors Related to Knowledge and Attitudes Towards Smoking Among Monks 2.3.1. Predisposing Factors Socio-demographic, environmental, behavioral, and personal factors can encourage the onset of tobacco use among adolescents. Young people from families with lower socio-economic status, including those adolescents living in single-parent homes, are at increased risk of initiating smoking. With regard to Knowledge and Attitudes towards smoking in the Lao PDR, 26.5% think that boys who smoke have more friends while 8.6% believe girls would have more friends if they smoke. 17.2% think that boys who smoke look more attractive whereas 8.1% think this is so of girls (CDC, 2003). Naowarut et al., (2004) also found that factors such as older age, monk’s status (full-fledged monks or novices), and longer period of monkhood are associated with smoking among monks in Thailand. Older, non-novice monks were more aware of smoking laws and regulations, diseases as consequences of smoking and the public’s negative view of monks’ who smoke smoking (Naowarut et al., 2004). They also found that less than half of respondents knew of the rules on smoking in their temples and the knowledge level about health risk from smoking and second hand smoke was generally high among monks. Other studies found that 89% of both smokers and non-smokers believed that smoking was harmful (Marshall et al., 2002) Naowarut et al., (2004) suggested that more than 82% of monk’s respondents felt that people should not offer cigarettes to monks and 57% pointed out that monks should refuse offered cigarettes. 2.3.2. Enabling Factors In many societies in South Asia, the act of offering a cigarette was described as an important social exchange. The appropriate etiquette was to accept an offer of cigarettes, because to refuse would be impolite and disrespectful: “In China, smoking is indispensable to social life. It seems that the most important thing in the first meeting between males is a cigarette. Cigarette plays a role of courtesy or politeness between people.” (Shin-Ping Tu et al., 2000). In the Lao society where Buddhism is an integral part of life, presenting gifts of food, including cigarettes and money to the temple which enable them to smoke is an act that will enable the Lao to gain merit. In terms of accessibility and availability of cigarettes, 14.2% of Lao youth usually smoke at home; 42.6% buy cigarettes in a store. 52.2% who bought cigarettes in a store were not refused from buying due to their age (CDC, 2003).

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2.3.3. Reinforcing Factors With regard to reinforcing factors, it seems that peer influence is powerful in the early stages of tobacco use; the first attempt at trying cigarettes and smokeless tobacco occur most often with peers, and the peer group may subsequently provide expectations, reinforcement, and cues for experimentation. Parental smoking does not appear to be as forceful a risk factor as peer influence; on the other hand, parents may put forth a positive influence by disapproving of smoking, being involved in their children's free time, discussing health matters with the children, and encouraging their children's academic achievement and school involvement. How adolescents perceived their social environment may be a stronger influence on behavior than the actual environment. For example, adolescents consistently overestimate the number of young people and adults who smoke. Those with the highest overestimates are more likely to become smokers than are those with more accurate perceptions. Similarly, those who perceive that cigarettes are easily accessible and generally available are more likely to begin smoking than are those who perceive more difficulty in obtaining cigarettes (CDC, 1994). Behavioral factors figure heavily during adolescence, a period of multiple transitions to physical maturation, to a coherent sense of self, and to emotional independence. Adolescents are thus particularly vulnerable to a range of hazardous behaviors and activities, including tobacco use that may seem to assist in these transitions. Young people who report that smoking serves positive functions or is potentially useful are at increased risk for smoking. These functions are associated with bonding with peers, being independent and mature, and having a positive social image. Since reports from adolescents who begin to smoke indicate that they have lower self-esteem and lower self-images than their non-smoking peers, smoking can become a self-enhancement mechanism. Similarly, not having the confidence to be able to resist peer offers of tobacco seems to be an important risk factor for initiation. Intentions to use tobacco and actual experimentation also strongly predict subsequent regular use (CDC, 1994). Initiation into smoking among Thai monks both before entering and after entering the monkhood is done on an experimental basis and is influenced by their peers who smoke. The amount smoked ranged from 10-14 cigarettes per day (Wongkraisithonh, 1985). Among the factors influencing the initiation of smoking, 26% of respondents said that an individual friend was the main influence to start smoking; Other factors are group pressure from friends or other monks (18%); complimentary cigarettes (21%); work/stress (12%); father’s influence (8%); advertising (3%); and other reasons (12%). As can be seen, these two influences – an individual friend and group pressure – account for almost half of all influences for starting smoking (Marshall, Smith & Takusei Umenai. 2002). The Global Youth Tobacco Survey (GYTS) found that 45.7% of surveyed youth around the world live in homes where others smoke in their presence and 52.39% mentioned that smoke from others is harmful to them. 58.8% are around others who smoke in places outside their home. 52.7% have one or more parents who smoke;

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6.9% have most or all friends smoke. Regarding prohibiting smoking, 48.8% of them pointed out that smoking should be banned from public places. 2.4. Intervention to Reduce Smoking Among Monks Advocacy for law/legislation development and implementation, providing awareness on tobacco damages to monks and urging public not to offer cigarette to monks to gain merits are important components in the intervention program. Integrating anti-smoking messages into the National Buddhist Curriculum, counseling on quit smoking, preaching, integrated training, etc. are among the routine activities that should be pursued (Kong Mom, MD, Adventist Development and Relief Agency - ADRA, 2001).

The intervention program should include introducing a law/regulation that prohibits smoking in temples, with the exception of certain areas, and the setting up of a

smoking cessation counseling service. The research team will develop the intervention program based on the exploratory research.

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3. RESEARCH METHODOLOGY This is a cross-sectional descriptive research on the factors related to smoking among monks in the Northern, and Central provinces of the Lao PDR. Firstly, quantitative research method was carried out to assess the baseline data of smoking among monks and to identify the predisposing, enabling and reinforcing factors related to tobacco among monks. Subsequently, qualitative research method was undertaken to find out the respondents’ perception regarding the regulation or law on smoking among monks and the role that monks can play in encouraging non-smoking. 3.1. Project Sites The Lao People’s Democratic Republic has a lot of temples which is mostly concentrated in the Central, Southern and Northern parts of the Country. According to the Buddhist Association, there were 4,111 temples with 11,582 monks and 12,463 novices in the country in 2006. The Lao PDR consists of 17 provinces which are divided into 3 parts or regions, namely the Northern, Central and Southern regions. For this study, one province was selected from each region based on the concentration of temples and monks/novices. Luang Prabang Province was chosen from the Northern region; in the Central region, Vientiane Capital was selected.

The project sites were four districts in Vientiane Capital City; while a number of temples had recently enacted laws/regulations on tobacco, they however, had yet to be actively implemented.

3.2. Target Population According to the Buddhist Association, in 2005, there were 11,582 monks and 12,463 novices in the Lao PDR. The inclusion criteria for the monks are that they should be a monk for at least 1 year, aged between 12 to 45 years old and be able to answer a self-administered questionnaire In order to estimate the prevalence of offering cigarettes among monks, a second target group was identified, and that was the nun/elderly, who take care of the temple. 3.3. Sample Size Sample size determination is an important and critical issue in planning a study. In fact, sample size calculations should be performed for all important population parameters. The sample size must take into account the largest sample size calculated in order to meet the requirements of the population parameter which requires the most precision. More often, the decision on sample size required compromises with theoretically correct sample sizes and the sample sizes allowed by available resources, which are subjected to factors such as time, human resources and transportation. The formula for the sample size, which is obtained by solving the maximum error of the estimate formula for the population proportion for n, is shown below.

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If we know the number of monks, thus this formula was used: n=Z2 x p q/d2 n=Number of sample size alpha=0.05, thus Z=1.96 Q=1-p P= proportion of smoking among males=41%. d2= relative error equal 2.5% 1.962 (0.59)(0.41) 3.84 x 0.2419 0.9288 n= = = = 371.5 0.052 0.0025 0.0025 Due to the lack of information on the proportion of monks who smoke, the prevalence of smoking among male in Lao PDR which is 41% was used; assuming the study is designed with confidence level of 95% at the 5% level of significance and precision of 5%. Therefore, the total sample size is 390 monks and novices. Table 2 presents the distribution of sample size by region. Table 2: Distribution of sample size by region No. Part No. of

Provinces No. of temples

Monk Population (Nh)

Sample size

1 Luang Prabang 1 203 1,307 90 2 Vientiane Capital

City 1 516 4,873 300

Total 2 719 6,180 390 All 390 monks/novices were recruited into the study and distributed by the districts and temples with probability proportional to size. Seven hundred and nineteen temples from 4 districts and 2 provinces were selected; and the number of monks/novices was selected according to the size of the temples. All the temples in each of the selected district from each selected province were listed and according to the number of monks residing in them. The sample size for the nun and elderly is as follows: P= proportion of offering smoking to monks=50% (We do not know exactly the proportion who offers cigarettes to monks, so we used the prevalence of 50%. d2= relative error equal 4%. 1.962 (0.50)(0.50) 3.84 x 0.2419 0.96 n= = = = 600 0.042 0.0004 0.0016 3.4. Sampling According to the report of the Buddhist Association, in 2006, there were 11,582 monks and 12,463 novices. Multi-stage stratified cluster sampling was used to sample the target population. Table 3 presents the distribution of monks by districts and temples and number of sample size of temples and districts by provinces.

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Step 1: For each selected province, a list of selected districts with the number of temples was prepared as the first stage of sampling. Only the urban districts within selected provinces were selected due to high concentration of temples. For Vientiane Capital City, 4 urban districts were purposively selected; however, in Luang Prabang province, there is only 1 urban district which was chosen purposively. Step 2: For each selected district, a list of temples was prepared as a sampling frame for the second stage and approximately 40 temples were selected by simple random sampling with probability of selection proportional to the number of temples in each selected district. Step 3: For each sample temple, a list of monks/novices aged 12-35 years old was identified and selected by systematic sampling with probability proportional to size in the selected temples. We sampled by systematic random sampling interval of the monks/novices (I=N/n) for each sample temple. The first sampling was randomly made and this was followed by taking one sample of every sampling interval and this continued until all required subjects were recruited. Monks and novices were sampled with probability proportional to size of the monks in each selected temple. Table 3: Number of monks and novices in the provinces/regions and number of sample size by region, province and district No. of Part/ Provinces

No. of monks & novices

No. of temples

No. of district

Sample of Temples

Sample district

Northern Luang Prabang 1307 203 11 10 1 Central Vientiane Capital

4873 516 9 30 4

Subtotal 6180 719 20 40 5

For the nun and elderly, we recruited them purposively on the moon day when they came to make merit at the temple.

Table 4: Distribution of sample size of nuns/elderly by province No Part No of

Provinces No of district

No of temples

Sample size

1 Luang Prabang 1 1 10 200 2 Vientiane Capital City 1 4 30 400 Total 2 5 40 600

3.5. Variables Assessed

Variables assessed included known predictors of smoking in adult populations, i.e. age and sex, smoking history (duration, frequency, previous quit attempts), socio-economic status (education), other smoking variables (the presence or absence of other smokers in the family and temple, whether friends and fellow monks smoked),

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predisposing factors (knowledge, attitudes and beliefs), enabling factors (accessibility, availability, regulations and policy related to smoking), reinforcing factors (family and peer influences) and intention to quit smoking, as indicated by one of the stages of change.

The baseline questionnaire was developed from questions in existing surveys. Questions about smoking history and current smoking patterns were based on the World Health Organization and a current review paper. Intention to quit smoking was measured using the transtheoretical (Stages of Change) model developed by Prochaska and DiClemente.

3.6. Instrument Tools Questionnaires were face-to-face administered which entailed general socio-demographic characteristics of monks (age, status, ranking, duration of monkhood, general education level, and religious education). Other variables included reasons for smoking and traditional uses of tobacco. Predisposing factors associated with tobacco-use behaviors included knowledge, attitudes and values related to smoking such as knowledge on the smoking regulation within the temple, temple’s smoking rules; quitting smoking; dangers of smoking to themselves and surrounding people; perception regarding offering of cigarettes to monks, acceptance of monk smokers; smoking behavior of monks - currently, formerly and daily smoking. Enabling factors encompass motivation, accessibility, availability, and regulations and policy and reinforcing factors which include peer group influences, smoking adopted as a coping mechanism. In-depth interview. The next phase involved talking in a greater depth with the Abbots of temples and the Directors of Buddhism associations. Interviews with the Director of the Buddhist Association from the central level and provincial level were conducted with the aim to collect information on the perception of the regulation on smoking, perception regarding offering cigarettes to the monks, acceptance of monk smokers, quitting process and health promotion to encourage monks to stop smoking and their personal point of views on how regulation or law related to smoking shape their smoking practices and on how to be role models for the general population. The key informants were purposively selected based on the abbots’ position in the temples. Before the start of the data collection, guidelines for in-depth interviews, and key informant interviews were field tested with a small sample of each corresponding category of participants for readability and comprehension, and revision was made to adapt it to the local culture and context if required. 3.7. Data analysis

Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 10.0. For the exploratory formative research, descriptive statistics such as frequency distribution, number, percentage, range, mean and standard deviation were analyzed to draw the general characteristics of monks and their knowledge, attitudes and smoking behaviors. Bi-variate analysis was conducted utilizing chi-square tests for the categorical variables and student’s t-tests for continuous variables to compare

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outcome between those who reported to have smoked and those who never smoked. Analysis of covariance and multiple logistic regressions were used to analyze to control confounding factors. The statistical significance used was alpha < 0.05.

Recorded tapes were transcribed by interviewers within seven days. Expanded field notes and transcripts from in-depth interviews, key informant interviews, and focus groups were computerized in the word document format. Qualitative data was analyzed using grounded theory, within a deductive and inductive approach. The procedures begin with a thorough reading of a small sample of text (line by line) to extract significant statements and phrases. Significant statements include all those referring to the research questions of interest. The next step in the analytic process involved identifying emergent themes or patterns across each significant statement or phrase. Themes were then clustered to develop key concepts and categories. More data from informants were gathered through reading the rest of the transcripts and incorporating each of the identical categories. Translation from Lao into English was carried out after coding. Coding categories that emerged were linked together in theoretical models, including comparing and contrasting (contradiction), cause and effect (a cause of), and attributes (a part of; a property of). 3.8. Data Collection The principal investigator wrote the letter to the Director of the Buddhism organizations and temples to inform them of the objectives of the study in order to receive their approval to conduct interviews with the monks and novices. After contacting with the Director of the Buddhism organizations and temples from the selected provinces and districts and temples, the research team started collecting quantitative and qualitative data as the exploratory research. After having collected all the questionnaire surveys and qualitative data, the research team developed and implemented the intervention program based on the findings. The principal investigator, the Faculty of Medical Sciences, was responsible for the daily management of the data. All questionnaire forms were checked for completeness and accuracy before performing data entry. After analyzing the data from the questionnaire surveys, the research team prepared the qualitative instrument and started collecting qualitative data in two provinces, namely, Vientiane Capital City and Luang Prabang Province. 3.9. Ethical Consideration 3.9.1. Approval by a Relevant Ethical Review Board in Lao PDR The procedure for conducting this research was reviewed and approved by a Relevant Ethical Review Board for the Protection of Human Subjects in the Ethical Review Board for Research at the Faculty of Medical Sciences, Ministry of Education. All of the proposed interviewing protocols and data collection instruments were approved prior to conducting the study.

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3.9.2. Research Material to be Obtained: Several forms of data were collected such as self-reported information related to knowledge, attitudes and behavior towards smoking. 3.9.3. Privacy and Confidentiality Protections The participants were given the right to determine the extent to which they disclose their personal information in answering questions posed by data collectors and to fill the questionnaire forms themselves. A personal identification number was assigned to each participant to maintain anonymity. The identification number was used to confirm consent status and to link them to their respective recruitment place. After the final data analysis is made at the end of the study, the identification numbers were destroyed. For the in-depth interviews, the conversations were tape-recorded. All tapes were labeled with the interview identification number and date of interview. The tapes were transcribed and then destroyed. No personal identification information (e.g., name, address, etc.) were used or reported in any manuscript, so that anonymity and confidentiality of all study participants were fully protected. All study records were kept in locked file cabinets and secured computer files. Access to data was restricted to the principal investigator or research assistant to ensure that confidentiality is protected. Only aggregate data were reported and released and none of the individual names were to appear in any report or article related to the study at any time throughout the process.

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4. RESULTS 4.1. Characteristics of the Study Population Table 5 presents data on the characteristics of monks and novices by provinces. A total of 390 monks were recruited for the study with the mean age of 19.84; SD=5.47 with a minimum age of 12 and maximum age of 45. About 75.9% of the samples fall in the age group between 15-24 years with a higher proportion of monks in Vientiane who are aged >=25 years compared to those in Luang Prabang (18% versus 4.4%). More young novices are concentrated in Luang Prabang than in Vientiane (20% versus 6% respectively). Approximately 91.3% are Laoloum with a small percentage who is Lao Theung (6.7%). There are no differences in ethnicity across the provinces. While 72.6% of monks have completed secondary/high school, only 1.1% of monks in Luang Prabang completed university/postgraduate degree compared to 21.3% of monks and novices in Vientiane. About 87.2% of monks and novices received religious education with a higher proportion of monks in Luang Prabang (96.7%) having received such education compared to monks and novices in Vientiane (84.3%). As mentioned above, the main purpose of ordination is to obtain merit and to receive higher education, especially for those monks/novices who come from poor families. So, it is not surprising to find monks with higher education with 16.7% of them having attended university and postgraduate studies. The mean age for monkhood is 14.78 years, with the minimum at 8 years and maximum at 45 years. The mean duration of monkhood is 4.92 years with SD (4.07), those having been monks for one to five years (65.4%); six to ten years (24.1%); and 11 to 15 years (7.9%). There is a statistical significant difference between Vientiane and Luang Prabang in terms of duration of monkhood (P-value <0.001). Buddhist monks belong to the two main disciplines; the stricter Thammayut or Theravadha accounts for 85.1%; while the Mahanikai presents a small percentage (14.9%). The highest Thammayut monks (88.9%) are in Luang Prabang; while the highest Mahanikai monks are in Vientiane (16%) compared to Luang Prabang (11.1%). Only 37.9% of respondents surveyed were full-fledged monks with Vientiane having more full-fledged monks compared to Luang Prabang (44% versus 17.8%; P-value<0.001). Novices were more dominant in Luang Prabang compared to in Vientiane (82.2% versus 56%). Only 5.1% of the monks and novices surveyed held a hierarchical ranking with some carrying the title of Abbot and holding Administrative positions. Table 5: Characteristics of monks and novices by region

LP VTE Total No. Variable N % N % N %

1 Age ( Mean= 19.84 ; Min=12; Max=45;SD= 5.47; P value < 0.001) <= 14 yrs 18 20.0 18 6.0 36 9.2 15 – 24 yrs 68 75.6 228 76.0 296 75.9 >= 25 yrs 4 4.4 54 18.0 58 14.9 Total 90 100.0 300 100.0 390 100.0 2 Ethnicity ( P = 0.225 ) Lao loum 79 87.8 277 92.3 356 91.3

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Table 5: Characteristics of monks and novices by region LP VTE Total No. Variable N % N % N %

Lao therng 10 11.1 16 5.3 26 6.7 Lao soung 0 0.0 2 0.7 2 0.5 Others 1 1.1 5 1.7 6 1.5 Total 90 100.0 300 100.0 390 100.0 3 What is the highest level of Schooling you completed ( P < 0.001 ) Primary 15 16.7 13 4.3 28 7.2 Secondary/High school 71 78.9 212 70.7 283 72.6 Technical/Vocational 1 1.1 4 1.3 5 1.3 University/Postgraduate 1 1.1 64 21.3 65 16.7 Others 2 2.2 7 2.3 9 2.3 Total 90 100.0 300 1 390 100.0 4.1 Religious Education (P = 0.002) Yes 87 96.7 253 84.3 340 87.2 No 3 3.3 47 15.7 50 12.8 Total 90 100.0 300 100.0 390 100.0

4.2 If yes, how many years (Mean = 3.58; SD = 2.410; P = 0.003 )

1 - 2 yrs 46 52.9 88 34.8 134 39.4 3 - 4 yrs 24 27.6 83 32.8 107 31.5 5 - 6 yrs 16 18.4 53 20.9 69 20.3 7 - 15 yrs 1 1.1 29 11.5 30 8.8 Total 87 100.0 253 100.0 340 100.0 5 Age of monkhood (Mean = 14.78; Min=8; Max=45;SD = 4.41; P =0.102 ) <= 14 yrs 61 67.8 167 55.7 228 58.5 15 – 24 yrs 28 31.1 124 41.3 152 39.0 >= 25 yrs 1 1.1 9 3.0 10 2.6 Total 90 100.0 300 100.0 390 100.0 6 Duration of monkhood (Mean = 4.92; Min=0; Max=28; SD = 4.07; P < 0.001) =<5 yrs 75 83.3 180 60 255 65.4 6 – 10 yrs 11 12.2 83 27.7 94 24.1 11-15 yrs 4 4.4 27 9 31 7.9 > 15 yrs 0 0 10 3.3 10 2.6 Total 90 100.0 300 100.0 390 100.0 7 Denomination ( P = 0.253 ) Thammayut 80 88.9 252 84.0 332 85.1 Mahanikai 10 11.1 48 16.0 58 14.9 Total 90 100.0 300 100.0 390 100.0 8 Status of monks/novices (P < 0.001) Monks with full-fledged 16 17.8 132 44.0 148 37.9 Novices 74 82.2 168 56.0 242 62.1 Total 90 100.0 300 100.0 390 100.0 9 Administrative position ( P = 0.154 ) Abbot/Administrative 2 2.2 18 6.0 20 5.1 Monk/Novice 88 97.8 282 94.0 370 94.9 Total 90 100.0 300 100.0 390 100.0

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4.2. Smoking Status of Monks and Novices The smoking data is categorized into never smoke, former or ex-smoker, experimenter and current smokers. About 11.8% of those surveyed are current daily smokers and 10.3% are occasional smokers; 50.8% never smoked; and 27.2% are former or ex-smokers. The proportion of current smokers varies little across provinces. Table 6 shows the prevalence of smoking among monks and novices. Prevalence of smoking among monks in VTE and Luang Prabang based on their daily smoking was 11.8% and there is little variation between Vientiane (11.7%) and Luang Prabang provinces (12.2%). In comparison, the smoking prevalence among the general male population in Lao PDR is almost 38% (2002) and among Buddhist monks in Thailand 56% (2004) which are higher than those in the current study. Table 6: Smoking status of monks and novices by province

LP VTE Total Q.No Variable N % N % N %

1 Smoking status (P-value = 0.868) Never smoked cigarettes 46 51.1 152 50.7 198 50.8 Quit smoking 26 28.9 80 26.7 106 27.2 Smoke occasionally 7 7.8 33 11.0 40 10.3 Smoke every day 11 12.2 35 11.7 46 11.8 Total 90 100 300 100 390 100 4.3. Ex-smokers Table 7 presents the percentage distribution of ex-smokers among monks and novices according to smoking status and by province. Among 106 former or ex-smokers, 21.7% of them were daily ex-smokers. About 51.9% started smoking before monkhood and 48.1% started smoking during monkhood. The mean age of regular smoking among monks in the past was 14.92 years with the minimum age at 6 and maximum age at 24 and SD 2.98. Most of them had quit smoking between the ages of 14-21 years which comprised of 72.6%; followed by those aged less than or equal to 13 years (13%). About 44.3% reported having smoked only 1 cigarette per day; followed by those having previously smoked at least 4 cigarettes a day. Among ex-smokers, the majority of them (76.7%) used to smoke rolling tobacco occasionally; while 23.3% used to smoke daily. Most of them smoked only 1 rolling tobacco per day (60.5%). With regard to quitting smoking, about 72.1% attempted to quit smoking at age 14-21 years; followed by those in the age groups of 13 years and less. The mean age of quitting smoking was 17.07, SD 4.59 with the minimum age at 8 and maximum age at 45.

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Table 7: Smoking status of monks and novices who are ex-smokers by province


2 Ex-smoker (P-value = 0.148) Occasionally 23 88.5 60 75.0 83 78.3 Daily 3 11.5 20 25.0 23 21.7 Total 26 100 80 100 106 100

3 Number of cigarettes smoked during one day in the past (Mean = 3.03; Min=1; Max=20; SD = 3.61; P-value = 0.205)

1 c 16 61.5 31 38.8 47 44.3 2 cs 4 15.4 17 21.3 21 19.8 3 cs 3 11.5 11 13.8 14 13.2 >= 4 cs 3 11.5 21 26.3 24 22.6 Total 26 100 80 100 106 100

4.1 Age of regularly smoking in the past (Mean=14.92; Min=6; Max=24; SD= 2.98; P-value = 0.360)

<= 12 yrs 3 11.5 14 17.5 17 16.0 13 - 17 yrs 21 80.8 53 66.3 74 69.8 >= 18 yrs 2 7.7 13 16.3 15 14.2 Total 26 100 80 100 106 100 4.2 When were you tried cigarettes on regular basis (P-value = 0.001) Before monk/novices 6 23.1 49 61.3 55 51.9 During period of monks 20 76.9 31 38.8 51 48.1 Total 26 100 80 100 106 100 5 Used rolling tobacco, snuff, and other during one day in the past (P-value = 0.184) Occasionally 2 50.0 31 79.5 33 76.7 Daily 2 50.0 8 20.5 10 23.3 Total 4 100 39 100 43 100

6 Number of rolling tobacco snuff, and other (Mean=2.58; SD=3.507 ; Min=1; Max=20; P-value = 0.236)

1 c 4 100 22 56.4 26 60.5 2 cs 0 0.0 8 20.5 8 18.6 >= 3 cs 0 0.0 9 23.1 9 20.9 Total 4 100 39 100 43 100

7 Age of smoking cessation (Mean = 17.07; SD= 4.59; Min=8; Max=45; P-value = 0.529)

<= 13 yrs 3 11.5 12 15.0 15 14.2 14 - 21 yrs 21 80.8 56 70.0 77 72.6 >= 22 yrs 2 7.7 12 15.0 14 13.2 Total 26 100 80 100 106 100

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4.4. Current Smokers Table 8 shows the distribution of monks and novices who are current smokers. The majority of monks and novices started smoking on a regular basis at the age of 15-20 years (72.1%) with a mean age of 17.23; SD 3.238, with the minimum age of 10 and maximum age of 30. About 79.1% of them reported that they started smoking during the monkhood period. The length of smoking on a regular basis varied from 1 to 21 years with a mean of 5.10 years, SD 5.14. A quarter of monks and novices (25.6%) reported that they smoked for 1 year. About 24.4% smoked from 3 to 4 years and 19.8% had smoked for more than 10 years. There is no difference between provinces. Most of them smoke 1 to 3 cigarettes per day (39.5%) while 30.2% smoke 4 to 9 cigarettes per day. Five in six respondents (82.6%) reported that they had smoked 100 cigarettes so far in their life. The majority of them (88.4%) reported that they ever attempted to quit smoking for at least one week and there is no variation between provinces. When we asked how they feel about quitting smoking, 53.5% reported that they are not ready to quit smoking within the next 6 months. Those who are either thinking about quitting within 6 months or are ready to quit now accounted for 23.3% each. About one third of respondents (33.7%) reported having their first cigarette within less than 15 minutes of waking up and 41.9% had their first cigarette within less than 1 hour. Overall, monks and novices in this study have a high level of dependency on tobacco. There was little difference by provinces in terms of the level of tobacco dependency among monks and novices. Among those who are current smokers, 83.8% used rolling tobacco occasionally and 16.2% used them regularly. This who used to smoke 1 rolling tobacco cigarette per day accounted for 43.2%. A small percentage used to smoke 5 to 10 rolling cigarettes per day (10.8%). About 48.6% reported having smoked 100 rolling cigarettes in their lifetime. The reasons of starting smoking among monks and novices were peer influence (48.7%), followed by to release stress (17.6%), imitate adults (9.2%), got them free (6.7%). As can be seen, friends’ influence was responsible for almost half of all influences that triggered the initiation of smoking. When asked where they obtained the cigarettes, 44.9% said they bought their own cigarettes; while only 24.6% said the cigarettes were offered to them by other people and 23.9% reported that they got the cigarettes from fellow monks. Less than half of monks and novices (46.5%) reported that they were exposed to smokers every day (7 days within a week). Only 12.8% reported no exposure to second hand smokers within the week. The most common areas that monks and novices smoked were the temple grounds (51.2%); followed by residential areas (45.3%). A small percentage of monks and novices smoked outside the temple areas (1.2%), which was uncommon.

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Table 8: Distribution of monks and novices who are current smokers by province

LP VTE Total No Variables N % N % N %

1 Age of first trying cigarette on a regular basis (Mean= 17.23; SD= 3.238; Min=10; Max=30 (P-value = 0.201)

<= 14 yrs 4 22.2 9 13.2 13 15.1 15 - 20 yrs 10 55.6 52 76.5 62 72.1 >= 21 yrs 4 22.2 7 10.3 11 12.8 Total 18 100 68 100 86 100 2 When did you start smoking (P-value = 0.617) Before monk/novices 3 16.7 15 22.1 18 20.9 During period of monks 15 83.3 53 77.9 68 79.1 Total 18 100 68 100 86 100

3 How long did you smoke regularly (Mean= 5.10; SD= 5.14; Min=1; Max=21; P-value = 0.456)

1 y 3 16.7 19 27.9 22 25.6 2 yrs 5 27.8 9 13.2 14 16.3 3 - 4 yrs 5 27.8 16 23.5 21 24.4 5 -9 yrs 3 16.7 9 13.2 12 14.0 >=10 yrs 2 11.1 15 22.1 17 19.8 Total 18 100 68 100 86 100

4 No. of cigarettes smoked during a day (Mean=7.64; SD= 8.83; Min=1; Max=40; P-value = 0.593)

1 -3 cs 9 50.0 25 36.8 34 39.5 4 - 9 cs 4 22.2 22 32.4 26 30.2 10 - 19 cs 2 11.1 13 19.1 15 17.4 >= 20 cs 3 16.7 8 11.8 11 12.8 Total 18 100 68 100 86 100 5 Have you smoked 100 cigarettes in your life (P-value = 0.548) Yes 14 77.8 57 83.8 71 82.6 No 4 22.2 11 16.2 15 17.4 Total 18 100 68 100 86 100 6 Have you ever stopped smoking for at least 1 week (P-value = 0.939) Yes 16 88.9 60 88.2 76 88.4 No 2 11.1 8 11.8 10 11.6 Total 18 100.0 68 100.0 86 100.0 7 Feeling about quitting smoking (P-value = 0.688)

Not ready to quit smoking within next 6 mos

8 44.4 38 55.9 46 53.5

Thinking about quitting within 6 mos

5 27.8 15 22.1 20 23.3

Ready to quit now 5 27.8 15 22.1 20 23.3 Total 18 100 68 100 86 100 8 Have you used rolling tobacco, snuff, and other (P-value = 0.427)

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Occasionally 3 100 28 82.4 31 83.8 Daily 0 0.0 6 17.6 6 16.2 Total 3 100 34 100 37 100 9 Number of rolling tobacco, snuff or pipes (Mean = 2.51; SD = 2.268;P-value = 0.232) 1 c 3 100.0 13 38.2 16 43.2 2 cs 0 0.0 9 26.5 9 24.3 3 - 4 cs 0 0.0 8 23.5 8 21.6 5 - 10 cs 0 0.0 4 11.8 4 10.8 Total 3 100 34 100 37 100 10 Have you smoked 100 cigarettes in your life (P_value = 0.580) Yes 1 33.3 17 50.0 18 48.6 No 2 66.7 17 50.0 19 51.4 Total 3 100 34 100 37 100 11 How long after getting up/waking up (P-value = 0.287) < 15 mns 9 50.0 20 29.4 29 33.7 15 - 30 mns 1 5.6 6 8.8 7 8.1 < 1 hr 5 27.8 31 45.6 36 41.9 Others 3 16.7 11 16.2 14 16.3 Total 18 100.0 68 100.0 86 100.0 12 Reason for starting smoking (Multiple responses) Boredom 0 0.0 4 4.3 4 3.4 Peer 13 52.0 45 47.9 58 48.7 To experience 0 0.0 0 0.0 0 0.0 To release stress 4 16.0 17 18.1 21 17.6 To imitate adult 4 16.0 7 7.4 11 9.2 Did not buy 0 0.0 8 8.5 8 6.7 Reduce hungry 1 4.0 2 2.1 3 2.5 Others 3 12.0 11 11.7 14 11.8 Total 25 100 94 100 119 100 13 Getting cigarettes from (Multiple responses) Buy 13 56.5 49 42.6 62 44.9 Get it from people 6 26.1 28 24.3 34 24.6 Get it from fellow monk 0 0.0 33 28.7 33 23.9 Others 4 17.4 5 4.3 9 6.5 Total 23 100 115 100 138 100

14 Number of days staying among smokers (out of 7 days) (Mean = 4.44; SD = 2.675; Min=0; Max=7 ;P-value= 0.100)

0 0 0.0 11 16.7 11 12.8 1 d 1 5.6 0 0.0 1 1.1 2 ds 2 11.1 12 17.6 14 16.3 3 ds 2 11.1 9 13.2 11 12.8 4 ds 2 11.1 4 5.9 6 7.0 5 ds 0 0.0 2 2.9 2 2.3

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6 ds 1 5.6 0 0.0 1 1.2 7 ds 10 55.6 30 44.1 40 46.5 Total 18 100 68 100 86 100 15 Place smoking more often (P-value = 0.080) In residences 11 61.1 28 41.2 39 45.3 In temple area 6 33.3 38 55.9 44 51.2 Outside temple area 1 5.6 0 0.0 1 1.2 Others 0 0.0 2 2.9 2 2.3 Total 18 100 68 100 86 100 4.5. Smoking Cessation Table 9 presents the distribution of smoking cessation among monks and novices by province. When all 390 respondents were asked about their desire to quit smoking, 97.7% of them said they wanted to quit smoking and there was no variation by provinces. Also, when all respondents were asked the reason of wanting to stop smoking, a total of 40.7% mentioned that they wanted to prevent illnesses; 22.1% mentioned about illness at or before quitting and 12.8% said it’s because they saw illnesses occurring in other smokers. The main reasons cited by those who failed to quit smoking were: they didn’t know how (36%); they didn’t really want to (5.8%); however, there was little variation by provinces. Slightly more than three quarter of respondents (76.7%) reported that they ever tried to quit smoking within the last year. Less than half of them (47%) stopped smoking within less than 1 month; and 42.4% stopped smoking between 1 to 5 months. Regarding the methods used to quit smoking, the majority of them (77.3%) used weaning method and 18.2% used cold turkey method. About 65.2% received advice to quit smoking, with Luang Prabang reported having a higher percentage (81.3%) among those receiving such advice compared to Vientiane Capital City (60%). Doctors and nurses (53.8%) most frequently advised them to quit; followed by fellow monks (36.2%). Table 9: Percentage distribution of smoking cessation among monks and novices


1 Want to quit smoking (P-value = 0.458) Yes 18 100.0 66 97.1 84 97.7 No 0 0.0 2 2.9 2 2.3 Total 18 100 68 100 86 100 2 Tried to quit smoking within last year (P-value = 0.170) Yes 16 88.9 50 73.5 66 76.7 No 2 11.1 18 26.5 20 23.3 Total 18 100 68 100 86 100 3 How long did you stop smoking (P-value = 0.486)

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< 1 month 10 62.5 21 42.0 31 47.0 1 – 5 months 6 37.5 22 44.0 28 42.4 6 - 11 months 0 0.0 4 8.0 4 6.1 1 year 0 0.0 2 4.0 2 3.0 2 years or longer 0 0.0 1 2.0 1 1.5 Total 16 100 50 100 66 100 4 Methods used to quit smoking (P-value = 0.039) Cold turkey 3 18.8 5 10.0 8 18.2 Drug therapy 1 6.3 1 2.0 2 4.5 Weaning 3 18.8 31 62.0 34 77.3 others 9 56.3 13 26.0 22 50.0 Total 16 43.8 50 74.0 44 100 5.1 Received advice on quit smoking (P-value = 0.403) Yes 13 81.3 30 60.0 43 65.2 No 3 18.8 20 40.0 23 34.8 Total 16 100 50 100 66 100 5.2 Person advised to quit smoking (Multiple response) Doctor/Nurse 0 0.0 7 58.3 7 53.8 Lay people 1 5.3 12 30.8 13 22.4 Other monks 9 47.4 12 30.8 21 36.2 Media 1 5.3 3 7.7 4 6.9 Others 8 42.1 12 30.8 20 34.5 Total 19 100 39 100 58 100 6 Primary reason for quitting smoking (P-value = 0.261)

Illness (at or before time of quitting),

3 16.7 16 23.5 19 22.1

Health, but wanted to prevent illness,

6 33.3 29 42.6 35 40.7

Seeing illness develop in other smokers,

2 11.1 9 13.2 11 12.8

Family disapproval, 1 5.6 4 5.9 5 5.8

Not enough money to buy tobacco,

0 0.0 2 2.9 2 2.3

Disapproval of friends and co-workers,

0 0.0 2 2.9 2 2.3

Don’t know/refuse to answer 6 33.3 6 8.8 12 14.0 Total 18 100 68 100 86 100 7 Reason of not quitting smoking (P-value = 0.354) Don’t know how 8 44.4 23 33.8 31 36.0 Just don’t want to 0 0.0 5 7.4 5 5.8 No advice 0 0.0 5 7.4 5 5.8 Others 10 55.6 35 51.5 45 52.3 Total 18 100 68 100 86 100

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4.6. Predisposing Factors 4.6.1. Understanding of the Health Effects of Smoking Table 10 presents the percentage distribution of knowledge about the health effects of smoking by province. Most monks, however, have high understanding of the specific detrimental effects that smoking has on health, as well as the effects of second hand smoke. However, few of them did not know about the rules in religious places as well as smoking law and the fatality of diseases related to tobacco. Slightly less than half (43.8%) knew about smoking rules in the religious places which varied by province. Monks and novices from Vientiane Capital City were more likely to report that they knew the temple’s smoking rules than those in Luang Prabang (48% versus 30%). Among the respondents surveyed, only slightly more than half (50.8%) knew that there was a law banning smoking in religious places. Furthermore, slightly more than half (51.5%) knew that smoking is more likely to cause fatality compared to illegal drugs, AIDS and accidents; with monks and novices from Luang Prabang being more aware of fatalities related to smoking than those in Vientiane Capital City (P-value=.001). The majority of monks and novices knew the harmful effects of smoking on health. Eighty one percent of monks and novices knew that people can get addicted to cigarette like they would to cocaine or heroine but this vary by province. Monks and novices from Luang Prabang province are more likely to be aware of the addictive dangers of nicotine than monks and novices from Vientiane Municipality (P-value-0.013). About 96.9% knew that smoking increases the risk of lung diseases while 86.4% reported that smoking increases the risk of heart diseases. Furthermore, they also knew about the effects of passive smoking, for example, passive smoking increases the risk of lung diseases (96.2%) and heart disease (85.1%). There is a statistical significant difference between Luang Prabang and Vientiane Capital City in terms of knowledge of passive smoking related to heart diseases (P-value=.005). Overall, monks and novices in this study have a high knowledge and understanding of these risks. Table 10: Knowledge about the health effects of smoking among monks and novices by province No. Variables LPB VTE Total N % N % N % 1 Smoking is harmful (P-value- = 0.437 ) Yes 90 100.0 298 99.3 388 99.5 No 0 0.0 2 0.7 2 0.5 Total 90 100 300 100 390 100 2 Nicotine in tobacco is highly addictive (P-value- = 0.324) Yes 81 90.0 258 86.0 339 86.9 No 9 10.0 42 14.0 51 13.1 Total 90 100 300 100 390 100%

3 People can get addicted to cigarette like they can get addicted to cocaine or heroine (P-value- ) = 0.013

Yes 81 90.0 235 78.3 316 81.0 No 9 10.0 65 21.7 74 19.0

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No. Variables LPB VTE Total N % N % N % Total 90 100 300 100 390 100

4 Passive smoking increases the risk of heart disease in non-smoking adults (P-value- = 0.005)

Yes 85 94.4 247 82.3 332 85.1 No 5 5.6 53 17.7 58 14.9 Total 90 100 300 100 390 100%

5 Passive smoking increases the risk of lung diseases in non-smoking adults (P-value=0.336)

Yes 85 94.4 290 96.7 375 96.2 No 5 5.6 10 3.3 15 3.8 Total 90 100.0 300 100.0 390 100.0 6 Smoking increases the risk of heart diseases (P-value= 0.067) Yes 83 92.2 254 84.7 337 86.4 No 7 7.8 46 15.3 53 13.6 Total 90 100.0 300 100.0 390 100.0 7 Smoking increases the risk of LRI (P-value= 0.054) Yes 90 100.0 288 96.0 378 96.9 No 0 0.0 12 4.0 12 3.1 Total 90 100.0 300 100.0 390 100.0

8 Tobacco kills more people each year than illegal drugs, AIDS & car crash (P-value= 0.011)

Yes 57 63.3 144 48.0 201 51.5 No 33 36.7 156 52.0 189 48.5 Total 90 100.0 300 100.0 390 100.0 9 Quit smoking reduces risk (P-value- = 0.696) Yes 88 97.8 291 97.0 379 97.2 No 2 2.2 9 3.0 11 2.8 Total 90 100.0 300 100.0 390 100.0 10 Know about smoking law in religious places (P-value= 0.037) Yes 37 41.1 161 53.7 198 50.8 No 53 58.9 139 46.3 192 49.2 Total 90 100.0 300 100.0 390 100.0 11 Know their temple's smoking rule (P-value= 0.003) Yes 27 30.0 144 48.0 171 43.8 No 63 70.0 156 52.0 219 56.2 Total 90 100.0 300 100.0 390 100.0

12 Smoke from cigarettes is harmful to people who are repeatedly exposed (P-value= 0.236)

Yes 85 94.4 286 95.3 371 95.1 No 5 5.6 14 4.7 19 4.9 Total 90 100.0 300 100.0 390 100.0

Table 11 presents the percentage distribution of knowledge about the health effects of smoking by smoking status. Former smokers or those who ever smoked represented the largest group (84.9%) who knew that people could get addicted to cigarettes like they would to cocaine or heroine; while never/experimenter smokers (81.9%) knew

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more than current smokers (61.4%) about the addictive element of smoking and the difference is statistically significant (P-value=.035). Former smokers were more aware that passive smoking increases the risk of heart diseases in non-smoking than never/experimenter and current smokers (94.3% versus 82.8% and 76.1%; P-value= 0.004 respectively). Table 11: Monk's and novice knowledge about the health effect of smoking by smoking status

No. Variables Current

Former

Never/ Experimenter

Total

N % N % N % N % 1 Smoking is harmful (P-value= 0.215 ) Yes 45 97.8 106 100.0 237 99.6 388 99.5 No 1 2.2 0 - 1 0.5 2 0.5 Total 46 100.0 106 100.0 238 100.0 390 100.0 2 Nicotine in tobacco is highly addictive (P-value= 0.160) Yes 36 78.3 92 86.8 211 88.7 339 86.9 No 10 21.7 14 13.2 27 11.3 51 13.1 Total 46 100.0 106 100.0 238 100.0 390 100.0

3 People can get addicted to cigarette like they can get addicted to cocaine or heroine (P-value = 0.035)

Yes 31 61.4 90 84.9 195 81.9 316 81.0 No 15 32.6 16 15.1 43 18.1 74 19.0 Total 46 100.0 106 100.0 238 100.0 390 100.0

4 Passive smoking increases the risk of heart disease in non-smoking adults (P-value= 0.004)

Yes 35 76.1 100 94.3 197 82.8 332 85.1 No 11 23.9 6 5.7 41 17.2 58 14.9 Total 46 100.0 106 100.0 238 100.0 390 100.0

5 Passive smoking increases the risk of lung diseases in non-smoking adults (P-value- = 0.355)

Yes 43 93.5 104 98.1 228 95.8 375 96.2 No 3 6.5 2 1.9 10 4.2 15 3.8 Total 46 100.0 106 100.0 238 100.0 390 100.0 6 Smoking increases the risk of heart diseases (P-value= 0.309) Yes 37 80.4 95 89.6 205 86.1 337 86.4 No 9 19.6 11 10.4 33 13.9 53 13.6 Total 46 100.0 106 100.0 238 100.0 390 100.0 7 Smoking increases the risk of LRI (P-value- = 0.716) Yes 44 95.7 102 96.2 232 97.5 378 96.9 No 2 4.3 4 3.8 6 2.5 12 3.1 Total 46 100.0 106 100.0 238 100.0 390 100.0

8 Tobacco kills more people each year than illegal drugs, AIDS & car crash (P-value= 0.457)

Yes 22 47.8 60 56.6 119 50.0 201 51.5 No 24 52.2 46 43.4 119 50.0 189 48.5

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No. Variables Current

Former

Never/ Experimenter

Total

N % N % N % N % Total 46 100.0 106 100.0 238 100.0 390 100.0 9 Quit smoking reduces risk (P-value= 0.718) Yes 45 97.8 104 98.1 230 96.6 379 97.2 No 1 2.2 2 1.9 8 3.4 11 2.8 Total 46 100.0 106 100.0 238 100.0 390 100.0 10 Know about smoking law in religious places (P-value= 0.632) Yes 23 50.0 58 54.7 117 49.2 198 50.8 No 23 50.0 48 45.3 121 50.8 192 49.2 Total 46 100.0 106 100.0 238 100.0 390 100.0 11 Know their temple's smoking rule (P-value= 0.303) Yes 22 41.8 52 49.1 97 40.8 171 43.8 No 24 52.2 54 50.9 141 59.2 219 56.2 Total 46 100.0 106 100.0 238 100.0 390 100.0

12 Smoke from cigarettes is harmful to people who are repeatedly exposed (P-value= 0.976)

Yes 44 95.7 101 95.3 226 95.0 371 95.1 No 2 4.3 5 4.7 12 5.0 19 4.9 Total 46 100.0 106 100.0 238 100.0 390 100.0 4.6.2. Attitudes Regarding Smoking Among Monks Tables 12 and 13 show the percentage distribution of monks’ and novices’ attitudes toward smoking by province and smoking status. Slightly higher than half of monks (63.3%) strongly agreed that smoking in all enclosed public places should be banned; while smaller percentages either disagreed or strongly disagreed [7.4% and 1.5%, respectively (P=.018)]. However, most of them (88.9%) felt that smoking should be banned in the temples. The percentage of monks who agreed that smoking in all enclosed public places should be banned was higher among current smokers (73.9%) compared to former smokers (60.4%) and never/experimenter smokers (62.6%) (P-value= .635). Only less than one quarter (23.8%) of monks strongly agreed that offering tobacco to monks should be prohibited; while a small percentage (9.2%) strongly agreed that monks should refuse cigarettes offered to them. About 21% of them mentioned they agreed that monks should refuse cigarettes offered to them with no variation between the provinces. More current smokers (30.4%) felt that offering tobacco to monks should be prohibited when compared to never smokers (23.9%) and former smokers (20.8%); however, the difference was not statistically significant. Approximately 89.8% felt that the public respects monks who do not smoke more than those who smoke and about 64.6% mentioned that monks who smoke are not accepted by the public. More of the never/experimenter smokers (42%) agreed to the latter statement than current smokers (41.3%) and former smokers (37.7%). A high percentage of monks (80.6%) strongly agreed that a campaign should be launched to urge the public not to offer cigarettes to monks and 94.6% of them either strongly

27

agreed or agreed to have a project on quit smoking for monks. More former smokers (29.2%) strongly agreed to have a public campaign to discourage the offering of cigarettes to monks compared to never smokers (25.6%) and current smokers (21.7%). However, 65.2% of current smokers felt that there should be a project on quit smoking or smoking cessation for monks/novices who smoke while 50% of former and non-smokers support this idea (P-value.356). Overall, the majority of monks supported the following opinions: smoking to be disallowed in all enclosed public places, including in temples; not to respect smoking among monks; advise people to quit smoking and campaign not to offer cigarettes to monks; however, they were less likely to agree with the prohibition on the offering of tobacco to monks and that monks should refuse cigarettes offered to them. This could be explained by the desire of the general public to gain merit by offering alms to their ancestors. It is believed that if the monks refuse their alms (in the form of cigarettes), this could mean that their ancestors would not receive the merit. Also, according to the Lao custom and tradition, it is impolite and disrespectful for the monks to refuse offers presented to them. Former smokers hold more negative attitudes towards smoking than never/experimenter smokers and current smokers. Table 12: Monk's and novice's attitudes towards tobacco use by province No Variables LPB VTE Total N % N % N % 1 Smoking in all enclosed public places should be banned (P-value=.018) Strongly agree 48 53.3 199 66.3 247 63.3 Agree 36 40.0 72 24.0 108 27.7 Disagree 4 4.4 25 8.3 29 7.4 Strongly disagree 2 2.2 4 1.3 6 1.5 Total 90 100.0 300 100.0 390 100.0 2 Smoking should be banned at the temples (P-value= .151 ) Strongly agree 32 35.6 124 41.3 156 40.0 Agree 48 53.3 127 42.3 175 44.9 Disagree 7 7.8 43 14.3 50 12.8 Strongly disagree 3 3.3 6 2.0 9 2.3 Total 90 100.0 300 100.0 390 100.0 3 Offering tobacco to monks should be prohibited (P-value= .088) Strongly agree 26 28.9 67 22.3 93 23.8 Agree 37 41.1 135 45.0 172 44.1 Disagree 18 20.0 82 27.3 100 25.6 Strongly disagree 9 10.0 16 5.3 25 6.4 Total 90 100.0 300 100.0 390 100.0 4 Monks should refuse cigarettes offered to them (P-value=. 882) Strongly agree 13 14.4 23 7.7 36 9.2 Agree 23 25.6 59 19.7 82 21.0 Disagree 41 45.6 174 58.0 215 55.1 Strongly disagree 13 14.4 44 14.7 57 14.6 Total 90 100.0 300 100.0 390 100.0 5 If monks don’t smoke, people would respect them more (P-value= .882)

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No Variables LPB VTE Total N % N % N % Strongly agree 36 40.0 123 41.0 159 40.8 Agree 46 51.1 145 48.3 191 49.0 Disagree 7 7.8 30 10.0 37 9.5 Strongly disagree 1 1.1 2 0.7 3 0.8 Total 90 100.0 300 100.0 390 100.0 6 Monks should routinely advise people to quit smoking (P-value= .402) Strongly agree 39 43.3 154 51.3 193 49.5 Agree 42 46.7 128 42.7 170 43.6 Disagree 8 8.9 15 5.0 23 5.9 Strongly disagree 1 1.1 3 1.0 4 1.0 Total 90 100.0 300 100.0 390 100.0

7 There should be a campaign to stop the public from offering cigarettes to monks (P-value= .367)

Strongly agree 26 28.9 76 25.3 102 26.2 Agree 43 47.8 169 56.3 212 54.4 Disagree 18 20.0 51 17.0 69 17.7 Strongly disagree 3 3.3 4 1.3 7 1.8 Total 90 100.0 300 100.0 390 100.0 8 There should be a project to stop smoking among monks/novices (P-value= .185) Strongly agree 50 55.6 152 50.7 202 51.8 Agree 32 35.6 135 45.0 167 42.8 Disagree 6 6.7 11 3.7 17 4.4 Strongly disagree 2 2.2 2 0.7 4 1.0 Total 90 100.0 300 100.0 390 100.0 9 People did not accept monks who smoke (smoking monks (P value.144) Strongly agree 18 20.0 32 10.7 50 12.8 Agree 43 47.8 159 53.0 202 51.8 Disagree 25 27.8 95 31.7 120 30.8 Strongly disagree 4 4.4 14 4.7 18 4.6 Total 90 100.0 300 100.0 390 100.0

10 Monks who use tobacco are less likely to advise people to stop smoking (P-value= .304)

Strongly agree 16 17.8 47 15.7 63 16.2 Agree 56 62.2 163 54.3 219 56.2 Disagree 16 17.8 83 27.7 99 25.4 Strongly disagree 2 2.2 7 2.3 9 2.3 Total 90 100.0 300 100.0 390 100.0

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Table 13: Monk's and novice's attitudes towards tobacco use by region and smoking status

No Variables Current Former Never/ Experimenter Total

N % N % N % N % 1 Smoking in all enclosed public places should be banned (P-value= .635) Strongly

agree 34 73.9 64 60.4 149 62.6 247 63.3

Agree 10 21.7 31 29.2 67 28.2 108 27.7 Disagree 2 4.3 10 9.4 17 7.1 29 7.4 Strongly

disagree 0 0 1 0.9 5 2.1 6 1.5

Total 46 100.0 106 100.0 238 100.0 390 100.0

2 Smoking should be banned at the temples (P-value= .355) Strongly

agree 15 32.6 37 34.9 104 43.7 156 40.0

Agree 20 43.5 51 48.1 104 43.7 175 44.9 Agree 10 21.2 15 14.2 25 10.5 50 12.8 Agree 1 2.2 3 2.8 5 2.1 9 2.3 Total 46 100.0 106 100.0 238 100.0 390 100.0 3 Offering tobacco to monks should be prohibited (P-value= .189) Strongly

agree 14 30.4 22 20.8 57 23.9 93 23.8


disagree 6 13 3 2.8 16 6.7 25 6.4

Total 46 100.0 106 100.0 238 100.0 390 100.0 4 Monks should refuse cigarettes offered to them (P-value= .092) Strongly

agree 3 6.5 9 8.5 24 10.1 36 9.2


disagree 13 28.3 9 8.5 35 14.7 57 14.6

Total 46 100.0 106 100.0 238 100.0 390 100.0 5 If monks don’t smoke, people would respect more (P-value= .268) Strongly

agree 19 41.3 40 37.7 100 42.0 159 40.8

Agree 23 50 60 56.6 108 45.4 191 49.0 Disagree 3 6.5 6 5.7 28 11.8 37 9.5 Strongly

disagree 1 2.2 0 0 2 0.8 3 0.8

Total 46 100.0 106 100.0 238 100.0 390 100.0 6 Monks should routinely advise people to quit smoking (P-value= .624) Strongly 24 52.2 50 47.2 119 51.3 193 49.5

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No Variables Current Former Never/ Experimenter Total

N % N % N % N % agree


disagree 0 0 0 - 4 1.7 4 1.0

Total 85 100.0 106 100.0 238 100.0 390 100.0

7 There should be a campaign to urge the public not to offer cigarettes to monks (P-value= .802)

Strongly agree

10 21.7 31 29.2 61 25.6 102 26.2


disagree 2 4.3 1 0.9 4 1.7 7 1.8

Total 46 100.0 106 100.0 238 100.0 390 100.0

8 There should be a project on quit smoking or smoking cessation for monks/novices who smoke (P-value= .356)

Strongly agree

30 65.2 53 50.0 119 50.0 202 51.8


disagree 0 0 0 - 4 1.7 4 1.0

Total 46 100.0 106 100.0 238 100.0 390 100.0 9 People did not accept monks who smoke (smoking monks) (P-value= .074) Strongly

agree 4 8.7 8 7.5 38 16.0 50 12.8


disagree 4 8.7 6 5.7 8 3.4 18 4.6

Total 46 100.0 106 100.0 238 100.0 390 100.0 10 Monks who use tobacco are less likely to advise people to stop smoking (P-value= .326) Strongly

agree 10 21.7 12 11.3 41 17.2 63 16.2


disagree 0 0 4 3.8 5 2.1 9 2.3

Total 46 100.0 106 100.0 238 100.0 390 100.0 4.7. Enabling Factors (Accessibility, Availability, and Policy) Tables 14 and 15 present the percentage distribution of monk’s and novice’s practice by province and smoking status. The majority of monks (74.9%) said that there was

31

no smoke-free policy in place at their temples. Monks in Luang Prabang were more likely to suggest that there is no smoke-free policy than monks in Vientiane (P-value= .018). However, some abbots have instituted regulations on smoking in their temples by prohibiting smoking in the premises, such as within the buildings in the temples, and in the public areas. Approximately 61.3% suggested that the abbots did not allow smoking in any public areas or common areas; more monks in Luang Prabang (70%) suggested that the temple has a smoking policy for indoors and common areas than monks in Vientiane (58.7%). Based on smoking status, current smokers (84.8%) were more likely to suggest that smoke-free policy is in place at the temple than non-smoker (73.9%) and former smokers (72.6%) (P-value= .248). A small percentage of monks (6.2%) received training on smoking cessation; while monks from Luang Prabang (7.8%) are more likely to receive training than monks in Vientiane (5.7%). Based on smoking status, there were no statistically significant differences among current, former and non-smokers (P-value=.968). Approximately 12.6% of monks reported that they ever preached about the effect of smoking, while 10.8% said they ever preached about quitting smoking to people in the last 30 days. There was a significant difference between provinces with a higher proportion of monks in Vientiane ever preached about the effect of smoking on health as well as about quitting smoking than monks in Luang Prabang (14.7% vs 5.6% respectively, P-value=.028 for preaching about the effects of smoking on health and 12.7% vs 4.4% respectively for preaching about quitting smoking). There was no statistically significant difference between ever preached about smoking and quitting smoking among current, former and non-smokers (P-value=.071 and P-value=.223 respectively). About one third of monks (30%) reported that they received cigarettes from the public in the past 30 days with a higher proportion reported among monks in Vientiane than in Luang Prabang (36.7% versus 7.8%, P-value=.032). About 36.9% of monks have advised the public on quitting smoking and there was a substantial difference by province. Monks in Vientiane are more likely to advise the public to quit smoking than monks in Luang Prabang (38.7% versus 31.1%, P-value<.000). Former smokers (34.9%) were more likely to receive free cigarettes offered by the public compared to current (34.8%) and non-smokers (26.9%). Table 14 : Monk's and novice's practice at temple by region No Variables LPB VTE

Total

N % N % N % 1 Smoke-free policy in place at the temple (P value.072) No smoking policy 74 82.2 218 72.7 292 74.9 No smoking allowed at all in

the premises 16 17.8 82 27.3 98 25.1

Total 90 100.0 300 100.0 390 100.0 2 Temple smoking policy for indoor public or common areas (P value.054) Not allowed in any public or

common area 63 70.0 176 58.7 239 61.3

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Table 14 : Monk's and novice's practice at temple by region No Variables LPB VTE

Total

N % N % N % Allowed in some public or

common area 0 0 17 5.7 17 4.4

Allowed in all public or common area

0 0 2 0.67 2 0.51

No official policy 27 30.0 105 35.0 132 33.8 Total 90 100.0 300 100.0 390 100.0 3 Received formal training on smoking cessation approaches (P value=.458) Yes 7 7.8 17 5.7 24 6.2 No 83 92.2 283 94.3 366 93.8 Total 90 100.0 300 100.0 390 100.0

4 Ever preached about the effect of smoking to people during the past 30 days (P-value=.028)

Yes 5 5.6 44 14.7 49 12.6 No 85 94.4 256 85.3 341 87.4 Total 90 100.0 300 100.0 390 100.0

5 Ever preached about quitting smoking to people during the past 30 days (P-value=.032)

Yes 4 4.4 38 12.7 42 10.8 No 86 95.6 262 87.3 348 89.2 Total 90 100.0 300 100.0 390 100.0

6

Ever received cigarettes offered by nuns or general population during the past 30 days (P-value=.032)

Yes 7 7.8 110 36.7 117 30.0 No 83 92.2 190 63.3 273 70.0 Total 90 100.0 300 100.0 390 100.0 7 Ever advised people to quit smoking (P-value<.001) Yes 28 31.1 116 38.7 144 36.9 No 62 68.9 184 61.3 246 63.1 Total 90 100.0 300 100.0 390 100.0

Table 15: Monk's and novice's practice at temple by smoking status No Variables Current Former Never Total N % N % N % N % 1 Smoke free policy in place at the temple (P value.248) No smoking

policy 39 84.8 77 72.6 176 73.9 292 74.9

No smoking allowing at all in the premises

7 20.0 29 27.4 52 26.1 98 25.1

Total 46 100.0 106 100.0 238 100.0 390 100.0 2 Temple smoking policy for indoor public or common areas (P value.245)

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Table 15: Monk's and novice's practice at temple by smoking status No Variables Current Former Never Total N % N % N % N % Not allowed in

any public or common area

28 60.9 56 52.8 155 65.1 239 61.3

Allowed in some public or common area

4 8.7 4 3.8 9 3.8 17 4.4

Allowed in all public or common area

0 0 1 0.94 0 - 2 0.51

No official policy

14 30.1 45 42.5 73 30.7 132 33.8

Total 46 100.0 106 100.0 238 100.0 390 100.0 3 Received formal training on smoking cessation approaches (P value.968) Yes 3 12.5 6 5.66 15 6.3 24 6.15 No 43 93.5 100 94.3 223 93.7 366 93.8 Total 46 100.0 106 100.0 238 100.0 390 100.0 4 Ever peached about the effect of smoking to people during the past 30 days (P

value.071) Yes 5 10.9 20 18.87 24 10.1 49 12.56 No 41 89.1 86 81.1 214 89.9 341 87.4 Total 46 100.0 106 100.0 238 100.0 390 100.0 5 Ever preached about quitting smoking to people during the past 30 days (P

value.223) Yes 5 10.9 16 15.09 21 8.8 42 10.77 No 41 89.1 90 84.9 217 91.2 348 89.2 Total 46 100.0 106 100.0 238 100.0 390 100.0 6 Ever received cigarette offered by nuns or general population during the past

30 days (P value.245) Yes 16 34.8 37 34.9 64 26.9 117 30.00 No 30 65.2 69 65.1 174 73.1 273 70.0 Total 46 100.0 106 100.0 238 100.0 390 100.0 7 Ever advised people to quit smoking (P value.385) Yes 16 34.8 45 42.45 83 34.9 144 36.9 No 30 65.2 61 57.5 155 65.1 246 63.1 Total 46 100.0 106 100.0 238 100.0 390 100.0 4.8. Reinforcing Factors 4.8.1. Family Member who Smoke Table 16 illustrates the percentage of family member who smoke by province. Approximately 71.5% of the monks and novices surveyed had at least one family member who smokes and there is little variation among the provinces. About 61.3% of them said that their fathers smoke while 21.5% suggested that their brothers smoked. It is interesting to note that a small percentage of respondents (2.2%) said

34

that their mothers smoke. About 13.8% of monks and novices mentioned that the general public offered them cigarettes regularly. There is a great difference between the provinces with Vientiane Capital City reported having a higher percentage of monks (17.7%) who were offered cigarettes by the public compared to those in Luang Prabang (1.1%). Table 16: Family member smoking by province

LP VTE Total No Variable N % N % N %

110.1 Family member smoking ( P = 0.667 ) Yes 66 73.3 213 71.0 279 71.5 No 24 26.7 87 29.0 111 28.5 Total 90 100.0 300 100.0 390 100.0 110.2 If yes, who are they ( P = 0.740 ) Brother 14 21.2 46 21.6 60 21.5 Father 43 65.2 128 60.1 171 61.3 Father, brother 6 9.1 25 11.7 31 11.1 Father, mother 2 3.0 4 1.9 6 2.2 Grandparent 1 1.5 4 1.9 5 1.8 Mother 0 0.0 6 2.8 6 2.2 Total 66 100.0 213 100.0 279 100.0 111 Public offer of cigarettes to monks (P < 0.001) Yes 1 1.1 53 17.7 54 13.8 No 89 98.9 247 82.3 336 86.2 Total 90 100.0 300 100.0 390 100.0

4.9. Intention to Participate in the Tobacco Control Programs Tables 17 and 18 present the percentage distribution of monk’s and novice’s intention to participate in tobacco control by province and smoking status. The majority of monks and novices agreed that tobacco control training should be integrated into the training curriculum for pre-monks (88.5%) and that monks should get specific training on smoking cessation. There was no variation between a monk’s smoking status and integrating tobacco control in the training curriculum. In terms of advising the public to quit smoking, most respondents reported that monks should advise the public not to smoke (94.9%) or to use other products (81.3%). Almost all of them (91.5%) agreed that their advice has resulted in an increased chance of people quitting smoking. However, there was no statistical significant difference between monk’s smoking status and advice to quit smoking. In terms of the monk’s role, most respondents believed that monks should serve as “role models” in participating in and implementing smoke free initiatives in the temples (94.9%) and should also serve as “smoke free life role models” (93.8%). This was followed by the belief that monks should serve as “role models” in advocating the abbots in advancing tobacco control policies (86.7%). There was significant differences between smoking status and the statements about monks as “role models”

35

in participating in and implementing smoke free temples (p=.023) and that monks should be “smoke free life role models” for the public (p=.048). Table 17: Percentage distribution of monk’s and novice’s intention to participate in Tobacco Control by province No Variables LPB VTE Total N % N % N %

1 Should tobacco control training be integrated into training curriculum for pre-monks? (P-value=.092)

Yes 75 83.3 270 90.0 345 88.5 No 15 16.7 30 10.0 45 11.5 Total 90 100.0 300 100.0 390 100.0 2 Should monks get specific training on cessation techniques? (P-value=.424) Yes 84 93.3 286 95.3 370 94.9 No 6 6.7 14 4.7 20 5.1 Total 90 100.0 300 100.0 390 100.0

3 Should monks routinely advise people who smoke to quit smoking? (P-value=.097)

Yes 82 91.1 288 96.0 370 94.9 No 8 8.9 12 4.0 20 5.1 Total 90 100.0 300 100.0 390 100.0

4 Should monks routinely advise people who use other tobacco products to quit using these products? (P-value=.089)

Yes 79 87.8 238 79.3 317 81.3 No 11 12.2 62 20.7 73 18.7 Total 90 100.0 300 100.0 390 100.0

5 Are people’s chances of quitting smoking increased if monks advise him or her to quit? (P-value=.666)

Yes 84 93.3 273 91.0 357 91.5 No 6 6.7 27 9.0 33 8.5 Total 90 100.0 300 100.0 390 100.0

6 Should monks serve as “role models” in participating in and implementing smoke free temples? (P-value=.097)

Yes 82 91.1 288 96.0 370 94.9 No 8 8.9 12 4.0 20 5.1 Total 90 100.0 300 100.0 390 100.0

7 Should monks serve as “smoke free life role models" for the public? (P-value=.129)

Yes 81 90.0 285 95.0 366 93.8 No 9 10.0 15 5.0 24 6.2 Total 90 100.0 300 100.0 390 100.0

8 Should monks serve as “role models” in advocating the abbots in advancing tobacco control policy? (P-value=.000)

Yes 64 71.1 274 91.3 338 86.7 No 26 28.9 26 8.7 52 13.3 Total 90 100.0 300 100.0 390 100.0

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Table 18: Percentage distribution of monk’s and novice’s intention to participate in Tobacco Control by smoking status. No Variables Current Former Never Total N % N % N % N %

1

Should tobacco control training be integrated into training curriculum for pre-monks? (P-value= .820 )

Yes 41 89.1 92 86.8 212 89.1 345 88.5 No 5 10.9 14 13.2 26 10.9 45 11.5 Total 46 100 106 100 238 100 390 100 2 Should monks get specific training on cessation techniques? (P-value= .221 ) Yes 46 100 99 93.4 225 94.5 370 94.9 No 0 0 7 6.6 13 5.5 20 5.1 Total 46 100 106 100 238 100 390 100 3 Should monks routinely advise people who smoke to quit smoking? (P-value= .894) Yes 43 93.5 101 95.3 226 95.0 370 94.9 No 3 6.5 5 4.7 12 5 20 5.1 Total 46 100 106 100 238 100 390 100

4 Should monks routinely advise people who use other tobacco products to quit using these products? (P-value= .653 )

Yes 38 82.6 83 78.3 196 82.4 317 81.3 No 73 18.7 Total 46 100 106 100 238 100 390 100

5 Are people’s chances of quitting smoking increased if monks advise him or her to quit? (P-value= .838)

Yes 43 93.5 96 90.6 218 91.6 357 91.5 No 3 6.5 10 9.4 29 8.4 33 8.5 Total 46 100 106 100 238 100 390 100 6 Should monks serve as “role models” in participating in and implementing smoke

free temples? (P-value= .023 ) Yes 40 87.0 100 94.3 230 96.6 370 94.9 No 6 13.0 6 5.7 8 3.4 20 5.1 Total 46 100 106 100 238 100 390 100 7 Should monks serve as “smoke free life role models" for the public? (P-value= .048 ) Yes 41 89.1 96 90.6 229 96.2 366 93.8 No 5 10.9 10 9.4 9 3.8 24 6.2 Total 46 100 106 100 238 100 390 100

8 Should monks serve as “role models” in advocating the abbots in advancing tobacco control policy? (P-value= .682)

Yes 38 82.6 92 86.8 208 87.4 338 86.7 No 8 17.4 14 13.2 30 12.6 52 13.3 Total 46 100 106 100 238 100 390 100

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4.10. Factors Related to Smoking Among Monks Tables 19 and 20 present the association of factors related to smoking status among monks. Among factors related to smoking, age was associated significantly with smoking status among monks (P<.001). It is indicated that younger monks are more likely to smoke than older monks. In other words, we can say that the likelihood of smoking among monks decreases with age. Monks between the ages of 15-24 years were more likely to smoke compared to monks in the other age groups (P-value=.005). Age at monkhood or ordination is significantly positively associated with the likelihood of smoking. It is interesting to note that ethnicity was associated with a monk’s smoking status. Monks from Lao loum ethnic group were more likely to smoke compared to monks from other ethnic groups. Status of monks/novices was statistically significantly associated with monks’ smoking. Full-fledged monks were more likely to smoke compared to novices (63% versus 34.6%; P-value<.001). The administrative position was not correlated with smoking status. Duration in monkhood was positively associated with current smokers (P-value=.0016). Those who have been monks for longer than 5 years were more likely to smoke in comparison with monks who have spent less than 5 years in the monkhood (54.3% versus 45.7%; P-value=.016). The duration spent on religious education was negatively correlated with smoking status among monks. Monks with less than a year’s education in religion were more likely to smoke than monks who have spent more years in religious education (P-value=.006). Knowledge on smoking among monks was assessed in dichotomous (1=yes and 0=no). To gauge their knowledge on smoking and health, a high score would be given to indicate a high knowledge and a low score to denote low knowledge. Attitudes toward smoking were assessed from answers with ordinal scale which ranged from 1 (Strongly disagree) to 4 (strongly agree). Smokers were more likely to have low knowledge than non-smokers (mean of .813 vs .773; p=.041) (Table 20). Similarly, questions on attitudes were summed together with higher scores to denote positive attitudes and lower scores to indicate negative attitudes toward smoking; however, there was no statistically significant difference between smoking status and attitudes toward smoking. Overall, monks’ smoking behaviors were significantly negatively associated with age and years of religious education; positively correlated with ethnicity, age at monkhood, status of monks (full-fledged/ novices), duration of monkhood and lower knowledge of the health effects of smoking. Table 19: Factors related to smoking status among monks

Non-Smokers Smokers Total No Variable N % N % N %

101 Age ( Mean= 19.87 ; SD= 5.63; P value < 0.001) 12 – 24 yrs 303 88.1 29 63.0 296 75.9 25 – 45 yrs 41 11.9 17 37.0 58 14.9 Total 344 100.0 46 100.0 390 100.0

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Table 19: Factors related to smoking status among monks Non-Smokers Smokers Total No Variable N % N % N %

102 Ethnicity ( P = 0.01 ) Lao loum 317 92.2 39 84.8 356 91.3 Lao theung 22 6.4 4 8.7 26 6.7 Lao soung 0 - 2 4.3 2 0.5 Others 5 1.5 1 2.2 6 1.5 Total 344 100.0 46 100.0 390 100.0 103 What is the highest level of schooling obtained (P-value= 0.171 ) Primary/High school 278 80.8 33 71.7 311 79.7 Vocational/University 66 19.2 13 28.3 79 20.3 Total 344 100.0 46 100.0 390 100.0 104 Age of monkhood (Mean = 14.78; SD = 4.44; P-value =0.017 ) <14 years old 210 61.0 18 39.1 228 58.5 > 15 - 24years old 126 36.6 26 56.5 152 39.0 >25 years old 8 2.3 2 4.3 10 2.5 Total 336 100.0 46 100.0 380 100.0 105 Denomination ( P-value = 0.376 ) Thammayut 295 85.8 37 80.4 332 85.1 Mahanikai 49 14.2 9 19.6 58 14.9 Total 344 100.0 46 100.0 390 100.0 106 Status of monks/novices (P < 0.001) Full fledged monks 119 34.6 29 63.0 148 37.9 Novices 225 65.4 17 37.0 242 62.1 Total 344 100.0 46 100.0 390 100.0 108 Administrative position ( P-value = 0.073 ) Abbot/Administrative 15 4.4 5 10.9 20 5.1 Monk/Novice 329 95.6 41 89.1 370 94.9 Total 344 100.0 46 100.0 390 100.0 109 Duration of monkhood ( Mean = 4.92; SD = 4.07; P-value =0.016) <= 5 yrs 234 68.0 21 45.7 255 65.4 > 5 yrs 110 32.0 25 54.3 135 34.6 Total 344 100.0 46 100.0 390 100.0 110 Religious education (P = 0.159) Yes 303 88.1 37 80.4 340 87.2 No 41 11.9 9 19.6 50 12.8 Total 344 100.0 46 100.0 390 100.0 110 If yes, how many years (Mean = 3.58; SD = 2.410; P-value = 0.006 ) 1 - 2 yrs 54 33.1 80 45.2 134 39.4 3 - 4 yrs 47 28.8 60 33.9 107 31.5 5 - 6 yrs 43 26.4 26 14.7 69 20.3 7 - 15 yrs 19 11.7 11 6.2 30 8.8 Total 163 100.0 177 100.0 340 100.0 111 Family members who smoke ( P-value = 0.303 ) Yes 249 72.4 30 65.2 279 71.5 No 95 27.6 16 34.8 111 28.5

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Table 19: Factors related to smoking status among monks Non-Smokers Smokers Total No Variable N % N % N %

Total 344 100.0 46 206.2 390 208.8 112 Public afford cigarettes to monks (P-value =0.654) Yes 49 14.2 5 10.9 54 13.8 No 295 85.8 41 89.1 336 86.2 Total 344 100.0 46 100.0 390 100.0

Table 20: Mean and SD of knowledge and attitudes towards smoking associated with smoking status Non-smokers Smokers Total Mean SD Mean SD Mean SD Knowledge of health effect of smoking** (P-value=.041 )

0.813 .121 0.773 .143 0.793 .132

Attitudes toward smoking (P-value=.551)

3.393 .420 3.354 .373 3.373 .394

4.10.1. Multiple Regressions Using Multiple Regression, this was applied to analyze factors that were related to “smoking” among respondents. Table 21 shows the result of logistic regression analysis for the dependent variable”Smoking” for monks and novices. An odds ratio greater than 1, for a particular variable, indicates that the respondents in that category were more likely to smoke than the respondents in the reference group. An odds ratio of less than one, indicates that the respondents were less likely to smoke in comparison with the reference group, whereas an odds ratio of “one” indicates no difference in the likelihood of smoking in comparison with the reference category. The multiple logistic regressions included the characteristic of surveyed monks and knowledge and attitudes regarding smoking. The results indicated that there was no relationship between”smoking” and level of knowledge on the effects of smoking on health and attitude toward smoking. The odds of a monk who smoke having a high level of knowledge were .074 times lower than the odds of those respondents who had a low level of knowledge of the effects of smoking on health. Table 21: Odds ratios for logistics regression analysis for respondents reporting smoking Characteristics Smokers OR P value Age 1.047 .599 Ethnicity .213 Laoloum 1 Others 1.877

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Highest level of education .855 Primary/Secondary 1 Others .926 Age of monkhood 1.007 .932 Denomination .534 Thammayut 1 Mahanikai 1.302 Status of monks .352 Novices 1 Monks with full-fledges .646 Administrative position .771 Monk/Novices 1 Abbot/ 1.208 Duration of monkshood 1.087 .356 Family member smoking .676 .280 Public afford cigarettes to monks .699 .503 Knowledge of the health effects .074 .056 Attitudes towards smoking 1.029 .947 Constant .001 -2 Log likelihood 252.949 Chi-square Model 30.049

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p- value .003 Percent Correct 89.0 Nahelkerke R2 .144 N 390 4.11. Prevalence of Offering Cigarettes to Monks Table 22 shows the percentage distribution of nuns and elderly offering cigarettes to monks by province. About 200 nuns/elderly were from Luang Prabang and 400 people were from Vientiane Capital City. The majority of people – 75.8% - were females. The mean age was 45.58 with standard deviation 13.860. The majority of them are Laoloum (96%). About 32.5% had primary education while 28.3% attended secondary schools. Table 22: Characteristics of nuns and elderly offering cigarettes to monks by province


1 Sex ( P < 0.001 ) Male 69 34.5 76 19.0 145 24.2 Female 131 65.5 324 81.0 455 75.8 Total 200 100.0 400 100.0 600 100.0 2 Age ( Mean= 45.58 ; SD= 13.860; P value < 0.001) 18 - 27 yes 4 2.0 39 9.8 43 7.2 27 – 37 yes 29 14.5 109 27.3 138 23.0 38 – 47 yes 42 21.0 128 32.0 170 28.3 48 – 57 yes 47 23.5 74 18.5 121 20.2

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Table 22: Characteristics of nuns and elderly offering cigarettes to monks by province LP VTE Total No. Variable N % N % N %

>= 58 yes 78 39.0 50 12.5 128 21.3 Total 200 100.0 400 100.0 600 100.0 3 Ethnicity ( P < 0.001 ) Lao loum 178 89.0 398 99.5 576 96.0 Lao therng 14 7.0 2 0.5 16 2.7 Lao soung 7 3.5 0 - 7 1.2 Others 1 0.5 0 - 1 0.2 Total 200 100.0 400 100.0 600 100.0 4 Religion ( P < 0.001 ) Buddhism 181 90.5 392 98.0 573 95.5 Ghost 18 9.0 4 1.0 22 3.7 Others 1 0.5 4 1.1 5 0.8 Total 200 100.0 400 100.0 600 100.0 5 What is the highest level of schooling obtained ( P < 0.001 ) Primary 78 39.0 117 29.3 195 32.5 Secondary/High school 68 34.0 102 25.5 170 28.3 Technical/Vocational 22 11.0 50 12.5 72 12.0 University/Postgraduate 25 12.5 112 28.0 137 22.8 Others 7 3.5 19 4.8 26 4.3 Total 200 100.0 400 100.0 600 100.0 6 Household status ( P = 0.010 ) Head household 102 51.0 147 36.8 249 41.5 Family member 98 49.0 253 63.3 351 58.5 Total 200 100.0 400 100.0 600 100.0 Table 23 shows the prevalence of offering cigarettes to monks by province. About 57.3% of the nuns and elderly surveyed offered cigarettes to monk with variations between provinces. Nuns and elderly in Vientiane are more likely to offer cigarettes than nuns and elderly from Vientiane and this was found to be statistically significant. This was confirmed by in-depth interviews with the abbots in Luang Prabang and Vientiane provinces. The abbots in Luang Prabang were more likely to campaign to stop the practice of offering cigarettes to monks; in particular, the Vice Director of the Monk’s Association had campaigned to stop such a practice by making the public aware of the harmful effects of smoking. The offering of cigarettes to the monks is a traditional custom that is practiced among the elderly (84%). A small percentage of them (9.3%) mentioned that they did it as an offer to a dead person/relative in which it is believed that such as act will earn those merits. On the other hand, the reasons for not offering cigarettes were that the nuns/elderly did not like cigarettes (34.4%) and harm to health (16.4%). A small percentage (6.6%) said that the reason they did not offer cigarettes to the monks was because the dead person whom they hope to earn merits from did not smoke.

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Table 23: Prevalence of offering cigarettes to monks Variables LPB VTE Total N % N % N % 1 Offering cigarettes to monk ( P < 0.001 ) Yes 87 43.5 257 64.3 344 57.3 No 113 56.5 143 35.8 256 42.7 Total 200 100.0 400 100.0 600 100.02 If yes, how many times ( Mean= 1.84 ; SD= 1.403;P < 0.001 ) 1 - 3 times 74 85.1 233 90.7 307 89.2 4 - 6 times 10 11.5 22 8.6 32 9.3 7 - 10 times 3 3.4 2 0.8 5 1.5 Total 87 100.0 257 100.0 344 100.03 If yes, Why ( P < 0.001 ) Tradition 62 71.2 227 88.4 289 84.0 Others 6 6.9 18 7.0 24 7.0 Total 87 100.0 257 100.0 344 100.0 4 If no, Why ( P < 0.001 ) Harmful to health 22 19.5 20 14.0 42 16.4 Don't like cigarettes 46 40.7 42 29.4 88 34.4 Parents who died did

not smoke 8 7.1 9 6.3 17 6.6

Monk did not smoke 9 8.0 4 2.8 13 5.1 Not suitable 0 - 12 8.4 12 4.7 Never 13 11.5 34 23.8 47 18.4 Don't known 5 4.4 15 10.5 20 7.8 Others 10 8.8 7 4.9 17 6.6 Total 113 100.0 143 100.0 256 100.0

4.12. Abbots’ Opinion Towards Smoking

4.12.1. Opinion About Smoking Among Monks

The majority of abbots mentioned that smoking among monks is a behavior that is uncharacteristic of a monk, puts them at a higher risk of contracting illnesses and increases their health expenditure. On the other hand, smoking among monks is a custom because the public offers cigarettes to the monks as a means to gain merits

However, some abbots mentioned that smoking is not good for the monks because it can cause a loss of money and increases their needs and violates the 5 precepts for the laity. Because smoking is harmful and not appropriate for the monks, the public therefore, should not offer cigarettes to them during the Buddhist festivals or when they invite the monks/novices to preach in their homes.

4.12.2. Acceptance of Smoking Among Monks

The general public still accepts monks who smoke as shown in the quantitative findings where only 26.2% strongly agreed that people did not accept smoking among monks. This is because the public still offer cigarettes to monks because of customs. So, respect for monks is not dependent on their smoking status; rather, it depends on their morals, spiritual practices and whether they follow their five

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precepts for the laity, refrains from taking life, from stealing, from illicit sexual activity, from speaking falsely, and from consuming inebriating substances.

The majority of abbots pointed out that about 95% of people accepted smoking among monks because they felt that it is a normal behavior. However, a few of them mentioned that the public generally does not condone smoking among monks.

4.12.3. Monks as Role Models

Because monks have a respectable position in society and they are looked upon as leaders with high morals by the people, the monks should therefore serve as good “role models” for quit smoking for the public.

In particular, monks who are dressed in yellow should not smoke because to do so means they will not have metatham or violate the five precepts for the laity which the dress symbolizes. Monks should also not smoke in public.

4.12.4. Offering Cigarettes to Monks by Public The majority of abbots surveyed in this study reported that about 100% of the public or general population offered cigarettes to monks when they invited monks/novices to pray at their houses or when they organized Buddhism ceremony at home. Cigarette is used as a symbol by which the people express their courtesy or politeness to monks. One respondent said, “If you did not accept a cigarette from the public, it might be considered as impolite and disrespectful,” and “As the people want to gain merit by offering cigarettes, rejecting the offer will cause the lost of their trust.”

Approximately 50% of nuns and the general population offered cigarettes to monks at the temples or when monks prayed at their houses. They offered cigarettes to monks because it is a tradition that has been practiced by their ancestors in the past as well as by the elderly. It is part of Lao custom to offer cigarettes as well as water and some desserts to monks who came to pray at the house, Cigarettes are used to welcome the monks in the house and as alms.

However, nuns and the elderly from Luang Prabang pointed out that 50% to 80% of the general public offered cigarettes to monks because of traditions. Few of them suggested that there is only a few people still offering cigarettes to monks based on customs or because the dead person to be honored had previously smoked. Some abbots in Luang Prabang did campaign to educate the general public not to offer cigarettes to monks and about the harmful effects of smoking on health.

4.12.5. Regulation or Law Related to Smoking in the Temples

The majority of abbots mentioned that they set up the regulations on smoking in their temples which include prohibiting monk/novices from smoking in common places or public places.

However, there is no official law or regulation on prohibiting smoking in the temples, The abbots tried to discourage smoking on medical grounds by reminding the monks and novices about the harmful effects of smoking regularly. Some of them also mentioned that they relied on the five precepts for the laity: refrain from

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taking life, from stealing, from illicit sexual activity, from speaking falsely, and from consuming inebriating substances which include tobacco as a means to discourage the monks/novices from smoking. Some of the abbots believe that there should be regulations or laws on smoking as this will ensure that the monks/novices will be healthier.

4.12.6. Influences on Monk’s Smoking Practices

Monks took up smoking because of curiosity or peer influence. The nuns/elderly also offer the monks cigarettes and the monks also consumed cigarettes offered by public as means to gain the public’s trust. Few abbots mentioned that they smoke because of loneliness or stress or that they were facing problems. Some mentioned that monks smoked because it seemed to be a smart thing to do and as a sign of manhood.

Because monks have much free time in their hands after performing their prayers and daily work, some of them spend their leisure by trying new things such as smoking. Fellow monks also encourage and persuade others to smoke. The other factor for smoking among monks, was that some monks used to smoke before entering monkhood, and after ordination, they continued to smoke or smoked more because they were offered free cigarettes.

4.12.7. Integrate Lessons of Smoking in the Training Curriculum

The majority of monks mentioned that lessons on smoking were not integrated into the training curriculum, but were only taught in the fifth precept which included drug addiction and tobacco use. This was because the Ministry of Education did not introduce lessons about smoking into the curriculum; on the other hand, the curriculum for religious education was full of other subjects and there were not enough hours to teach about smoking.

Few abbots mentioned that in the religious education, there were some subjects on health education such as on hygiene and sanitation which teach about smoking. Some of them said they had provided health education related to smoking in the temples and schools.

4.12.8. Preaching about the Effects of Smoking to People

The majority of abbots agreed that preaching about the effects of smoking to people was good because it would encourage people to quit smoking. Most monks did not have any experience in preaching about the effects of tobacco use, as they usually talked in general about the fifth and tenth precepts. There were only 3 abbots who mentioned that they used to preach about the effects of smoking on health.

Some abbots did not talk to monks about not smoking because they themselves also smoked. About half of the abbots interviewed said that they only prayed in general about the fifth and tenth precepts and did not warn monks or prohibited them from smoking because there was no prayer about smoking or its harmful effects in Buddhism nor were there official laws related to smoking in Buddhism.

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Few abbots only warned their monks under their supervision about smoking and posted some posters and stickers on no-smoking in their temples. They did not discuss outside their temples because they were afraid that this would affect other monks who were smoking. Also, as mentioned by other monks, there were no official laws or regulations on smoking in Buddhism. Some abbots mentioned that they warned monks about the effects of smoking on health and prohibited monks from smoking and that they did campaign to persuade the public not to smoke.

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5. DISCUSSION 5.1. Prevalence of Smoking Among Monks The study revealed that the overall prevalence of daily current smoking among monks in the two provinces was 11.8% which lower than the study in Thailand (24.4%) (Naowarut et al., 2004). This is much lower than the current smoking rate among adults in Lao PDR which found that 40.3% of the general people were currently smoking with a higher proportion of males smoke than females (67.7% versus 16% respectively). In comparison with studies in Pnom Penh found that the prevalence of daily current smokers among Buddhist monks in Cambodia is 44%, which is much lower. This could be explained that monks in this study might receive some influence on the campaign on not smoking such as some abbots prohibited them not to smoke as confirmed by the qualitative data. In addition, monks from this study have high knowledge on the effect of smoking on health, thus their smoking behavior is reduced compared to previous researches. 5.1.1. Prevalence of Offering Cigarettes to Monks The findings showed that the prevalence of offering cigarettes to monks was 57.3%. The quantitative findings were similar to the qualitative finding which showed that the majority of the public still offered cigarettes to monks because of traditional customs, to gain merit; and as offering of alms especially when monks came to preach in their homes. 5.2. Predisposing Factors The findings from this study suggested that monks have high knowledge of the harmful effects of smoking on health as well as the effects of second hand smoke. This study reported a higher knowledge among monks in Lao than the Thai study (Naowarut et al., 2006) as about 60% of monks knew that smoking was a major morbidity and mortality risk for monks. However, the current and the Thai study were similar in that both found that monks had high knowledge on second hand smoking (94% and 96.2%, respectively). This could be due to the abbots’ efforts in warning and reminding them about the risk of smoking and prohibiting them from smoking in the temples, particularly in common areas or public places. Less than half of them (48.3%) knew about the rules of smoking in their temples. Similarly, the Thai study (Naowarut et al., 2006) also found that less than half of surveyed monks (42.5%) knew about the rules on smoking in their temples. Data from in-depth interviews with the abbots also revealed that there were no official laws or regulations on smoking in the temples. The abbots merely warned or reminded the monks not to smoke and there was no punishment meted to those who smoked as smoking was considered not a major issue, This is unlike if they were to violate the 5 precepts, which was considered a major offense and monks could be expelled from the temples. The current study reported that the 67.7% of monks support a ban on the offering of cigarettes to monks; and 30.2% believe that monks should refuse cigarettes offered to them. This was lower than the Thai study which found that 82% of monks felt that

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people should not offer cigarettes to monks and 57% thinks that monks should refuse cigarettes offered to them. In contrast, the Cambodian study found that only about one third (34%) of all respondents thought that people should not offer cigarettes to monks, while an equivalent percentage (38%) thought that people should not offer cigarettes to monks. Approximately another one third said they were not sure (Marshall & Takusei, 2000). This study found that former smokers hold more negative attitudes towards smoking than never/experimenter smokers and current smokers. However, the difference was not statistically significant. 5.3. Enabling Factors The findings from this study revealed that the majority of monks (74.9%) said that there was no smoke-free policy in place at their temples; however, some abbots maintained that they have regulations on smoking in their temples including the prohibition on smoking at the premises such as in the buildings of the temples, and in public areas. This finding is in accordance with the qualitative data which showed that there were no official regulations and laws related to smoking. Whether such regulations exist depend on the abbots who are the ones who set up the regulations in their temples. These abbots also serve as role models for not smoking. In comparison, the Cambodian study found that 91% of respondents said there was no mention about smoking in the teachings of Buddha; but when asked if there should be a Buddhist law that recommends monks not to smoke, 71% replied “yes” (Marshall & Takusei, 2000). In this study, 34.8% of monks who are current smokers received cigarettes from the public. This is higher than the 17.1% reported in the Thai study. 5.4. Reinforcing Factors This study revealed that approximately 71.5% of the monks and novices surveyed had at least one family member who smokes and there was little variation among provinces. About 61.3% of them said that their fathers smoke, while 21.5% suggested that their brothers smoke. A study carried out in Cambodia showed that among the influencing factor for starting smoking, 26% of respondents said that an individual friend was the main influence; 18% said group pressure from friends or other monks; 21% complimentary cigarettes; 12% work/stress; 8% father’s influence; 3% advertising; and 12% other reasons. As can be seen, these two influences – alone/individual friends and group pressure - were responsible for almost half of all influences for starting smoking (Marshall & Takusei, 2000). 5.5. Factors Related to Smoking The study revealed that factors such as younger age, ethnicity, age at entering monkhood, status of monks/novices, duration of monkhood, length of religious education and knowledge of health effect of smoking are correlated with monk’

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smoking. However, the Thai study found that older age was positively associated with smoking among monks, in contrast with the finding of this study. With regard to the association between status of monks/novices, duration of monkhood and smoking status among monks, this study found similar results with the Thai study (Naowarut et al., 2004) which suggested that status of monks and duration of monkhood were correlated with monk’s smoking. However, after controlling for confounding variables, only level of knowledge was correlated with smoking among monks. Monk smokers (n=46) tend to have attained somewhat lower levels of education in comparison to non-smokers (n = 344), a finding which is consistent with previous studies (Friis et al., 2006). 5.6. Limitations This is the first study on smoking among monks in Lao PDR; however, this study was conducted only in the urban and sub-urban areas in Vientiane Capital City and Luang Prabang, thus, the findings may not apply to larger communities or those with a different demographic structure or nationwide. The other constraint is the change in monk’s population as monk enters and leaves the monkhood which makes it difficult for sampling. The qualitative approach undertaken only explored the opinions of abbots towards smoking and did not explored cultural values and attitudes pertinent to cigarette smoking among monks.

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6. CONCLUSION Overall, the prevalence of daily smoking among monks was 11.8% and there was little variation between Vientiane (11.7%) and Luang Prabang provinces (12.2%). The prevalence of offering cigarettes to monks was 57.3% and similar to the qualitative data. The predisposing factors such as Knowledge, Attitudes, and Practices related to smoking among monks revealed that they have high knowledge on addiction of nicotine and that passive smoking increased risk of heart diseases; however, none of the attitudes correlated with smoking. Among current practices, the majority of monks and novices started smoking on a regular basis at the age of 15-20 years. The reason for starting smoking among monks and novices were peer influence (48.7%), followed by to release stress (17.6%), intimate adults (9.2%), and freedom (6.7%). The enabling factors related to smoking among monks in temples were the availability of cigarettes and lack of no-smoking regulations and policies. The availability of cigarettes offered by the public was one factor that enabled monks to smoke. No smoking policy was only enforced in temples where the abbots have instituted such regulations in their temples. The reinforcing factors related to smoking among monks were the presence of family members who smoke. Factors related to smoking among monks are age, ethnic group, monk’s status, age at entering to monkhood, duration of religious education and level of knowledge of the harmful effects of smoking on health; however, after controlling for confounders; none of these factors were statistically significantly associated with smoking status of monks.

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7. RECOMMENDATIONS

Based on the findings from this study, there are some recommendations that need to be implemented:

1. Public Policy The government of Lao PDR, included the monk’s associations should set up regulations and public policies such as banning smoking in temples as well as the giving of cigarettes to monks. 2. Health Education Program There is a need to organize health education programs regularly for monks and provide information, education and communication (IEC) materials such as stickers, posters, brochures, leaflets on the harmful effects of smoking that target the young in the age group 12-24 years old. At the same time, smoking cessation programs should be introduced to provide skills on how to quit smoking. There should be a campaign to educate the public not to offer cigarettes to monks or not to afford cigarettes to monks due to the negative effects of smoking on health. Monks should be the health educators together with the health staff in providing health education to monks and the public. 3. Advocacy Monks should take up an advocacy role by organizing campaigns on anti-smoking to encourage monks and the public not to smoke. 4. Role Models The monk’s associations should put in place regulations prohibiting smoking in the temple areas. Monks should serve as “role models’ for not smoking because the majority of Lao people believe in Buddhism which plays an important role in the daily life of the people. 5. Smoking Cessation Program Smoking cessation programs for monks should be introduced among the monks and then expanded to the public at large. Monks should be trained in smoking cessation and gain the skills on how to quit smoking. These programs should incorporate multiple stakeholders, including Director of monk’s association, abbots, monks/novices, providers, public, and mass organizations.

7.1 Develop Intervention Program for Tobacco Control Marin et al. (1990) has proposed a set of criteria for a culturally appropriate community intervention. First, use of the values of a culture as a foundation of the intervention should be considered. Second, an intervention should be culturally appropriate to the group’s subjective culture, including attitudes, expectancies, and norms toward smoking. Thirdly, the actual strategies that are a part of the intervention should fit within the preferred behavioral range of the targeted group. This would

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include possible channels of intervention, the credibility and perceived usefulness of the strategies among the group’s members, as well as the actual preferences of the members of the targeted group for certain strategies (Marin, 1993). According to the quantitative and qualitative data revealed from this study, develop effectiveness intervention program for Tobacco Control which is crucial for monks. The following components in the intervention program should be considered: Integrating anti-smoking messages into the National Buddhist Curriculum, quitting counseling, preaching, and integrating smoking lessons in the training curriculum are among the routine activities. There should be some smoking cessation project for monks to educate them about the health effects of smoking regularly and a smoking cessation counseling service. A gradual decline in cigarette consumption is more consistent with traditional Lao health beliefs, and the introduction of pharmacotherapy within the construct of “balancing” the body deserves further study for tobacco cessation strategies among monks. Providing quitting skills and appropriate health information are issues that need to be addressed to promote tobacco cessation among monks. The Buddhism Association should set up rules and regulation to prohibit smoking among monks and for smoking monks to quit, and provide IEC materials to the temples such as stickers, posters and pamphlets. In addition, the abbots should prohibit the offering of cigarettes to monks. On the other hand, lay people must also not promote smoking among the monks.

Abbots or the head of the Buddhism Association should be the role models for not smoking. Family and schools should also play a role in ensuring that monks do not

smoke.

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REFERENCES Anon. Influence of religious leaders on smoking cessation in a rural population—Thailand, 1991. MMWR Morb Mortal Wkly Rep 1993; 42:367–9. CDC. 2003. Smoking & Tobacco Use. Global Youth Tobacco Survey (GYTS). La People’s Democratic Republic- Vientiane Province Fact Sheet. Available at website: http://www.cdc.gov/tobacco/global/GYTS/factsheet/wpro/2003/laospdrvientianeprovince. Retrieved on 10/5/2007. CDC. 1994. Smoking and Tobacco Use. 1994 Surgeon General's Report—Preventing Tobacco Use Among Young People. Chapter 1: Summary. Available at website: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_1994/summary_intro.htm. Retrieved on 10/5/2007. Country Profiles Tobacco or Health 2000. Tobacco-Free Initiative Western Pacific Region. Culture of Laos. 2007. History and Ethnic relations. Available on website: http://www.evertculture.com/Ja-Ma/Laos.html. Retrieved on 15/3/2007. Friis. H, Forouzesh. M, Him S. Chhim, Sheetal Monga and Donna Sze. 2006. Sociocultural determinants of tobacco use among Cambodian Americans. Health Education Research 2006 21(3):355-365. Available from websites: http://her.oxfordjournals.org/misc/terms.shtml. Retrieved on 20/4/2007. Green, L.; Kreuter, 1991. M. In: Health Promotion Planning: An educational and Environmental Approach. Palo Alto: Mayfield; 1991. Health promotion today and a framework for planning. HHS. Preventing Chronic Diseases: Investing Wisely in Health. Preventing Tobacco Use. Hyeon Chang Kim, Federica Barzi, TH Lam, Rachel Huxley, Mark Woodward. 2007. The Impact of Cigarette Smoking on Mortality in the Asia- Pacific Region. http://www.hku.hk/ptid/programme/abstracts/hckim.pdf. Retrieved on 25/2/2007 Kong Mom, MD. Adventist Development and Relief Agency (ADRA), 2001. Buddhist Monk in Tobacco Control. Laos. Religion. 2007. Available on website: http://countrystudies.us/laos/58.htm. Retrieved on 15/3/2007. Marin BV, Marin G, Perez-Stable EJ, Otero-Sabogal R, Sabogal F. 1990. Cultural Differences in Attitudes Toward Smoking: Developing Messages Using the Theory of Reasoned Action. J Applied Soc Psych; 20 (6): 478–93. Marin G. 1993. Defining Culturally Appropriate Interventions: Hispanics as a Case Study. Am J Comm Psych. 21;:149–61.

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Marshall.T, S. Smith and Takusei Umenai. 2002. Smoking Among Buddhist Monks in Phnom Penh, Cambodia. Tobacco Control,9; 111. Avalaible at the website: http://tc.bmjjournals.com/cgi/content/full/9/1/111. Retrieved on 20/1/2007 National Statistical Center, 2005. National Household Census. Educational printing Services. Naowarut Charoenca et al. 2004. Smoking Prevalence Among Monks in Thailand.Unpublished report. Shin-Ping Tu, Walsh, Tseng & Thompson. 2000.Tobacco Use by Chinese-American Men: An Exploratory Study of the Factors Associated with Cigarette Use and Smoking Cessation. Asian American Pacific Island Journal Health; 8(1): 46–57. Swaddiwudhipong W, Chaovakiratipong C, etal. A Thai monk: an agent for smoking reduction in a rural population. Int J Epidemiol, 1993;22:660–5. Smith M, Umenai T, Radford C. Prevalence of smoking in Cambodia. J Epidemiol 1998;8:85–9. 4 Chitanondh H. Tobacco use: an update—April,1991. Bangkok, Thailand: Ministry of Public. Wikipedia. 2007. Buddhism in Laos. Available at the website: http://en.wikipedia.org/wiki/Buddhism_in_Laos. Retrieved on 2/2/2007. WHO. 2000. Country Profiles Tobacco or Health 2000. Tobacco-Free Initiative Western Pacific Region. Available at website: www.wpro.who.int/NR/rdonlyres/751257EA-1037-4E62-98F7-EBEEE278ADAF/0/countryprofiles2000.pdf. Retrieved on 2/7/2006.

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APPENDIX Questionnaire Survey of KAP towards Smoking Among Monks You are being invited to participate in a research study that will investigate the smoking behaviors and know1edge and attitudes about smoking among monks, including novices and nun in Lao PDR .The study being conducted by members of the Faculty of Medical Sciences, National University of Laos will involve monks, novices, and nuns in Lao PDR. The questionnaire should only take about 25 minutes to complete. It is anonymous, meaning that we do not ask for your name on the questionnaires. Please also be assured that all responses are strictly confidential and will only be used by the research team for this study. To ensure that it remains confidential, every answer of yours will be strictly kept in confidentiality. All of the raw data in this survey will not be disseminated to anyone, only the result in terms of statistics of this survey will be reported. Your participation in completing this questionnaire is voluntary. If you decide not to take part, it will not affect your participation in the Faculty of Medical Sciences, National University of Laos in any way. Finally, when the study is completed, we will be sending the results to each province so that everyone has access to them. Also, the principal investigator will organize the dissemination workshop at the central level and we may organize a dissemination workshop in the northern and southern provinces. If you have any questions or would like to ask more details on this study, you may contact Dr. Vanphanom Sychareun, Principal Investigator, Director of Postgraduate Studies and Research Division at 5609729, email: [email protected] or Dr. Alongkone Phengsavanh, the Co-Principal Investigator at 2245407, email [email protected].

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Instructions Please fill in as much as possible your personal information in this questionnaire form. If you have difficulties in recalling, please do as best as your memory allows. Date of interview:..................................... Name of supervisor..................................... Name of interviewers................................... Name of temple............................................ 1- Provincial code......................................... 3. District code............................................. 2- Code of temple........................................ I. Socio-demographic Characteristics Questions Skip to 101 How old are you?

--------------------------

102 Ethnicity 1. LaoLoum 2. Laotheung 3. Laosoung 4. Other

103 What is the highest level of schooling completed?

1. Primary 2. Secondary/high school 3. Technical/Vocational 4. University/ Postgraduate 5. Other

104 At what age were you when you became a monk?

Age ______________years

105 Denomination 1. Thammayut 2. Mahanikai

106 Status of monks/novices 1. Full-fledged monks 2. Novices

107 Hierarchical ranking 1. Yes 2. No

108 Administrative positions 1. Abbot/Administrative 2. Monk/Novice

109 Duration in the monkhood

_____________________years

110.1 Religious education 1. Yes 2. No

110.2 If yes, how many years _________________years

110.3 What level 1. Level 1 2. Level 2 2. Level 3

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3. Other 110.4 Do you have any members in

your family who smoke? 1. Yes 2. No

110.5 If yes, who are they? ----------------------- 111 Does the public offer you

cigarettes? 1. Yes 2. No

II. Cigarette Smoking and Other Tobacco Use No. Questions Categories of answers Skip 201 Which of the following best describes

your smoking behavior? 1. I have never smoked cigarettes 2. I have quit smoking 3. I currently smoke occasionally 4. I currently smoke everyday

Q301 Q205 Q202 Q202

For those who smoked in the past (Ex-smokers) 202 When you did smoke in the past, how

often did you smoke? 1. Occasionally (Some days) 2. Daily

203 On the day that you smoke, how many cigarettes did you smoke a day?

204.1

How old were you when you first tried a cigarette on a regular basis?

Age----------------------years

204.2

When did you first try cigarettes on a regular basis?

1. Before becoming monk/novices 2. During monkhood 3. Others...

205 Have you ever used rolling tobacco, snuff, or pipes?

1. Smoke occasionally 2. Smoke everyday

206 On the day that you smoke, how many rolling tobacco, snuff or pipes do you smoke a day?

Average--------------------/day

207 How old were you when you stopped smoking completely?

Age-----------------------years

Next section

For those who currently smoke (Current smokers) 208 How old were you when you first

tried a cigarette on a regular basis? Age-----------------------years

209 When did you start smoking? 1. Before monkhood 2. During monkhood

210 How long did you smoke regularly? -------------------------------years 211 On the day that you smoke, how

many cigarettes do you smoke a day?

Average--------------------/day

212 Have you smoked 100 cigarettes in your life?

1. Yes 2. No

213 Have you ever stopped smoking for at least one week?

1. Yes 2. No

214 Which of the following best describe how you feel about smoking?

1. Not ready to quit smoking within next 6 mos

Q216

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2. Thinking about quitting within 6 mos

3. Ready to quit now

Q216 Q216

215 Have you ever used rolling tobacco, snuff, and others?

1. I currently smoke occasionally 2. I currently smoke everyday

216 On the day that you smoke, how many rolling tobacco, snuff or pipes do you smoke a day?

Average--------------------/day

217 Have you smoked 100 rolling cigarettes, snuff, and others in your life?

3. Yes 4. No

218 How long after getting up/waking up do you take your first cigarette of the day?

1. Less than 15 min 2. Within 15-30 min 3. More than 1 hr 4. Other

219 Reason for smoking initiation 1. Boredom 2. Peer 3. To experiment 4. To release stress 5. To imitate

adults/actors/singers 6. Given free cigarettes 7. Decrease hunger for food 8. Others…

220 How do you obtain cigarettes? 1. Purchase 2. Offer 3. Asked from fellow monks 4. Given by fellow monks 5. Others

221 During the past 7 days, how many days have people smoked in your presence, in places other than where you live or work?

---------------------------days

222 What are the places that you smoked more often?

1. In residence 2. In temple area 3. Outside temple areas 4. Other

223 Do you want to quit smoking? 1. Yes 2. No

224 Have you tried to quit smoking within the past year?

1. Yes 2. No

Q228

225 How long ago did you stop smoking cigarettes?

1. Less than 1 month 2. 1-5 months 3. 6 – 11 months 4. 1 year 5. 2 years 6. 3 years or longer

226 What are the methods used to quit 1. Cold turkey

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smoking 2. Drug therapy 3. Weaning 4. Others

227.1

Do you receive advice to quit smoking

1. Yes 2. No

Q224

227.2

If yes, from whom did you receive advice?

1. Doctor/Nurse 2. Lay people 3. Other monks 4. Media 5. Others

228 What was your primary reason for quitting tobacco use? (quitting during the time described)

1. Illness (at or before time of quitting),

2. Health (at or before time of quitting) but wanted to prevent illness,

3. Seeing illness developed in other smokers,

4. Family disapproval, 5. Health Education Program, 6. Not enough money to buy

tobacco, 7. Disapproval of friends and co-

workers, 8. Don’t know/refuse to answer

229 Why can’t you quit smoking? 9. Don’t know how 10. Just don’t want to 11. No advice 12. Others

III. Knowledge About the Health Effects of Tobacco Use N Statement Yes No 301 Smoking is harmful to your health 302 Nicotine in tobacco is highly addictive 303 People can get addicted to cigarette smoking just like

they can get addicted to cocaine or heroin

304 Passive smoking increases the risk of heart disease in non-smoking adults

305 Passive smoking increases the risk of lung disease in non-smoking adults

306 Smoking increases the risk of heart disease 307 Smoking increases the risk of lower respiratory tract

illnesses such as pneumonia and lung cancer

308 Tobacco kills more people each year than illegal drugs, AIDS and car crashes

309 Quit smoking reduces risk 310 Know about smoking law in religious places 311 Know their temple’s smoking rule

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312 Smoke from cigarettes is harmful to people who are repeatedly exposed to it, not just to the smoker

IV. Attitudes Towards Tobacco Use No Statement Strongly

agree Agree Disagree Strongly

disagree 401 Smoking in all enclosed public

places should be banned

402 Smoking should be banned in the temples

403 Offering tobacco to monks should be prohibited

404 Monks should refuse cigarettes offered to them.

405 If monks don’t smoke, people would respect them more

406 Monks should routinely advise people to quit smoking

407 There should be a campaign to educate the public not to offer cigarettes to monks

408 There should be a project to quit smoking or smoking cessation for smoking monks/novices

409 Monks who smoke are not accepted by their fellow monks

410 Monks who use tobacco are less likely to advise people to stop using tobacco

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V. Temple Practices

No. Questions Categories of answers Skip 501 Where is your temple located? 1. Urban

2. Suburban 3. Rural

502 What sort of smoke-free policy is in place at your temple?

1. No smoking policy 2. Smoking rooms available 3. No smoking allowing at all on the promises

Q504 Q503 Q503

503 Is the smoke-free policy enforced? 1. Yes, always 2. Yes, sometimes 3. No 4. Don’t know

504 Which of the following best describes your temple smoking policy for indoor public or common areas (i.e., rooms, restrooms, dining areas and the area of temple)?

1. Not allowed in any public or common area

2. Allowed in some public or common areas

3. Allowed in all public or common areas

4. No official policy

505 Have you ever received any formal training on smoking cessation approaches to use with the people during monkhood?

1. Yes 2. No

506 Have you ever preached about the effects of smoking to people during the past 30 days?

1. Yes 2. No

507 Have you ever preached about quitting smoking to people during the past 30 days?

1. Yes 2. No

508 In the past 30 days, have you ever received cigarette offered by nuns or general population?

1. Yes 2. No

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VI- Intention to Participate in Tobacco Control in the Future

No. Questions Categories of answers Skip 601 Should tobacco control training be integrated

into training curriculum for pre-monks during their religious education?

1. Yes 2. No

602 Should monks get specific training on cessation techniques?

1. Yes 2. No

603 Should monks routinely advise people who smoke to quit smoking?

1. Yes 2. No

604 Should monks routinely advise people who use other tobacco products to quit using these products?

1. Yes 2. No

605 Are people’s chances of quitting smoking increased if monks advise him or her to quit?

1. Yes 2. No

606 Should monks serve as “role models” in participating and implementing the smoke-free temples?

1. Yes 2. No

607 Should monks serve as “smoke-free life role models" to the public?

1. Yes 2. No

608 Should monks serve as “role models” advocating the Abbots in advancing tobacco control policy?

1. Yes 2. No

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Guidelines for In-depth Interview with Key Buddhist Leaders Each of the following questions should be posed to each interviewee. 1. Key demographic information (age, general and religious education, administrative positions, duration in monkhood)

2 What do you think about smoking among monk? Is smoking among monks acceptable to the general population? Why? What do you think about monks as role models?

3 What are the proportions of nun/general population offering cigarettes to monks? Why do they offer cigarettes to monks?

4 What do you know about the regulation or law related to smoking in the temples? What were the influencing factors on your smoking behavior?

5 What sort of smoke-free policy is in place at your temple? Is the smoking policy enforced? If yes, Why? If no, Why not?

6 Are there any lessons on smoking in the training curriculum? What are they?

7 What do you think about preaching about the effects of smoking to people? What about on quitting smoking?

8 What are the policies regarding the quitting process and the health promotion to encourage monks to stop smoking in your temple? What are they? If none, Why not?

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Questionnaire for Nuns/elderly on the Offering of Tobacco to Monks Date of interview:..................................... Name of supervisor..................................... Name of interviewers................................... Name of temple............................................ 3- Provincial code......................................... 3. District code............................................. Questions Skip to 101 How old are you?

--------------------------

Sex 1. Male 2. Female

102 Ethnicity 1. LaoLoum 2. Laotheung 3. Laosoung 4. Other

103 What is the highest level of schooling completed?

1. Primary 2. Secondary/high school 3. Technical/Vocational 4. University/ Postgraduate 5. Other

104 Religion 1. Buddhism 2. Ghost 3. Others

105 Household status 1. Head household 2. Family member

106 Did you offer cigarettes to monks in the last year?

1. Yes 2. No

107.1 If yes, how many times? -------------------times 107.2 If yes, Why? 107.3 If no, Why not?

………………………………………………………………………………………………….. About SEATCA The Southeast Asia Tobacco Control Alliance (SEATCA) works closely with key partners in ASEAN member countries to generate local evidence through research programs, to enhance local capacity through advocacy fellowship program, and to be catalyst in policy development through regional forums and in-country networking. By adopting a regional policy advocacy mission, it has supported member countries to ratify and implement the WHO Framework Convention on Tobacco Control (FCTC) Contact persons: Ms. Bungon Ritthiphakdee: SEATCA Director Email: [email protected] Ms. Menchi G. Velasco: SEATCA Research Program Manager Email: [email protected]; [email protected] Southeast Asia Tobacco Control Alliance (SEATCA) Address: Thakolsuk Apartment Room 2B, 115 Thoddamri Rd., Nakornchaisri

Dusit, Bangkok 10300, THAILAND Tel./Fax: +662 241 0082

Website: http://www.seatca.org …………………………………………………………………………………………………..

FACTORS RELATED TO TOBACCO USE AMONG MONKS IN … Use among Monks i… · AND LUANG PRABANG...

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