Int. Med J Vol. 6 No 2 December 2007

Perception of the Islamic ruling on smoking among muslim adults in Malaysia; a preliminary survey.

  T. C.A. Shahrin, S.M.S. Azarisman, P.A.M. Melor, A.R. Jamalludin and S.H. How

Department of Internal Medicine, Kuliyyah of Medicine, International Islamic University Malaysia

ABSTRACT

Introduction: Smoking is prevalent among Muslims in this country despite public knowledge regarding smoking as haram (unlawful). This may be due to ignorance of the consensus of the  ' mufti ' on the ' fatwa ' on smoking or a result of poor education and understanding of health-related risks of smoking.

Methods: A cross-sectional, questionnaire-based survey was carried out among the public who attended the IIUM Faculty of Medicine open day in Kuantan, Pahang on June 12^th, 2004. Knowledge of smoking-related illnesses and the religious ' fatwa '(edict) on smoking was assessed.

Results: Seventy four muslims participated in the survey. 46(63%) were smokers (including ex-smokers) and 28(37%) were non–smokers. There was no statistically significant difference between the knowledge of smoking-related illnesses and their knowledge of the religious edict which regards smoking as haram between smokers and non-smokers. Only 6.7% of smokers perceive smoking as haram compared to 48% of non-smokers (p<0.001).

Conclusion: The conviction that smoking is haram among smokers is still poor among smokers. This could be one of the main reasons contributing to the high prevalence of smoking in our society. There was no difference between smokers and non-smokers concerning their knowledge on the religious edict on smoking and the health-related hazards of smoking.                                       

KEYWORDS: Smoking, prevalence, religious edict, Islam.

INTRODUCTION

The National Health and Morbidity Survey in 1996 showed that 49.2% of adult males and 3.5% of females smoked.¹ Studies conducted by the World Health Organization in 2000 quoted similar figures of 41% for males and 4% for females.² The prevalence of smoking among females have remained constant (3.5 -4.0% over a ten year period, 1986/7 – 1996/7) despite rising trends elsewhere. It could be that in Malaysia females are not expected to smoke.²

Malays, almost all entirely Muslims has the highest prevalence of smoking (27.9%), followed by the Chinese (19.2%) and Indians (16.2%)¹ .  This is despite the increasing awareness among Muslims that tobacco consumption from the respective of the syariah is a forbidden act (haram) and is thus sinful. The high prevalence amongst Malays could be attributed to the fact that smoking is seen as an important cultural role and considered important in normal social intercourse.²

In the past, smoking was viewed as permissible by many muslim scholars. This is because it was not an intoxicant and only resulted in bad breath, which did not go against any basic Islamic tenet.

Following mounting evidence on the dangers of smoking, more muslim scholars have issued ' Fatwa' (edicts) that consider smoking as haram or prohibited in Islam.^{3, 4} This is because Syariah principle views preservation of  life as being mandatory and any act to directly or indirectly harm life will have to be considered as haram.⁴

Given that Muslim smokers constituted a significant majority of the smoking population in Malaysia, it would be interesting to assess their perception of the religious edict on smoking. It would also be pertinent to observe whether there were any differences in perception between smokers and non-smokers.

Religion may play a part in health beliefs and behaviour such as smoking and could well be used to advantage as a public health intervention to reduce tobacco use in the community. Several studies have reported on the use of religious settings, religious professionals and/or faith based intervention to promote a reduction in smoking^5-7. The results of this survey could be used as a guide in formulating local religion-based tobacco control interventions.

OBJECTIVE

Our objective is to determine whether muslims have any awareness of the opinions of muslim scholars regarding their edict on smoking in Islam. We will also observe whether there are any differences of perception regarding the Islamic ruling on smoking between muslim smokers and non-smokers.

MATERIALS AND METHODS

Consecutive attendees of the International Islamic University Malaysia, Faculty of Medicine open day were recruited into the study. A self-administered questionnaire was then distributed to each participant. Knowledge of smoking-related illnesses which include myocardial infarction, chronic obstructive pulmonary disease, stroke, lung cancer, oesophageal cancer and abortion was assessed by a knowledge score, with a minimum score of 0, and a maximum score of 7 for each participant. Knowledge on the religious edict regarding smoking was also assessed. The study protocol was approved by the medical research and ethics committee of the institution, and written informed consents were obtained from the subjects.

DEFINITIONS

Ever smoker:  a person who has smoked at least once previously and smoked more than 100 cigarettes.

Non-smoker: someone who has never smoked in his/her lifetime.

Ex-smoker: smoker who has stopped smoking for at least 6 months previously.

Current smoker: a person who still smokes at the time of the survey.

Haram : forbidden or prohibited, and sinful in Islam.

Makruh: distasteful or reprehensible but still permissible in Islam.

Harus or Mubah: permissible in Islam.

Statistical Analysis

Data for continuous, closely symmetrical variables were analyzed using standard descriptive methods to estimate means ± SD. Chi-square and Mann-Whitney U test were used to determine the statistical significance of comparisons made between the variables. A p value of < 0.05 was taken as statistically significant.

The statistical software package for the social sciences, SPSS version 13.0 was used to perform the analysis.

RESULTS

A total of 74 participants were recruited into the survey of which 46(63%) were ever smokers and 28(37%) were non–smokers. The median age of ever smokers was 29 and that of non-smokers was 23. The median smoking duration was 10 years (range 1-30 years) and the median starting age for smoking was 16 (range 10-31 years old). Among ever-smokers, 63% received secondary education and 35% had tertiary education. This is compared to the figures for non-smokers, of which 15% had secondary education and 85% had tertiary education. (p<0.001)

As illustrated in Table 2, there was no statistical difference in the knowledge of smoking-related illnesses between the ever smokers and non-smokers (p=0.231). 96.4% of non-smokers perceived smoking as dangerous compared to only 66.6% of ever smokers (p<0.01). Passive smoking was regarded as dangerous by 96.4% of non-smokers and 78.3% of ever smokers, respectively (p=0.058).

Ever smokers and non-smokers showed no difference in their knowledge of the religious edict which proclaims smoking as haram (58% vs 42% respectively, p=0.167). However, among ever smokers, only 6.7% perceive smoking to be haram, as compared to the non-smokers where the figure was 48.1% (p<0.001).

82% of ever smokers believed it to be makruh compared to 40.7% of non-smokers (p<0.001).

Current smokers when asked about the reasons for starting smoking, 54% cited peer pressure as the main reason and another 22% smoked out of self-curiosity. 92% of current smokers have tried to quit before, albeit unsuccessfully, with 52% of them trying to quit on more than three occasions. Only 6.5% of those who tried to quit attended no-smoking clinics and only 6.5% used nicotine supplements in order to stop smoking. The majority of them (78%) attempted to quit on their own.

91% of current smokers would like to stop smoking if they could.

DISCUSSION

In the past, smoking was viewed as either permissible (harus or mubah) or at worst permissible but highly discouraged or reprehensible (makruh).^{8, 9} This stems from the fact that smoking or tobacco consumption does not result in intoxication as does alcohol or drugs such as marijuana. More recently though, in light of the increasing evidence of harm from smoking, more religious scholars began issuing edicts declaring smoking as haram (prohibited). This decision was reached based on consultation with medical practitioners which resulted in a ‘consensus edict’ which consider smoking to be haram.¹⁰

Paradoxically, the perception or belief that smoking is not haram may well be one of the factors which account for muslims starting to smoke. In a study on school children in several schools in an outlying district of Kuala Lumpur by Abu Bakar et al, less than half of all secondary school children from publicly funded schools perceived smoking as haram. The author concluded that the wrong perception among adolescents on the Islamic edict on smoking could be the reason for the high smoking prevalence in the community.¹¹

Our study showed that there was a higher prevalence of smoking among the less well educated (63% had only secondary level education whereas 85% of non-smokers had tertiary education). They also tended to be older (median age of 29 compared to 23 for non-smokers) and married (43% of smokers compared to just 15% of non-smokers). This supports the notion that smoking plays an important cultural role and is seen as indispensable to social intercourse in which the older and married tend to partake in.² It also lends credence to the anecdotal belief that the more highly educated tend to shy away from smoking which is a significant paradigm shift from the 60s and 70s when smoking was regarded as a status symbol befitting the elite.

Surprisingly both smokers and non-smokers alike scored maximal points in their knowledge of smoking-related illnesses. This showed that the public health campaigns educating the masses on the risks of smoking had been a success but it did not ensure smoking cessation. This could mean the failure to provide adequate follow on institutional changes in support of that message. This is graphically exemplified by the fact that although 92% of smokers in our study had tried to quit, only 6.5% utilised quit-smoking aids such as nicotine supplements or attended quit-smoking clinics.

Another important paradox in our study showed that although a majority of them (74.4% of smokers and 85.2% of non-smokers) were aware of the edicts by some scholars declaring smoking as haram, most smokers hold the opinion that it is only makruh (82.2% of smokers compared to 40.7% of non-smokers). The finding that the majority of ever smokers viewed smoking as makruh is also consistent with a previous study.¹² This can be attributed to the fact that most Islamic scholars believe in the concept of ikhtilaf (accepting differences in opinion regarding issues which do not corrupt the basic tenets of the religion).⁸ Furthermore, most scholars tend to shy away from casting large sections of their communities as partaking in a prohibited and thus sinful activity.⁹

Several reports have suggested that religiousness in various faiths, including Islam is associated with reduced smoking.^13-16 The use of religion-based public health intervention for the control of smoking has been increasingly studied and some researchers advocate adopting more of these approaches to reduce tobacco use.^5-7,17,18 Using the religious perspective to improve smoking cessation may complement currently available methods. However the key ingredient to the success of such a strategy relies on a uniform attitude amongst Islamic scholars regarding the status of smoking in Islam.

Despite the existence of effective cessation methods, most smokers in this study tried to stop smoking independently, a finding which was also observed elsewhere.¹⁹ Not surprisingly, due to the chronic relapsing nature of tobacco dependence, most smokers who attempt to quit unaided failed. This is again observed in this study, in which 52% of the smokers had had repeated attempts at quitting without success. A possible reason for this may be that smokers tend to underestimate the benefit of effective cessation methods or that the follow on support measures may be non-existent or inadequate.^20,21 It is interesting to note that despite this, an overwhelming majority (91%) of current smokers in our study would like to stop smoking.

The major limitations of this study are that the sampling was not random, the numbers are small and there was no female representation amongst smokers. Therefore the findings of this study cannot be generalized to the whole population. However, we believe that it adequately answers the questions that we had at the start of the study and therefore our appraisal of the smoking attitudes amongst muslims in Malaysia can be extrapolated to the entire population.

In conclusion, our study has found that most smokers tended to be less educated, in the older age group and with a family. This lead some supports to the theory of smoking and its cultural role. We have also found that although most muslims are aware of the religious edicts against smoking, most tend to favour the opinion of other scholars whose views are more akin to theirs. Interestingly, an overwhelming majority of smokers do want and try to quit but there exists several impediments to their success this needs to be addressed.

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19.  Fiore M, Novotny T, Pierce J, et al. Methods used to quit smoking in the United states: do cessation programs help? J Am Med Assoc 1994; 271:1940-1947

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21.  Hammond D, McDonald PW, Fong GT, Borland R. Do smokers know how to quit? Knowledge and perceived effectiveness of cessation assistance as predictors of cessation behaviour. Addiction 2004; 99:1042-1048

Tables

Corresponding author;

Dr Azarisman Shah Mohd Shah

Department of Internal Medicine,

International Islamic University Malaysia,

Jalan Hospital Campus, 25150 Kuantan,

Pahang Darul Makmur, MALAYSIA.

(Off) +609 5132797 extension 3449 (Fax) +609 5133615

(Mobile) +6016 2096984

e-mail – risman1973@hotmail.com