Religious Involvement and Cigarette Smoking in Young Adults: The CARDIA Study Religious Involvement and Cigarette Smoking in Young Adults The CARDIA Study Mary A. Whooley, MD; Alisa L. Boyd, MPH; Julius M. Gardin, MD; David R. Williams, PhD, MPH Background: Results of previous studies have sug- gested that involvement in religious activities may be as- sociated with lower rates of smoking. We sought to de- termine whether frequent attendance at religious services is associated with less smoking among young adults. Methods: This prospective cohort study of 4569 adults aged 20 to 32 years included approximately equal num- bers of blacks and whites and men and women from 4 cities in the United States who attended the 1987/1988 examination of the Coronary Artery Risk Development in Young Adults (CARDIA) study. Frequency of atten- dance at religious services and denominational affilia- tion were determined by self-report questionnaire in 1987/ 1988. Cigarette smoking was determined by interview at this time and again 3 years later. Results: Of 4544 participants who completed the to- bacco questionnaire in 1987/1988, 34% (891/2598) who attended religious services less than once per month or never and 23% (451/1946) who attended religious ser- vices at least once per month reported current smoking (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.5- 2.0; P�.001). This association between less frequent at- tendance at religious services and current smoking was found in most denominations and remained significant after adjusting for potential confounding variables (OR, 1.5; 95% CI, 1.3-1.8; P�.001). During 3-year follow- up, nonsmokers who reported little or no religious in- volvement had an increased risk of smoking initiation (adjusted OR, 1.9; 95% CI, 1.3-2.7; P�.001). Conclusions: Young adults who attend religious ser- vices have lower rates of current and subsequent ciga- rette smoking. The potential health benefits associated with religious involvement deserve further study. Arch Intern Med. 2002;162:1604-1610 C IGARETTE SMOKING ranks as the primary cause of premature death in in- dustrialized countries throughout the world.1,2 Despite an ongoing decline in smoking among older adults,1,3 the recent increase in smoking among youths (from 28% in 1991 to 36% in 1997)4 is alarming. Because the negative health effects of cigarette smok- ing are cumulative, the risk of developing a smoking-attributable disease increases the earlier that smoking begins.4 Previous studies2,5-16 have suggested that involvement in religious activities may affect smoking behavior. However, most studies were cross-sectional, limiting in- ferences about cause and effect2,5-7,9-14,16; many did not examine whether employ- ment, education, or social network might confound the association between smok- ing and religion5,9,11,12; and the results of oth- ers may not be generalizable.2,13,14 We analyze the association between re- ligious involvement and cigarette smoking and describe the distribution of religious af- filiation among young men and women and black and white participants enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study. We exam- ined whether frequent attendance at reli- gious services was associated with smok- ing prevalence and whether it predicted subsequent smoking 3 years later. RESULTS CHARACTERISTICS OF PARTICIPANTS Table 1 lists the distribution of partici- pants by religious denomination. Almost half of the participants were either Bap- tist or Roman Catholic. Most Baptists were black, and most Roman Catholics were white. Of the 4569 participants, 1953 (43%) reported attending religious ser- vices at least once per month in 1987/ 1988 (Table 2). Compared with those who attended religious services at least ORIGINAL INVESTIGATION From the Department of Veterans Affairs Medical Center, San Francisco, Calif (Dr Whooley and Ms Boyd); the Departments of Medicine, Epidemiology, and Biostatistics, University of California, San Francisco (Dr Whooley); the Division of Cardiology, St John Hospital and Medical Center, Detroit, Mich (Dr Gardin); and the Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor (Dr Williams). (REPRINTED) ARCH INTERN MED/ VOL 162, JULY 22, 2002 WWW.ARCHINTERNMED.COM 1604 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 PARTICIPANTS AND METHODS PARTICIPANTS The CARDIA study is a multicenter prospective cohort study designed to describe the evolution of coronary heart dis- ease risk factors in young adults and to identify associated habits, behaviors, and lifestyles. The study design and base- line characteristics of the participants have been de- scribed previously.17 Between March 1985 and June 1986, we recruited 5115 participants, aged 18 to 30 years, in- cluding approximately equal numbers of black and white participants and men and women, from 4 American cities (Birmingham, Ala; Chicago, Ill; Minneapolis, Minn; and Oakland, Calif). Participants were recruited primarily through telephone contact, except in Oakland, where a health plan membership roster was used. The appropriate institutional review boards approved the study, and all par- ticipants provided written informed consent. MEASUREMENTS From May 1987 to July 1988, 4569 participants com- pleted the following self-report question: “How often do you attend religious services such as those at a church or synagogue?” The 7 response categories were every day, more than once a week, once a week, 2 or 3 times a month, once a month, less than once a month, and never. We defined high-frequency attendees as those attending religious services at least once per week; moderate-fre- quency attendees as attending 1, 2, or 3 times per month; and low-frequency attendees as attending less than once per month or never. We also asked participants: “What is your religion? Please specify a religious denomination.” We coded de- nominations using 25 categories: Baptist, Roman Catho- lic, Methodist, Lutheran, Pentecostal, Presbyterian, Jew- ish, Episcopal, Christian Church or Church of Christ, Seventh Day Adventist, Congregational or United Church of Christ, Orthodox, Reformed, Muslim, Mormon, Bud- dhist, Christian Scientist, Quaker, Mennonite, Hindu, Mora- vian, atheist, agnostic, other, or none/don’t know/unable to code. For this study, we collapsed participants into 11 denominational groups, including 1 for each of the 9 groups with at least 50 participants, 1 for other, and 1 for agnos- tic, atheist, or none/don’t know/unable to code. Smoking status was determined in 1987/1988 and in 1990/1991 based on responses to 3 interview-administered questions: 1. Have you ever used any tobacco product, such as cigarettes, cigars, tobacco pipe, chewing tobacco, snuff, or nicotine chewing gum? 2. If yes to number 1, have you ever smoked ciga- rettes regularly for at least 3 months? By “regularly,” we mean at least 5 cigarettes per week, almost every week. 3. If yes to number 2, do you still smoke cigarettes regularly? Participants were defined as current smokers if they responded “yes” to all 3 questions. All other participants were considered nonsmokers. In 1987/1988, we asked cur- rent smokers the following yes/no question: “Have you tried to stop smoking cigarettes in the past 2 years?” We also ascertained the number of cigarettes smoked by asking, “How many cigarettes do you smoke per day on the aver- age?” In 1987/1988, we determined age, sex, ethnicity, mari- tal status, years of education, employment status, family history of myocardial infarction (MI), presence of hyper- tension, presence of diabetes mellitus, body mass index, alcohol use, level of physical activity, social network, and whether participants belonged to any organizations or clubs. The physical activity score was defined as the sum of the total number of months (weighted by frequency and in- tensity) during which each of 13 activities was performed during the previous year.18,19 Social network adequacy was measured using a 4-item scale (How often do you [1] feel lonely, [2] find yourself wishing someone would comfort you, [3] feel that other people really care for you [reverse scored], and [4] wish that you had more close friends?). Each question had 4 response categories (4 indicates frequently; 3, occa- sionally; 2, rarely; and 1, never), with higher scores indi- cating a better social network. For participants who com- pleted only 2 or 3 of the 4 items (n = 4), we assigned the mean value of nonmissing responses to the other items. Participants who answered fewer than 2 of the questions did not receive a score. As an additional measure of social activity, we asked participants the following yes/no ques- tion: “Do you belong to any organizations or clubs (such as political groups, athletic teams, or regular groups you play sports with)?” STATISTICAL ANALYSIS For the primary analysis, we decided a priori to compare ciga- rette smoking in participants who reported attending reli- gious services at least once per month (high- or moderate- frequency attendees) with those who reported attending religious services less than once per month or never (low- frequency attendees). Differences in characteristics be- tween groups were compared using �2 tests for dichoto- mous variables and 2-tailed t tests for continuous variables. We used backwards elimination logistic regression for a cross- sectional analysis examining the risk of current smoking in participants who were less frequent attendees of religious ser- vices compared with those who attended religious services more frequently. We added any variables that were associ- ated with smoking (at P�.05) to multivariate models that included frequency of attendance at religious services. Tests of P for trend were calculated using the �2 test for trend in proportions. We examined the association between frequency of at- tendance at religious services in 1987/1988 and subse- quent smoking in 1990/1991 using analyses stratified by initial smoking status. Among participants who were not smoking in 1987/1988, we examined the association be- tween frequency of attendance at religious services in 1987/ 1988 and starting to smoke by 1990/1991. Among partici- pants who reported current smoking in 1987/1988, we examined the association between frequency of atten- dance at religious services in 1987/1988 and smoking ces- sation by 1990/1991. For these analyses, we reported odds ratios (ORs) and 95% confidence intervals (CIs). Analyses were performed using statistical software (SAS version 6.12; SAS Institute Inc, Cary, NC). (REPRINTED) ARCH INTERN MED/ VOL 162, JULY 22, 2002 WWW.ARCHINTERNMED.COM 1605 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 once per month, participants attending less than once per month or never were slightly older; were more likely to be male, white, and unmarried; and reported greater al- cohol consumption (Table 2). Less frequent attendees were also more physically active, were more likely to be- long to an organization or club, and had a lower body mass index. However, these participants had poorer so- cial network scores than those who attended religious ser- vices more frequently. Geographic location was strongly associated with attending religious services, but there were no differences in education, employment, family his- tory of MI, presence of diabetes mellitus, or presence of hypertension by frequency of attendance. Current Smoking Greater frequency of attendance at religious services was associated with less current smoking. High-frequency attendees (�1/wk) had the lowest prevalence (17%) (Figure 1). Of the 4544 participants who completed the tobacco questionnaire in 1987/1988, 34% (891/2598) who attended religious services less than once per month or never reported current smoking compared with 23% (451/ 1946) who attended religious services at least once per month (OR, 1.7; 95% CI, 1.5-2.0; P�.001). This asso- ciation was diminished but still significant after adjust- ing for potential confounding variables (OR, 1.5; 95% CI, Table 1. Distribution of 4569 Participants by Religious Denomination and Proportion Who Reported Current Smoking in 1987/1988 Denomination Black Participants White Participants Total % Current SmokersMen Women Men Women Baptist 487 675 115 122 1399 36 Roman Catholic 74 91 296 346 807 30 Methodist 58 66 75 90 289 29 Lutheran 19 16 113 126 274 34 Pentecostal 55 95 7 17 174 25 Presbyterian 5 7 57 49 118 18 Jewish 0 1 62 48 111 12 Episcopal 10 9 29 45 93 24 Christian Church/Church of Christ 27 22 17 17 83 31 Other* 82 165 114 143 504 20 Agnostic/atheist/none/don’t know/unable to code 149 123 205 212 689 27 Missing 5 7 8 8 28 29 Total 971 1277 1098 1223 4569 29 *Seventh Day Adventist, Congregational/United Church of Christ, Orthodox, Reformed, Muslim, Mormon, Buddhist, Christian Scientist, Quaker, Mennonite, Hindu, or Moravian. Table 2. Characteristics of 4569 Participants by Religious Service Attendance Characteristic �1/mo or Never (n = 2616) �1/mo (n = 1953) P Value Age, mean ± SD, y 27.1 ± 3.6 26.8 ± 3.7 .008 Female, % 50 61 .001 Ethnicity Black 41 61 .001 White 59 39 Married, % 26 37 .001 Education, mean ± SD, y 14.2 ± 3.4 14.2 ± 2.2 .50 Employment, % Full- or part-time 84 84 .60 Not working 16 16 Current drinks per week, mean ± SD, No. 6.2 ± 10.4 3.2 ± 7.0 �.001 Family history of myocardial infarction, % 12 12 .60 Diabetes mellitus, % 1 1 .10 Hypertension, % 2 2 .90 Body mass index,* mean ± SD 24.8 ± 5.0 25.7 ± 5.8 �.001 Physical activity score, mean ± SD 400 ± 288 358 ± 288 �.001 Social network score, mean ± SD 2.7 ± 0.5 2.8 ± 0.5 �.001 Belong to organization or club, % 32 28 .007 Geographic location, % Birmingham, Ala 14 36 Chicago, Ill 23 21 .001 Minneapolis, Minn 32 22 Oakland, Calif 31 21 *Calculated as weight in kilograms divided by the square of height in meters. (REPRINTED) ARCH INTERN MED/ VOL 162, JULY 22, 2002 WWW.ARCHINTERNMED.COM 1606 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 1.3-1.8; P�.001) (Table 3). Among smokers (n = 1342), less frequent attendees reported smoking a greater mean number of cigarettes per day than more frequent attend- ees (14 ± 10 vs 12 ± 9; P�.001). In subgroup analyses, less frequent attendance at religious services was associated with current smoking in all race-sex subgroups except black men (Table 4). Among participants who attended religious ser- vices 1 to 3 times per month (moderate-frequency at- tendees), 30% (267/890) reported current smoking com- pared with 17% (184/1056) of those who attended religious services once per week or more (OR, 2.0; 95% CI, 1.6-2.5; P�.001). This association remained signifi- cant after adjusting for age, ethnicity, marital status, edu- cation, employment status, alcohol use, belonging to an organization, and geographic location (OR, 1.9; 95% CI, 1.5-2.4; P�.001). Religious Denomination The prevalence of smoking ranged from 12% among Jew- ish participants to 36% among Baptists (Table 1). Over- all, Baptists and Pentecostals who attended religious ser- vices less than once a month or never had the greatest prevalence of smoking (Table 5). Jewish and Presby- terian participants had the lowest prevalence of smok- ing, regardless of how frequently they attended reli- gious services. Participants in the “other” category who reported attending religious services at least once per month also had a low prevalence of smoking. Less frequent attendees of religious services had a greater prevalence of smoking than did more frequent attendees across all denomination categories, with the ex- ception of Presbyterians, who had a relatively low preva- lence of smoking regardless of frequency of attendance at religious services (Table 5). However, in multivariate analyses, these associations were statistically significant at the P�.05 level in the Baptist, Pentecostal, and “other” denominational categories only. Smoking Incidence Of the 4569 study participants, 4072 (89%) had fol- low-up smoking data in 1990/1991. Of these, 1741 (43%) attended religious services at least once per month in 1987/ 1988 compared with 212 (43%) of the 497 participants who were lost to follow-up (P = .97). A total of 2913 of 3202 participants (91%) who were nonsmokers in 1987/1988 completed the follow-up to- bacco questionnaire in 1990/1991. Greater frequency of attendance at religious services was associated with less 40 30 35 25 15 20 10 5 0 Low (n = 2598) High (n = 1056) Moderate (n = 890) Frequency of Attendance at Religious Services Cu rr en t S m ok er s, % P Value for Trend <.001 Figure 1. Participants reporting current smoking by frequency of attendance at religious services. Low indicates less than once per month or never; moderate, 1, 2, or 3 times per month; and high, at least once per week. Table 3. Univariate and Multivariate Predictors of Current Smoking (Among All Participants) and Smoking Initiation (Among Nonsmokers)* Predictor (in 1987/1988) Current Smoking Smoking Initiation During 3-Year Follow-up Unadjusted OR (95% CI) (n = 4544) Adjusted OR (95% CI)† (n = 4439) Unadjusted OR (95% CI) (n = 2913) Adjusted OR (95% CI)† (n = 2902) Attending religious services �1/mo or never 1.7 (1.5-2.0) 1.5 (1.3-1.8) 1.8 (1.3-2.5) 1.9 (1.3-2.7) Age (per 10-y increase) 1.0 (0.8-1.1) 1.5 (1.3-1.9) 1.0 (0.6-1.5) . . . Female 0.8 (0.7-0.9) . . . 1.0 (0.7-1.3) . . . Black 1.5 (1.3-1.7) 1.2 (1.0-1.4) 1.6 (1.1-2.1) 1.5 (1.0-2.1) Married 0.6 (0.5-0.7) 0.7 (0.6-0.9) 0.7 (0.5-0.9) . . . Education (per 3-y increase) 0.4 (0.3-0.4) 0.4 (0.4-0.5) 0.5 (0.4-0.6) 0.6 (0.5-0.7) Employed 0.5 (0.4-0.6) 0.7 (0.6-0.9) 0.7 (0.5-1.1) . . . Current drinks per week (per 7-drink increase) 1.5 (1.5-1.6) 1.5 (1.4-1.6) 1.2 (1.1-1.3) 1.1 (1.0-1.3) Family history of myocardial infarction 1.1 (0.9-1.4) . . . 0.9 (0.5-1.4) . . . Diabetes mellitus 1.2 (0.6-2.1) . . . 1.7 (0.5-5.6) . . . Hypertension 1.0 (0.7-1.6) . . . 1.4 (0.5-3.5) . . . Body mass index‡ (per 5.4 increase) 1.0 (0.9-1.1) . . . 1.0 (0.9-1.2) . . . Physical activity score (per 577-point increase) 0.9 (0.8-1.0) . . . 1.0 (0.8-1.4) . . . Social network score (per 1-point increase) 0.8 (0.7-0.9) . . . 0.9 (0.7-1.2) . . . Belong to organization or club 0.5 (0.4-0.6) 0.7 (0.6-0.8) 0.7 (0.5-1.0) . . . Geographic location Birmingham, Ala 0.9 (0.7-1.0) 1.4 (1.1-1.7) 0.9 (0.6-1.3) . . . Chicago, Ill 0.9 (0.8-1.1) 1.3 (1.1-1.7) 0.8 (0.5-1.2) . . . Minneapolis, Minn 1.8 (1.6-2.1) 1.8 (1.4-2.1) 1.7 (1.2-2.4) 1.7 (1.1-2.6) Oakland, Calif 0.6 (0.5-0.7) . . . 0.8 (0.5-1.1) . . . *OR indicates odds ratio; CI, confidence interval; and ellipses, variables that were not included in the model. †Based on a backward elimination logistic regression model including all variables in Table 2. Variables associated with smoking (at P�.05) were retained in the adjusted models. ‡Calculated as weight in kilograms divided by the square of height in meters. (REPRINTED) ARCH INTERN MED/ VOL 162, JULY 22, 2002 WWW.ARCHINTERNMED.COM 1607 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 smoking initiation, with high-frequency attendees (�1/ wk) having the lowest incidence (3%) (Figure 2). A total of 7% (109/1571) of nonsmokers who attended reli- gious services less than once per month or never started smoking cigarettes during 3-year follow-up compared with 4% (54/1342) of those attending religious services at least once per month (OR, 1.8; 95% CI, 1.3-2.5; P�.001). In multivariate analyses, participants attending re- ligious services less frequently in 1987/1988 had a 90% increased risk of starting to smoke during 3-year fol- low-up compared with participants attending religious services at least once per month (adjusted OR, 1.9; 95% CI, 1.3-2.7; P�.001) (Table 3). The independent asso- ciation between less frequent attendance at religious ser- vices and starting to smoke seemed to be present in all race-sex subgroups except black men (Table 4). Among nonsmokers who attended religious services 1 to 3 times per month (moderate-frequency attendees), 5% (29/554) started to smoke during 3-year follow-up com- pared with 3% (25/788) of those who attended services once per week or more (OR, 1.7; 95% CI, 1.0-2.9; P = .06). This association remained present but not statistically signifi- cant after adjusting for ethnicity, education, alcohol use, and geographic location (OR, 1.6; 95% CI, 0.9-2.8; P = .11). Smoking Cessation In 1987/1988, 57% of the 891 smokers who attended re- ligious services less than once per month or never re- ported efforts to quit in the previous 2 years compared with 67% of the 451 smokers who attended religious services at least once per month (adjusted OR, 0.7; 95% CI, 0.6- 0.9; P=.005). However, of the 1159 participants (86%) who were smokers in 1987/1988 and who completed the fol- low-up tobacco questionnaire in 1990/1991, only 15% (117/ 760) of the less frequent attendees reported that they were no longer smoking compared with 17% (69/399) of those attending religious services at least once per month (OR, 0.9; 95% CI, 0.6-1.2; P = .4). Multivariate analysis that ad- justed for potential confounding variables produced simi- lar results (OR, 0.8; 95% CI, 0.6-1.1; P = .2). COMMENT Compared with participants who attended religious ser- vices frequently, less frequent attendees were more likely to report current smoking and to start smoking during 3-year follow-up. This association was particularly evi- dent for the Baptist, Pentecostal, and “other” (Seventh Day Adventist, Congregational/United Church of Christ, Orthodox, Reformed, Muslim, Mormon, Buddhist, Chris- tian Scientist, Quaker, Mennonite, Hindu, or Moravian) denominations and was present in all race-sex sub- groups except black men. Other independent predic- tors of current smoking included age; being black, un- married, less educated, or unemployed; consuming more alcohol; and belonging to a club or organization. Other independent predictors of smoking initiation included being black or less educated and consuming more alco- hol. Living in Minneapolis was associated with current and incident smoking. As with any observational study, we cannot elimi- nate the possibility of confounding because the charac- Table 4. Adjusted Risk of Current and Incident Smoking Associated With Attending Religious Services Less Than Once per Month or Never by Race-Sex Subgroups* Adjusted Odds Ratio (95% CI)† P Value Current Smoking Among All Participants White men (n = 1095) 1.6 (1.1-2.3) .01 White women (n = 1205) 1.7 (1.2-2.3) .003 Black men (n = 942) 1.2 (0.9-1.6) .30 Black women (n = 1248) 1.6 (1.2-2.2) �.001 Smoking Initiation During 3-Year Follow-up Among Participants Who Were Nonsmokers at the Outset White men (n = 760) 2.5 (0.9-6.8) .07 White women (n = 860) 2.8 (1.2-6.3) .01 Black men (n = 517) 1.1 (0.6-2.1) .80 Black women (n = 770) 2.4 (1.3-4.5) .01 *CI indicates confidence interval. †Based on a backward elimination logistic regression model including all variables in Table 2. Variables associated with smoking (at P�.05) were retained in the models. Table 5. Risk of Current Smoking Associated With Attending Religious Services Less Than Once a Month or Never vs Once or More per Month by Religious Denomination Denomination �1/mo or Never �1/mo Odds Ratio (95% CI)* Total No. % Smokers Total No. % Smokers Unadjusted Adjusted† Baptist 615 47 778 27 2.3 (1.9-2.9) 1.6 (1.2-2.0) Roman Catholic 516 33 283 24 1.5 (1.1-2.1) 1.3 (0.9-1.8) Methodist 143 34 145 24 1.6 (1.0-2.7) 1.6 (0.9-3.0) Lutheran 195 36 79 29 1.4 (0.8-2.5) 0.9 (0.5-1.8) Pentecostal 35 51 139 19 4.6 (2.1-10.1) 2.6 (1.0-6.8) Presbyterian 68 18 50 18 1.0 (0.4-2.5) 1.2 (0.4-3.7) Jewish 102 13 7 0 . . . . . . Episcopal 51 27 41 20 1.6 (0.6-4.2) 2.4 (0.7-7.8) Christian Church/Church of Christ 35 34 48 29 1.3 (0.5-3.2) 1.0 (0.4-2.9) Other‡ 212 30 289 12 3.2 (2.0-5.2) 2.8 (1.6-4.9) *CI indicates confidence interval. †Adjusted for age, ethnicity, marital status, education, employment status, alcohol use, belonging to an organization, and geographic location. ‡Seventh Day Adventist, Congregational/United Church of Christ, Orthodox, Reformed, Muslim, Mormon, Buddhist, Christian Scientist, Quaker, Mennonite, Hindu, or Moravian. (REPRINTED) ARCH INTERN MED/ VOL 162, JULY 22, 2002 WWW.ARCHINTERNMED.COM 1608 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 ter traits leading to religious involvement may also re- sult in avoidance of smoking. Likewise, we cannot exclude the possibility that smokers may have chosen not to at- tend religious services owing to concerns about social pressures against smoking. However, given the low prob- ability values, it is unlikely that the strength of the ob- served association between religious involvement and smoking is due to chance. It is also unlikely that biased ascertainment of smoking (eg, underreporting by those who attend religious services) is responsible for this find- ing given the high validity of self-reported smoking in CARDIA study participants.20 If attending religious services does affect cigarette smoking, what are the potential reasons for this associa- tion? Although some denominations, such as Mor- mon,21 prohibit substance use, most do not have ex- plicit proscriptions against smoking. Religious beliefs may provide coping mechanisms that reduce the impact of stressful circumstances that would otherwise precipi- tate cigarette smoking.22 Faith-based coping strategies have been related to improved well-being,23 and religious be- haviors are useful in managing stressful life changes.24 Women seem to derive particular support from reli- gious activities15 and are more likely than men to use re- ligion as a coping mechanism for stress.24 This could ex- plain the stronger association between attendance at religious services and less frequent smoking initiation among women in our study. Another causal possibility is that frequent atten- dance at religious services may provide an educational and supportive social environment. Religious involvement of- fers a sense of belonging to a group with shared values,7 and this environment may promote healthy behaviors.25 Religious adherents may be more likely to adopt healthy practices because many religions emphasize respect for the body26 and discourage risk-taking behavior.27 Two other cohort studies have examined the asso- ciation between religious involvement and cigarette smok- ing, but we are unaware of any studies demonstrating an association between attending religious services and not starting to smoke. One study2 found that participation in private religious activity predicted less subsequent smok- ing in the elderly, but attendance at religious services was not associated with subsequent smoking. Another study15 of adults aged 16 to 94 years found that attendance at re- ligious services was associated with smoking cessation, but its effects on smoking prevalence or incidence were not examined. Other studies5-7,9-14 of religious involvement and smoking have used only cross-sectional analyses or lacked appropriate multivariate adjustments. It is unclear why we observed an association be- tween religious attendance and cigarette smoking in all race-sex groups except black men. This apparent inter- action likely is not due to chance because it was present for both current and incident smoking. It is possible that black men attend religious services for different reasons than do women or white men. Perhaps black men are more likely to attend services to accommodate other family members, less likely to adopt coping strategies associ- ated with religious involvement, or less likely to derive support from the social and educational environment of a church because of more stressful life circumstances. Although our categories of religious denomination may not have captured the considerable variation within distinct denominational subgroups,28,29 they reveal some interesting findings. We observed substantial differ- ences in the distribution of participants across religious denominations. Black participants were more likely than white participants to be Baptist or Pentecostal and less likely to be Roman Catholic, Lutheran, Presbyterian, Jew- ish, or Episcopal. We also observed a wide range of smok- ing prevalences across denominational categories. Jew- ish and Presbyterian participants were less likely to smoke than were members of any other denomination, regard- less of their frequency of attendance at religious ser- vices. Baptist and Pentecostal participants who at- tended religious services fewer than 1 time per month or never had a greater prevalence of smoking than mem- bers of any other denomination. Although differences in ethnicity and socioeconomic status may account for some of these discrepancies, it is possible that some religions but not others espouse themes that promote healthier be- haviors and lifestyle. Our study has 2 major limitations. First, although frequency of attendance at religious services is a com- monly used measure, it does not represent all aspects of religious involvement.22,28 Second, the health effects of involvement in religious activities may not differ from those associated with participation in other community organizations.28 However, even after adjusting for the CARDIA study’s measure of social network and for be- longing to organizations or clubs, the association between attendance at religious services and smoking be- havior was unchanged. In summary, frequent attendance at religious ser- vices is associated with a decreased risk of current smok- ing and smoking initiation in white men, white women, and black women, but not in black men. Whether less smok- ing may explain part of the association between religious involvement and decreased mortality15,30 is unknown. Fur- ther studies are needed to clarify the role that religious in- volvement may play in disease prevention through its effect on cigarette smoking and other behaviors. Accepted for publication November 29, 2001. This study was supported by a Research Career De- velopment Award from the Department of Veterans Affairs 8 6 7 5 3 4 2 1 0 Low (n = 1571) High (n = 788) Sm ok in g In iti at io n, % Moderate (n = 554) Frequency of Attendance at Religious Services P Value for Trend <.001 Figure 2. Nonsmokers reporting smoking initiation at 3-year follow-up by frequency of attendance at religious services. Low indicates less than once per month; moderate, 1, 2, or 3 times per month; and high, at least once per week. (REPRINTED) ARCH INTERN MED/ VOL 162, JULY 22, 2002 WWW.ARCHINTERNMED.COM 1609 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 Health Services Research and Development Service (Dr Whooley); the Robert Wood Johnson Generalist Physician Faculty Scholars Program (Dr Whooley); and contracts NO1- HC-48047, N01-HC-48048, N01-HC-48049, and N01-HC- 48050 from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md (the CARDIA study). We thank Stephen Hulley, MD, MPH, for his com- ments on the manuscript and Li-Yung Lily Lui, MA, MS, and Michael Shino, BA, for their assistance with data analysis. Corresponding author and reprints: Mary A. Whooley, MD, Department of Veterans Affairs Medical Center (111A1), 4150 Clement St, San Francisco, CA 94121 (e-mail: whooley @itsa.ucsf.edu). REFERENCES 1. Bergen AW, Caporaso N. Cigarette smoking. J Natl Cancer Inst. 1999;91:1365- 1375. 2. Koenig HG, George LK, Cohen HJ, Hays JC, Larson DB, Blazer DG. 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