Religious attitude associated with general health and smoking in Iranian students.

BACKGROUND: Given the university students' model role in the society and the importance of period of university education in selecting behavioral methods and lifestyles in the future have made it necessary to study the smoking pattern and its associated factors and complications among students. The aim of this study was to compare religious attitude and mental health between smoking and non-smoking students.
METHODS: In this research, religious attitude and mental health was studied in 1065 smoking and non-smoking students of Kerman University of Medical Sciences. In this study, three questionnaires were used (Demographic Questionnaire, General Health Questionnaire and Religious Attitude Scale Questionnaire) which were completed by the students voluntarily. The data were analyzed by descriptive statistic methods, multivariate analysis of variance (MANOVA), t-test, Pearson correlation, and regression coefficient.
FINDINGS: The mean age of smokers was 20 years and most of the smokers were male (78.9%), single (86.5%) and in BS or BA degree (52.5%). Most of them smoked a cigarette or more in the past month. The average age of start of smoking was 18 years. There was no significant difference between religious attitude and mental health in smoking students in terms of gender but in non-smoking students there was a significant difference in this regard. Smoking students had lower mental health status and religious attitude in comparison with non-smoking students. Between religious attitude and general health in smoking and non-smoking students was also a direct association.
CONCLUSION: Due to psychological and physiological consequences of cigarette smoking, promoting smoking prevention by religious missionaries and university professors, and helping the students to quit smoking by counselors, psychologists and psychiatrics are necessary.

Introduction

Cigarette smoking is a significant factor in mortality and has a negative effect on mental and physical health.1 Mental, physical and social performances are considered as causes and effects of cigarette smoking.2 Studies showed that depression and anxiety are related to cigarette smoking.3–5 Study of Morissette et al indicated that smokers have higher anxiety in comparison with non-smokers.6 In another study that Mykeltun et al has done about smoking consequences, the results indicated a relationship between smoking in youths and depression-anxiety disorders.7 The study of Samimi and Valizadeh in this field showed that smokers had less general health and lower quality of life.8 The other factor that could be discussed in this field is the religion; religion is a subject with long-standing history.9 Religion had been discussed by psychologists like Freud and Jung. Thereafter, thinkers like Stanley Hall and Allport have spent their time in explanation and representation of religion. Moreover, Eric stated that deterministic religion leads to mental disorders but philanthropic and optimistic religion lead to health and growth of individual talent.10 Studies indicated that religious tendencies cause improvement in general health, quality of life, life expectancy and even social communications.11–13 Trevino et al also stated that religious beliefs increase the self-esteem.13 Koenig, based on the studies has done in this field said that “religious beliefs do not always lead to mental health” because clinical psychologists are often faced with patients who feel guilty, ruminated, anxious and rejected which could be due to the contents of their religious beliefs.14 Unlike this finding, Bayani et al,9 Khodayarifard,15 Mir Zamani and Mohamadi16 in various studies showed that religious tendency is conversely related to individuals’ depression and anxiety. The probability of cigarette smoking can be predicted by various factors such as religious attitudes and activities, anxiety and mood disorder.8, 10, 17 Religious commitment and belonging to a valid class which contains desirable social values have been considered as two protective factors from cigarette smoking.18, 19 In another study, religious and spiritual beliefs led to increase in self-esteem, life satisfaction, social relations improvement, adaptive mechanism and decrease in anxiety; the effects of these outcomes reduced cigarette consumption.17 Another study showed that the prevalence of heart diseases was much less common in people with stronger religious attitudes. This subject was related with people's healthy behaviors such as smoking and exercise.14 Religious beliefs and activities prohibit the individual from starting the cigarette smoking and continuing this habit.18, 20 Whooley et al showed that the probability of smoking was less in youths that had deeper religious beliefs and were committed in participating in religious ceremonies.21 Nollen et al have come to realize that social supports and religious tendencies are effective in cigarette smoking.22 A research among Iranian university students showed that the prevalence of smoking has increased, and this period is a specific time point for many to start smoking.23 Given the students’ model role in the society and the importance of university education period in selecting behavioral methods and lifestyles in the future have made it necessary to study cigarette smoking pattern and its associated factors and complications among students.9, 24–26 The general objective of the current study was to compare religious attitude and mental health between Iranian smoking and non-smoking students.

Methods

This research was approved by the Ethics Committee of Neuroscience Research Center of Kerman University of Medical Sciences by moral code number EC/KNRC/87-16. This study was a cross-sectional study on 1065 students of Neuroscience Research Center of Kerman University of Medical Sciences (821 females and 244 males) selected by convenience sampling method. Of these students, 976 were non-smokers and 89 were smokers. Three questionnaires were used in this study. The first questionnaire was for collecting data such as age, marital status, the age of first time started smoking, and the smoking pattern in the past month and past year. To assess religious attitude, we used Religious Attitude Scale Questionnaire. This questionnaire was made by Khodayarifard in 1999 at Tehran University and contained 40 questions based on 5-level Likert scale which was graded from completely agree to completely disagree. Religious attitude score was calculated between 40 and 200. Those who gained 40 to 84 had low religious attitude and a score of 166 to 200 indicated a high religious attitude. The content of questionnaire evaluated ethics, values, the effect of religion on personal and social life style and behavior, ideology and religion beliefs. The reliability of this questionnaire was assessed by open test method which was 83% indicating a high credibility of test.27 The reliability of this questionnaire was calculated 89% by ronbach's alpha coefficient. To assess the mental health, GHQ-28 questionnaire (general health questionnaire) was used. Goldberg and Hillier 1979 designed this questionnaire with 28 questions and four sub-scales: anxiety, physical performance, social function and depression. The grading was based on 4-level Likert scale (never, rarely, usual and more than usual for 0, 1, and 3 respectively). Different studies in Iran reported its reliability as 96% and 84%.28 The reliability of the current questionnaire was calculated as 86% by Cronbach's alpha coefficient method.

The data of this research were analyzed by descriptive statistic methods, multivariate analysis of variance (MANOVA), t-test, Pearson correlation, and regression coefficient.

Results

The scores obtained from this questionnaire were analyzed by utilizing SPSS13 software. As results showed the mean age of the students was almost at the age of twenty and most of the cigarette consumers were male, single, in BS or BA degree and most of them smoked one cigarette or more in the past month. The average age of starting the smoking was at the age of 18 (Table 1). T-test results showed a significant difference between non-smoking males and females in terms of religious attitude and general health (P = 0.001 and P = 0.001, respectively). But, in terms of religious attitude and general health between the two genders in smoking students, no significant difference was observed (Table 2 and 3).

Table 1

Descriptive results of smoking and non-smoking students

Variables		Smoking Number (%)	Non-smoking Number (%)
Gender	Male	75 (78.9)	169 (17.3)
	Female	14 (21.1)	807 (82.7)
Marital status	Single	77 (86.5)	845 (86.7)
	Married	12 (7.3)	130 (13.3)
Educational Degree	AA/AS associate	31 (34.8)	319 (32.7)
	BA/BS bachelor	47 (52.8)	575 (58.9)
	MA/MS master	5 (5.6)	26 (2.7)
	PhD	6 (6.7)	56 (5.7)
Age	20 years old	45 (50.6)	757 (77.56)
	25 years old	42 (42.7)	198 (20.28)
	30 years old	2 (2.2)	21 (2.15)

Table 2

The results of t-test of general health and religious attitude between non-smoking males and females

Variable	Group	Number	Mean	Standard deviation	t-test	Significant level
General health	Female	807	58.93	10.81	4.52	0.001
	Male	109	65.95	9.03
Religious attitude	Female	807	158.60	15.22	4.46	0.001
	Male	109	152.43	20.74

Table 3

The results of significant t-test of general health and religious attitude between smoking males and females

Variable	Groups	Number	Mean	Standard deviation	t-test	Significant level
General health	Female	14	45.92	16.94	0.89	0.41
	Male	75	50.01	9.03
Religious attitude	Female	14	134.42	21.02	0.17	0.86
	Male	75	133.38	20.67

Meanwhile, the results indicated that the correlation between religious attitude and general health variables and its subscales which influenced by factors such as the age of starting smoking, education degree and marital status would either decrease or increase. The results showed that the mean scores of general health and all its subscales (anxiety, depression, physical performance, and social functioning) were higher in smoking students than those in non-smoking students; i.e., depression and anxiety scores in smoking students were higher while social and physical performance scores were lower in comparison with non-smoking students (Table 4). MANOVA tests in association with variables of general health group (Wilks's Lambada = 0.751, F = 14.32, P < 0.01) were significant. In all subscales of general health, there was a significant difference between the two groups as follows: depression (P = 0.01), social performance (P = 0.01), physical performance (P = 0.01) and anxiety (P = 0.01); i.e., depression and anxiety levels were higher in smoking students and social and physical performance levels were lower in comparison with non-smoking students. The results showed that between the two groups there was a significant difference in terms of general health (P = 0.01); i.e., smoking students had much less general health in comparison with non-smoking students. Also, between the two groups there was a significant difference in terms of religious attitude (P = 0.01); i.e., smoking students had less religious attitude in comparison with non-smoking students. The results of Pearson correlation test indicated a significant relationship between religious attitude and general health of smoking students (P = 0.05) and non-smoking students (P = 0.01) (Table 5). The results of simultaneous regression for both general health and religious attitude variables on smoking rate (P = 0.02) showed that religious attitude (β = 0.11) had stronger role in smoking than general health (β = 0.06). Moreover, by controlling religious attitude variable, general health correlation in cigarette smoking reduced from 0.09 to 0.06, while by controlling general health factor, religious attitude correlation in cigarette smoking reduced from 0.133 to 0.109. It seems that religious attitude, as a separate factor regardless of general health, had stronger effect on reduction of cigarette smoking. Simultaneous regression analysis of variables in smoking students (P = 0.17) indicated the following results: depression (β = 0.13), anxiety (β = 0.06), sleeping (β = 0.042), social performance (β = 0.03) and religious attitude (β = 0.12).

Table 4

Descriptive results of mental health subscales in both smoking and non-smoking groups

Variable	Groups	Number	Mean	Standard deviation
Depression	Smoking	89	18.05	3.94
	Non-smoking	976	17.26	4.62
Social performance	Smoking	89	13.42	2.69
	Non-smoking	976	12.73	3.13
Physical performance	Smoking	89	16.39	3.51
	Non-smoking	976	14.88	4.02
Anxiety	Smoking	89	16.21	3.29
	Non-smoking	976	14.74	4.27
General health (Total score)	Smoking	89	64.08	7.94
	Non-smoking	976	59.63	10.63

Table 5

The association of religious attitude and general health in smoking and non-smoking students

Groups	Variable	Number	Mean	Standard deviation	r	Significant level
Non-smoking	Mental health	976	59.63	10.67	0.22	0.001
	Religious attitude	976	157.53	16.46
Smoking	Mental health	89	64.08	7.94	0.29	0.005
	Religious attitude	89	133.33	20.60

Discussion

The current research has studied the religious attitude and general health in smoking and non-smoking students. In this study, smoking rate was higher in males than that in females which was in accordance with Divsalar et al18 However, it is noteworthy that despite cultural and traditional issues in Iran and Islamic nations for female smokers as an antisocial action,29 the rate of smoking among females is increasing.30 The average age of start of smoking was at the age of 18, which was in accordance with other studies.10, 26, 31 This issue emphasizes the necessity of proper planning in order to prevent adolescents and youths from smoking. On the other hand, most of the smoking students were single; that was in accordance with Divsalar et al18, Divsalar and Nakhaee.23 The more social responsibilities, the less possibility of smoking; so, being married -as one of the hardest responsibilities can be a remarkable and significant preventing factor of smoking.1 In this research, there was a difference between non-smoking female and male students in terms of religious attitude; i.e., religious attitude was higher in females than in males, but the related results were not in accordance with the results of Bayani et al9, Cheraghi and Molavi.10 Besides, this study showed that non-smoking males had a higher general health than females which was in accordance with Samimi and Valizadeh8 and Bayani et al,9 but was not in accordance with Cheraghi and Molavi.10 In study of Samimi and Valizadeh, religious attitude and general health of smoking females were higher than those of smoking males, while in the current study there was no difference between these two groups.8 The results of this study indicated that the religious attitude rate in smoking students was lower than that in non-smoking students; the findings, therefore, are in accordance with Samimi and Valizadeh,8 Nollen et al,22 Nonnemaker et al,20 and Divsalar et al.18 Religious attitude and beliefs can be considered as an obstacle for smoking tendency, and also participating in religious ceremonies leads to less cigarette smoking among smoking students.18, 32 The results of the above-mentioned studies indicated the necessity of increasing the knowledge of students in order to promote religious beliefs which can be carried out in different ways such as parents, clergies, teachers, mass media and religious activity groups of the university. From the other point of view, the results of this study showed that general health of smoking students is lower than that of non-smoking students and smoking students had higher anxiety, depression, and lower social performance and sleeping time. The obtained data were in accordance with Morissette et al,6 Mykletun et al,7 Samimi and Valizadeh,8 and Tavakolizadeh et al31 Smoking leads to physical consequences such as pulmonary and heart diseases, and psychiatric disorders such as anxiety and depression. These changes can reduce individual's physical, mental and social life quality. Smoking people smoke cigarette to reduce negative emotions like anxiety, depression and etc. while smoking itself increases their stress.31 Between smoking and anxiety depression disorders, there is a mutual relationship; i.e., smoking leads to these disorders or by having these disorders the individual tends to smoke.21

The results of this study indicated a direct association between religious attitude and general health of non-smoking students. The findings of this study are in accordance with studies of Halling and Unell,11 Smith et al,33 Trevino et al,3 Cheraghi and Molavi,10 and Bayani et al9 Giving hope to life, religion leads to increase in mental health, and the ability to face the stress. Religious attitude leads to self-reliance sense, lack of dependency to others, using people with high religious attitude as models of their life and consequently, accepting the difficulties of life. The religious attitude also leads to increase in social life, protection of peer group and learning the proper ways of decision making for solving the problems.34 Moreover, the results indicated that smoking people with deep religious attitudes have also better general heath. Religious beliefs and participating in the ceremonies can reduce the smoking tendency.23 Religious activities witch close the individual to God and help him/her get rid of frustrations and hopelessness may bring about decrease in depression and anxiety leading to reduction in smoking rate and consequently, improve the quality of life. University admission is a big change in individual's life and prepares him/her for the acceptance of future responsibilities of the society. Lack of adjustment and having improper stress can also be considered as a risk factor for students to smoke. Regarding the increase rate of university admission of students in our country and the increase of vulnerability to smoking, paying specific attention to the youths (especially with regard to their model roles in the society) seems to be necessary in order to accomplish control and prevention interventions. Thus, it is necessary to inform the students by religious missionaries, university professors, consultants, psychologists and psychiatrists regarding the physical and mental consequences of smoking. The authorities and officials can have important roles in reducing smoking tendency of adolescents and youths by creating employment opportunities and proper recreations. The parents and professors also can accomplish this very important job by guidance and creating friendly environments for students.