Relationship between religiosity and smoking among undergraduate health sciences students

Abstract Introduction The university period is often characterized as a critical period of vulnerability for smoking habit initiation. Objective The purpose of this cross-sectional study was to assess the relationship between religiosity and smoking among undergraduate students on health sciences courses. Methods A total of 336 students on four health sciences courses (occupational therapy, speech therapy, nutrition, and physiotherapy) completed a cigarette smoking questionnaire along with the Duke University Religion Index. Results Smoking prevalence was 8.3% among females and 12.7% among males. Prevalence among students who do not have a religion, but do believe in God, was higher than among those who do have a religion (16.3 and 6.3%, respectively). Organizational religious activity has a significant effect on smoking status. Conclusion The students have health habits that are not only motivated by the technical knowledge acquired on their undergraduate courses, since there was a possible influence of social norms stimulated by religious institutions on their attitudes, knowledge and practices in health.


Introduction
Age-standardized prevalence of daily smoking in 2015 among the overall Brazilian population was estimated at 8.2% among females and 12.6% among males. 1 These percentages are relatively low when compared with those reported in countries such as Portugal (12.7 and 24.9%, respectively), Spain (18.6 and 25.6%), Switzerland (16.5 and 21.9%), and Argentina (14.6 and 21.1%), but similar to those found in the United States (11.7 and 14.4%). 1 Although Brazil has experienced a large decline in smoking prevalence due to tobacco control interventions implemented in the last few decades, 2 the direct annual cost of smoking to the public healthcare system is nonetheless estimated at 6.3 billion US dollars (at the prevailing exchange rate in 2019). 3 The university period is often characterized as a critical period of vulnerability for smoking habit initiation. [4][5][6] Smoking habits of students on health science courses deserve special consideration, since they presumably have reasonable knowledge about the harmful effects of tobacco and will become behavioral models, conveying the basic concepts of health into the community. 5,7 In Brazilian studies that have been carried out in populations of undergraduate health sciences students, the smoking habit is found to be more prevalent among male students and is associated with variables such as the course semester attended, alcohol consumption, [6][7][8][9] and use of antidepressants or anxiolytics. 10 One factor that can protect university students from risky behaviors such as smoking is religiosity, as shown in a recent Iranian study. 11 A number of other studies have also suggested that religiosity is associated with smoking habits in students from different cultural and ethnic backgrounds. For example, Nabipour et al. 12 observed that waterpipe smoking has grown in popularity among youth and adolescents in Iran, but that religious observance may play a protective role in lowering waterpipe usage among Iranian university students. Isralowitz et al. 13 found evidence that female Israeli college students who were more religious reported lower use of tobacco, alcohol, and other drugs.
Pule et al. 14 showed that intrinsic religiosity had effects on health risk behaviors, including smoking, among black university students in Limpopo, South Africa.
Considering university students, not much is known about religiosity's protective role against smoking in the Brazilian context. In 2009, a population-based study entitled "First nationwide survey on the use of alcohol, tobacco and other drugs among college students in the 27 Brazilian state capitals" showed that use of tobacco was higher among students who did not attend religious groups or attended occasionally than among those attending religious services at least once a month. 15 However, this study and others 5,7,15,16 only considered religious affiliation and religious involvement as outcomes related to religiosity, but did not include other important dimensions, such as intrinsic religiosity. Therefore, the present cross-sectional study aims to investigate the prevalence of tobacco smoking and dimensions of religiosity measured by the Duke University religion index (DUREL) among undergraduate health sciences students at a Brazilian public university.

Participants and procedure
The study was conducted at the Ribeirão Preto campus of the Universidade de São Paulo, in Southeast Brazil, from August to November of 2018. Students on four health sciences courses (occupational therapy, speech therapy, nutrition, and physiotherapy) were interviewed in their classrooms during school hours with their teachers' permission. Exclusion criteria were not adopted, in order to represent the full diversity of the characteristics of the student population. A printed questionnaire was used to collect data. All students gave their informed consent, and the study protocol was approved by the ethics committee at the Faculdade de Medicina de Ribeirão Preto.

Instruments
The DUREL was used to measure religiosity. 17 This five-item instrument assesses the following dimensions of religiosity: organizational religious activity (ORA), non-organizational religious activity (NORA), and intrinsic religiosity (IR). 18 17,19 Self-perception of religiosity was measured by the question: "Are you a religious person?," with the following response options: very religious, moderately religious, a little religious, and not at all religious. Participants were classified into current cigarette smokers, ex-smokers, and those who had never smoked.

Statistical analysis
Multinomial logistic regression was used to estimate sex and age-adjusted odds ratios (OR) for the relationships between smoking status (current smokers, ex-smokers, or students who had never smoked) and the categories of independent variables (sex, age groups, graduation course, self-perception of health, religion affiliation, and self-perception of religiosity  for the dimensions ORA, NORA, and IR, according to smoking status. We found that women who had never smoked tended to have higher mean scores for ORA and IR than women who currently smoke. DUREL = Duke University Religion Index; IR = intrinsic religiosity; NORA = non-organizational religious activity; ORA = organizational religious activity; SD = standard deviation. * Statistically significant differences from the reference group (current smokers) according to an age-adjusted beta-binomial regression model are marked with an asterisk.

Discussion
The smoking prevalence rates observed in the present study ( and 21.1% in Várzea Grande (Mid-West region). 9 These regional differences suggest that smoking habits may be strongly associated with cultural and social factors.