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Keywords:

  • Fasting;
  • Islam;
  • smoking;
  • smoking cessation;
  • smoking reduction

Ramadan restricts smoking and leads to reduction. Recent research on reduction has focused upon using nicotine replacement therapy (NRT) as a substitute for missed cigarettes and behavioural approaches have been neglected, despite evidence of efficacy. Ramadan reminds us of the need to harness these natural experiments to enhance smoking reduction and hence cessation.

Ramadan, the ninth month of the Islamic calendar, marks the period when Muslims fast during daylight hours to learn patience, humility, sacrifice, self-restraint and, above all, God-consciousness. It is a time of increased devotion to God and spiritual renewal. During the month, Muslims should not eat, drink (any liquid) or smoke from dawn to dusk. In the United Kingdom, there is a national smoking cessation service that has ambitious targets for throughput and a responsibility to reach all ethnic groups. Many public health authorities have used the start of Ramadan as a spur to encourage smoking cessation [1,2], using several lines of reasoning. Enforced abstinence from smoking during daylight will engender withdrawal for many regular smokers [3]. With sustained abstinence withdrawal will subside, but not with continued smoking during darkness, so the period of Ramadan is uncomfortable for many smokers unless they become totally abstinent. Secondly, lapsing during a quit attempt makes achieving prolonged abstinence much less likely [4], and the prohibition against smoking during the day and the absence of others smoking could assist the quit attempt [5]. Thirdly, the element of spiritual renewal could lead to changes in a person's sense of self that might bolster cessation success. Gonzales et al. reported that nine out of 10 smokers in Oregon, United States, had previously believed or currently recognized some higher power [6]. Three-quarters of smokers reported believing that drawing upon spirituality could be helpful when quitting, and the same proportion felt that smoking cessation counsellors should encourage smokers to do so in clinics. This is similar to the treatment of other addictions where discussion of spiritual resources is common, for example, in Alcoholics Anonymous [7].

There are, however, potential disadvantages to encouraging abrupt cessation at the start of Ramadan. Chief among these is that few Muslims take the opportunity to attend smoking cessation clinics. It is possible that our current focus on cessation at the expense of the perhaps more achievable target of smoking reduction is alienating those who might otherwise engage. Whether unassisted attempts at cessation are common is not known, and whether they are more successful at this time is also unknown. Furthermore, most supported cessation attempts involve medication, but many Muslims believe that Ramadan precludes oral medication during daylight, meaning that oral nicotine replacement therapy (NRT) is inappropriate and so, perhaps, is varenicline and bupropion. Abstaining from food increases the urge to smoke [8,9], which might make Ramadan a more difficult time to stop smoking abruptly. Finally, forced abstinence in itself does not lead to permanent cessation in most people [10,11].

Is it possible to make better use of the Ramadan fast to enhance cessation? One way might be through smoking reduction as an initial target. The fast means that smokers cannot smoke during daylight and this is likely to result in reduced smoking. Most smokers do not want to stop imminently, but most report trying to reduce [12]. There is good evidence that smoking reduction programmes enhance cessation [13,14]. Most of these programmes used short-acting NRT to replace missed cigarettes, but this is not an option during Ramadan. However, there are behavioural approaches to smoking reduction. All these behavioural methods constrain when smokers can smoke, as does Ramadan. Several behavioural methods have been used. These include scheduled smoking, where a person smokes on a strict time schedule (for example, every hour) which lengthens progressively [15]. Smoking is precluded at all other times. Hierarchical smoking requires a person to describe the times that they smoke and then eliminate particular cigarettes progressively, starting with the easiest or the hardest [16]. Another method described is for a person to avoid smoking in the first hour after waking and then increase this period of morning abstinence progressively until the whole day is covered [17]. One method we have used, which fits well into a culture that outlaws smoking in many situations, is use of smoke-free periods [18]. People map their ‘smoking breaks’ and decrease these gradually by lengthening the period between breaks. There is some evidence that these behavioural methods are more effective than simply advising cutting down and leaving the choice of when to miss cigarettes to the person [15,19]. One reason why behavioural approaches might work is that a person is no longer ‘allowed’ to smoke in particular circumstances, and this could undermine a learned association between cue and smoking that many believe maintains tobacco addiction.

Most recent research on smoking reduction has focused upon NRT. However, population data suggest that NRT use for reduction does not achieve the same success as achieved by programmes with behavioural support [12,20]. Behavioural approaches to reduction require that a person learns and follows the approach. If we are to use Ramadan to enhance cessation through reduction, we are likely to need to engage Muslim smokers not only to follow the fast, but to continue the method of controlling their smoking after the fast is broken. Explaining why this might help and providing support are likely to be necessary but so, too, is further research to develop and test behavioural approaches to reduction.

Declarations of interest

  1. Top of page
  2. Declarations of interest
  3. Acknowledgements
  4. References

Paul Aveyard has received funding and hospitality from manufacturers of products for smoking cessation.

Acknowledgements

  1. Top of page
  2. Declarations of interest
  3. Acknowledgements
  4. References

The ideas for this editorial came from work funded by the National Prevention Research Initiative of the UK (G0501288). This National Prevention Research Initiative (http://www.npri.org.uk) receives support from the following organizations: British Heart Foundation; Cancer Research UK; Chief Scientist Office, Scottish Government Health Directorate; Department of Health; Diabetes UK; Economic and Social Research Council; Health and Social Care Research and Development Office for Northern Ireland; Medical Research Council; Welsh Assembly Government; and World Cancer Research Fund. We are grateful to our colleagues who are working with us. Paul Aveyard is funded by the National Institute for Health Research. Paul Aveyard, Rachna Begh and Amanda Amos are part of the UK Centre for Tobacco Control Studies.

References

  1. Top of page
  2. Declarations of interest
  3. Acknowledgements
  4. References
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