Testing the Feasibility and Acceptability of a Religiously-Tailored Text Messaging Intervention to Reduce Smoking Among Somali Muslim Men During Ramadan

Abstract

Introduction

The prevalence of smoking among Somali Muslim male immigrants residing in Minnesota is estimated at 44%, however smoking reduction is common during the month of Ramadan. This study evaluated the feasibility and impact of a religiously tailored text message intervention delivered during Ramadan to encourage smoking reduction among Somali Muslim men who smoke.

Methods

Fifty Somali men were recruited. Participants received two text messages per day starting 1 week prior to and throughout the month of Ramadan. Approximately half were religiously tailored and half were about the risks of smoking and benefits of quitting. Smoking behavior was assessed at baseline, and at weeks 4 (end of Ramadan), 8, and 16. Outcomes included feasibility, acceptability, and preliminary impact of the text message intervention on smoking reduction and bioverified abstinence.

Results

The average age was 41 years. Average time to first cigarette was 1.8 hours at baseline, and 46% of participants smoked menthol cigarettes. Eighteen of 50 participants selected English and 32 selected Somali text messages. Subjects significantly reduced self-reported cigarettes per day (CPD) from 12.4 CPD at baseline to 5.8 CPD at week 16 (p < 0.001). Seven subjects reported quitting at week 16, five completed CO testing, confirming self-reported abstinence. The majority of participants found the cultural and religious references encouraging at the end of the week 16 survey.

Conclusions

Religiously tailored text messages to decrease smoking are feasible and acceptable to Somali Muslim men who smoke during Ramadan. This intervention for addressing smoking disparities is worthy of further study.

Implications

Recruitment of Somali Muslim men who smoke is feasible and supports the idea that further studies targeting smoking during Ramadan are practical. Ramadan presents a window of opportunity upon which to build smoking cessation interventions for smokers who identify as Muslim. These preliminary findings suggest that text messaging is a feasible and acceptable intervention strategy, and that religious tailoring was well received. Such an approach may offer potential for addressing smoking disparities among Somali Muslim male smokers.

Trial Registration

ClinicalTrial.gov: NCT03379142

Introduction

Globally, Muslim communities have a high smoking prevalence,^1–5 despite evidence supporting the use of pharmacotherapy and counseling for smoking cessation.^6,7 A 2017 survey of United States Muslims showed a smoking prevalence of 62.8% and 41.3% in men and women, respectively,⁸ which is high compared to the average smoking prevalence in the United States of 15.1%.⁹ While the general US population has experienced declines in smoking,¹⁰ there is no indication that such benefits are being experienced by Muslim communities. There have been few studies that have explored how to promote the benefits of smoking cessation to Muslims, even though there are now an estimated 3.45 million Muslims in the United States.¹¹ The high prevalence of smoking is apparent among Somali immigrants in the United States, who overwhelmingly identify as Muslim (estimated prevalence of smoking among Somali men in Minnesota of around 44%). Smoking is generally considered a stigmatized behavior among Somali women, and this is reflected in a lower smoking prevalence of around 4%.¹

The reasons for high smoking prevalence in this community are unclear, however, there are circumstances that can result in temporary smoking reduction or cessation in Muslim communities, such as during Ramadan, the holy month observed by Muslims.^12,13 Ramadan is considered the most sacred month of the Islamic calendar, and for many Muslims, this is a time when smokers are motivated to quit smoking.¹⁴ Throughout Ramadan, Muslims practice patience, humility, sacrifice, and self-restraint by fasting during daylight hours.¹⁵ There are differing views regarding tobacco use during Ramadan; some, but not all Muslims consider tobacco forbidden during that time.¹³ However, while tobacco use is not necessarily forbidden, tobacco use is considered to violate several Islamic principles, such as engaging in frivolous spending, or damaging one’s health. Several studies have documented changes in smoking behavior (ie, cessation or smoking reduction) during Ramadan.^14,16 These reductions in smoking however are commonly the result of willpower alone,¹³ typically accomplished without aids such as nicotine replacement therapy. Research has also shown that Muslims who are more spiritual and pray daily are generally less likely to smoke at any time.^13,17,18

Muslim health-related behaviors are commonly influenced by faith, including the influence of religious leaders,^19–23 with religiosity often viewed as an important protective factor for health.^24,25 Previous attempts to culturally tailor cancer prevention interventions that draw on the Muslim faith as a strength in the community, particularly to address breast and cervical cancer screening, have been shown to be effective in the Somali community.^26–28 There may be benefits in applying an approach to smoking cessation that engages religious perspectives on tobacco use, along with discussing the risks of tobacco through education and increasing access to programs that promote prevention and cessation.¹⁸ Smoking reduction or cessation during Ramadan may offer an opportunity to tailor a smoking cessation intervention that fosters long-term abstinence. However, to date studies have not sought to leverage spontaneous reductions in smoking during Ramadan, and target that time as an opportunity for smoking cessation interventions.

Text messaging is an evidence-based intervention that can lead to long-term cessation.^29,30 A recent systematic review also found text messaging programs for smoking cessation can increase quit rates when used in conjunction with other interventions.³¹ However, both reviews highlight the need for further research on the impact of text messaging interventions in diverse populations. Text messaging interventions have the potential to be easily tailored to better reach and engage more diverse tobacco users. The objective of this study was to gain knowledge about the acceptability and feasibility of developed text-messaging intervention to reduce or stop smoking by Somali Muslim men during Ramadan. To our knowledge, this is the first study to use text messaging as an intervention to promote smoking cessation in the Somali Muslim community.

Methods

We conducted a single-arm observational study that utilized religiously tailored text messages for 50 Somali Muslim men, starting one week before the beginning of Ramadan and extending throughout the month of Ramadan. Seventy-eight text messages were delivered (2/day); approximately half were religiously tailored and the rest were standard text messages about the risks of smoking and benefits of quitting from the QuitNowTXT Message Library.³² A full account of the data collected to inform the tailoring of the religiously tailored messages has been previously published.³³ Data about smoking behavior and experience with the intervention were collected 4, 8, and 16 weeks after the intervention.

Participants

Somali Muslim men who smoke were recruited through a community partner (Wellshare International, Minneapolis) who made contacts with potential participants in mosques, social gatherings, and coffee shops in Minneapolis, Minnesota. In 2018, Ramadan occurred from May 15 to June 14 and recruitment began approximately one month before that time. All participants received the intervention one week before the start of Ramadan. Inclusion criteria were: self-reported Somali male, 18 years and older, practicing Muslim, ability to read in either Somali or English, current smoker (defined as smoking at least one cigarette per day and at least 100 cigarettes in their lifetime), owning a working cell phone with a text message plan, and having plans to observe Ramadan. Smokers were included regardless of if they used regular or mentholated cigarettes. Exclusion criteria included insufficient smoking. Screening, consent, and data collection procedures were conducted by trained, bilingual study staff at Wellshare International. Participants received up to $160 for participating in the study, with $40 at baseline, $10 for weeks 4 and 8, and $100 at week 16.

Intervention

A total of 78 messages were developed for the intervention. The religiously tailored messages (approximately half of the total) were developed in conjunction with a local imam and informed by input from focus groups conducted among Somali Muslim men who smoke.³³ The religiously tailored messages were combined with messages drawn from the publicly available QuitNowTXT Message Library (“health-related message”),³² as focus group participants expressed a preference for both health-related and religiously tailored messages.³³ Participants were not explicitly asked to stop smoking or commit to a quit date, but rather were recruited on the basis they would be willing to consider quitting in order to test the acceptability and feasibility of the tailored intervention. Messages encouraging quitting smoking were delivered in order to test the acceptability and the impact of such messages on smoking behavior. One religiously tailored and one health-related message per day was delivered, making a total of two messages per day. Messages were sent in the same order to all participants; sample messages can be found in Table 1. Messages were timed to be delivered at sunrise and sunset, starting one week before the beginning of Ramadan and continuing throughout the month of Ramadan (total 5 weeks). Participants were able to select messages in English or Somali.

Table 1.

Example Text-Messages Used in the Study Intervention

Message type	Example message content
Religiously tailored messages	Smoking is forbidden among faithful Muslims.
	As Muslims we must protect the health and safety of all life, our own, and others that are around us.
	Don’t kill yourselves, and make not your own hand contribute to your destruction. [(Qur’an 2:195)].
	Stop. Breathe. Remind yourself, Allah is with you. He’s watching over you. He’s testing you because He loves you. He hasn’t forgotten you. He’s making you stronger. Alhamdulillah. Smile.
	Spend your wealth for the cause of Allah, and be not cast by your own hands to ruin; and do good. Indeed! Allah loves the righteous.
QuitNowTXT message library messages	In the United States, tobacco kills more people than AIDS, alcohol, car accidents, murders, suicides, drugs, and fires combined. Quit today!
	There are so many benefits to being smokefree. Tell a friend what you look forward to most!
	There is NO such thing as safe tobacco. Cigars, pipes, hookah, and dip carry many of the same health risks as cigarettes, like addiction.
	Many people use cigarettes to deal with stress or boredom. Try going to the gym, taking a jog, or talking to a friend instead of smoking.
	You may feel strange when you quit- this is withdrawal. You are addicted to nicotine and your body is used to smoking. These feelings will go away.

Data Collection

Trained bilingual study staff collected data in person from study participants. Surveys were administered at baseline, and at weeks 4, 8, and 16.

Demographics

Age, gender, education, marital status, income, employment status, and race/ethnicity were collected at baseline. Religious beliefs and faith were assessed using the Iranian Religious Coping Scale, which measures five different domains of religious coping, being religious practice, negative feelings towards God, benevolent reappraisal, passive, and active states.³⁴ General health status and a brief anxiety and depression screen (PHQ4)³⁵ were also collected at baseline as psychosocial variables can have an impact on smoking, and week 16 to assess any changes in psychological state.³⁶

Smoking

Baseline data included 24-hour quit attempts in the past year, average number of cigarettes smoked per day (CPD), age of smoking initiation, time to first cigarette, menthol cigarette use, and a brief assessment of smoking urges.³⁷ Motivation was assessed through instruments asking about the importance of quitting and confidence to quit, measured on a 10 point scale (one was not important/confident and 10 was extremely important/confident).³⁸ Additionally, a measure of thoughts of quitting smoking was taken using an 11 point scale from 0, no thoughts of quitting to 10, taking action to quit.³⁸ Measuring motivation and confidence were included as they can be predictors of outcomes.³⁸ Smoking reduction was measured by self-reported CPD over the last 7 days at weeks 4, 8, and 16. A measure of expired carbon monoxide (CO) was attempted for all participants who reported having quit at week 16 using a portable CO monitor, with <8 ppm being used as the threshold for quit. The cutoff of <8 ppm was selected as a widely used measure,^39,40 and due to the absence of any data specific to this population indicating a lower level would provide better accuracy.

Intervention Acceptability

At week 4 participants were asked to rate how often they read the text messages they received. At week 16 participants rated their satisfaction with various components of the intervention (including satisfaction with the study, the text messages, and the number of messages sent), and of the overall program on a five-point Likert scale ranging from “not at all helpful” to “very helpful.” They were also asked if they were willing to recommend the program to other Somali Muslim men who smoke on five-point scale, where one was “Not satisfied at all” and five was “Very satisfied” Additionally, three open-ended questions asked what participants liked about the program, disliked, and what other suggestions they had for improvement.

Statistical Analysis

Descriptive statistics were used to summarize baseline and follow-up data. Linear mixed models with a categorical variable for week of assessment and a random intercept for correlation of observations within the same individual were used to analyze the primary outcomes over time. Time to first cigarette was analyzed among participants who reported smoking. Results were presented separately for the thinking of quitting scale for all participants and those who did not quit. When comparing time to first cigarette for those who did not quit, a one-sample Student’s t test was used to compare each week to baseline. CO at week 16 was summarized using mean, standard deviation, median and range, and a test for correlation between CO and CPD at week 16 was performed. Self-reported frequency of reading text messages at week 4, and self-reported satisfaction with the intervention at week 16 were summarized. General and psychological health was compared between baseline and week 16 using a one-sample Student’s t test. All reported p-values are two-sided and a significance level of .05 was used. Analyses were performed using R Statistical Software (version 3.4.2). Open text comments were analyzed through coding the text and conducting a thematic analysis of responses.⁴¹

Human Subjects

All study procedures were approved and monitored by the University of Minnesota’s Institutional Review Board.

Results

Table 2 shows the summary of the baseline characteristics (N = 50). The average age of participant was 41 years, more than half had a household income less than $30 000, 74% were married, and nearly all participants had been in the United States for 5 years or longer. Participants smoked an average of 12.4 CPD, and 46% smoked menthol cigarettes. During Ramadan in the previous year, participants reported smoking an average of 4.9 CPD and 34% reported stopping smoking completely.

Table 2.

Summary of Baseline Characteristics and Demographics (N = 50).

Variable	Option	All subjects
Demographic variables
Age, mean (SD)		40.8 (8.1)
Race, n (%)	Black	48 (98.0)
	White	0 (0.0)
	Other	1 (2.0)
Length in United States (years), n (%)	≤1	0 (0.0)
	2–4	1 (2.0)
	≥5	49 (98.0)
Household income, n (%)	<$15 000	10 (20.8)
	$15 001–$20 000	11 (22.9)
	$20 001–$30 000	10 (20.8)
	$30 001–$45 000	4 (8.3)
	$45 001–$60 000	9 (18.8)
	$60 001–$75 000	0 (0.0)
	>$75 001	4 (8.3)
Education, n (%)	Less than high school	25 (50.0)
	High school or greater	25 (50.0)
Marital status, n (%)	Never married	8 (16.0)
	Married for the first time	33 (66.0)
	Remarried	4 (8.0)
	Separated	0 (0.0)
	Divorced	5 (10.0)
	Widowed	0 (0.0)
Number of people at home, mean (SD)		4.3 (2.6)
Job status, n (%)	Employed	39 (81.2)
	Unemployed	9 (18.8)
Religious coping variables1
Religious practice subscale, mean (SD)		4.6 (0.7)
Benevolent reappraisal subscale, mean (SD)		4.4 (0.9)
Passive subscale, mean (SD)		4.1 (1.3)
Active subscale, mean (SD)		4.9 (1.0)
Negative feelings towards God subscale, mean (SD)		2.4 (1.8)
Tobacco-related variables
Cigarettes per day, mean (SD)		12.4 (6.8)
Menthol, n (%)		23 (46.0)
Number of 24-hour quit attempts, mean (SD)		2.8 (2.5)
Age started regularly smoking, mean (SD)		18.5 (3.4)
Importance of quitting,2 mean (SD)		9.1 (1.2)
Confidence of quitting,3 mean (SD)		8.6 (1.7)
Planning to quit during Ramadan, n (%)	No	3 (6.1)
	Yes	39 (79.6)
	Reduce	7 (14.3)
Thinking of quitting, n (%)	0: No thought of quitting	0 (0.0)
	1	0 (0.0)
	2: Think I need to consider quitting	0 (0.0)
	3	0 (0.0)
	4	1 (2.0)
	5: Think I should quit but not quite ready	5 (10.0)
	6	2 (4.0)
	7	2 (4.0)
	8: Starting to think about how to change my smoking patterns	14 (28.0)
	9	11 (22.0)
	10: Taking action to quit (for example: setting a quit date or cutting down)	15 (30.0)
Current rules about smoking inside the home, n (%)	Not allowed	46 (92.0)
	Allowed in some rooms or at some times	4 (8.0)
	Allowed anywhere	0 (0.0)
Number of family and friends that smoke, mean (SD)		6.2 (15.5)
Cigarettes per day in past Ramadan (one year prior), mean (SD)		4.9 (3.4)
Cigarettes per day in past Ramadan (one year prior), median (range)		5 (0, 18)
Smoke before Iftar (the breaking of the daily fast), n (%)		1 (2.0)
Smoke after Iftar, n (%)		43 (86.0)
Smoke during Iftar, n (%)		4 (8.0)
Quit smoking last Ramadan, n (%)		17 (34.0)

¹Religious coping variables were measured using a 6-point scale where 1 is ’Never’ and 6 is ’Many times a day’. The 5 subscales were calculated as an average of the questions in that subscale.

²Importance of quitting was measured using a 10-point scale where 1 is “Not important” and 10 is “Extremely important.”

³Confidence of quitting was measured using a 10-point scale where 1 is “Not confident” and 10 is “Extremely confident.”

Changes Associated With the Intervention

Subjects smoked significantly fewer cigarettes per day at weeks 4, 8, and 16 compared to baseline (all p < .001, see Table 3). Participants reported an average change of −6.7 CPD (95% CI:−8.7, −4.6, p < .001) over 16 weeks. For time to first cigarette, there was a significant increase from baseline to weeks 8 and 16 (both p = .007). There was also a significant increase in thinking of quitting scale between baseline and week 4 (p = .013), although this difference attenuated at week 16. Seven subjects reported quitting at week 16, five completed CO testing, confirming self-reported abstinence.

Table 3.

Comparison of Outcomes Over Time

Outcome	Baseline N = 50	Week 4 N = 47	Week 8 N = 48	Week 16 N = 46	Mean difference1 (95% CI)	p-value2
Cigarettes per day, mean (SD)	12.4 (6.8)	7.3 (4.7)	7 (4.6)	5.8 (4.1)	−5.3 (−7.3, −3.3)	<0.001
median (range)	12 (1, 30)	7 (0, 15)	7 (0, 20)	5.5 (0, 15)	−5.8 (−7.8, −3.8)	<0.001
					−6.7 (−8.7, −4.6)	<0.001
Cigarettes per day = 0, n (%)	0 (0.0)	3 (6.4)	5 (10.4)	7 (15.2)
Cigarettes per day > 0, n (%)	49 (100.0)	44 (93.6)	43 (89.6)	39 (84.8)
Time to first cigarette in the morning (hours), mean (SD)	1.8 (1.8)	2.3 (1.2)	2.7 (1.6)	2.7 (1.8)	0.5 (−0.1, 1.9)	0.093
					0.9 (0.2	0.007
					0.9 (0.2	0.007
Time to first cigarette in the morning ≤ 30 minutes, n (%)	7 (14.0)	1 (2.3)	0 (0.0)	1 (2.6)
Time to first cigarette in the morning > 30 minutes, n (%)	43 (86.0)	42 (97.7)	43 (100.0)	37 (97.4)
Thinking of quitting,3 mean (SD)	8.3 (1.7)	9.2 (1.1)	8.2 (1.7)	7.2 (2.6)	0.9 (0.2, 1.6)	0.013
					−0.01 (−0.7, 0.7)	0.984
					−1.1 (−1.8, −0.4)	0.002
Thinking of quitting for those who didn’t quit,4 mean (SD)	8.3 (1.7)	9.1 (1.2)	8.0 (1.7)	6.7 (2.6)	0.8 (0.2, 1.4)	0.008
					−0.3 (−1.1, 0.5)	0.455
					−1.5 (−2.4, −0.6)	0.003

¹Three mean difference and 95% confidence intervals are listed for the comparison of week 4 to baseline, week 8 to baseline, and week 16 to baseline.

²p-value is for linear mixed model with a random intercept to account for correlation within individuals. Each p-value is for the comparison of each outcome between baseline and weeks 4, 8, and 16.

³Thinking of quitting was measured using an 11-point scale where 0 is “No thought of quitting” and 10 is “Taking action to quit.”

⁴This outcome was analyzed using a one-sample Student’s t test for change from baseline. For week 4 to baseline comparison, subjects who quit at week 4 were excluded, for week 8 to baseline comparison, subjects who quit at week 4 or week 8 were excluded, and for week 16 to baseline comparison, subjects who quit at week 4, 8, or 16 were excluded.

There was a significant reduction in total PHQ-4 score from baseline to week 16 (p = .007, Table 4). With regard to individual items of PHQ-4, there was a significant reduction in feeling nervous, anxious, or on edge, and feeling down, depressed or hopeless between baseline and week 16 (p = .03 and p = .02, respectively).

Table 4.

Pre and Post Intervention Comparison of General and Psychological Health

Variable	Baseline N = 50	Week 16 N = 46	Mean difference (95% CI)	p-value3
General health,1 mean (SD)	4.0 (0.8)	3.6 (1.1)	−0.3 (−0.7, 0.02)	0.062
PHQ-42
Feelings and emotions total score, mean (SD)	1.8 (2.1)	00.9 (1.5)	−0.9 (−1.6, −0.3)	0.007
Feeling nervous, anxious, or on edge, mean (SD)	0.4 (0.6)	0.2 (0.5)	−0.2 (−0.4, −0.02)	0.031
Not being able to stop or control worrying, mean (SD)	0.5 (0.6)	0.3 (0.5)	−0.2 (−0.4, 0.02)	0.071
Feeling down, depressed or hopeless, mean (SD)	0.5 (0.6)	0.2 (0.5)	−0.2 (−0.4, −0.04)	0.020
Little interest in doing things, mean (SD)	0.5 (0.7)	0.3 (0.5)	−0.2 (−0.5, 0.01)	0.062

¹General health was measured using a five-point scale where one is “Poor” and five is “Excellent.”

²PHQ-4 variables were measured using a four-point scale where 0 is “Not sure” and three is “Nearly every day.” Total score was calculated as a total of the PHQ-4 questions.

³p-value is for a one-sample Student’s t test for change from week 16 to baseline.

Feasibility of the Intervention and Protocol

Study retention rates were 47/50 (94%) at week 4, 48/50 (96%) at week 8, and 46/50 (92%) at week 16. At week 4, participants were asked to describe how often they read the text messages they received: 66% said “always,” 21.3% said “often,” 4.3% said “sometimes,” 8.5% said “occasionally.” No participants described never reading the messages. Participants described high levels of satisfaction with the intervention (Table 5), and 91.3% of participants said they would recommend the program to others.

Table 5.

Self-Reported Satisfaction with Intervention at Week 16 (N = 46)

Variable	Option	All subjects
Overall program satisfaction,1 mean (SD)		4.6 (0.7)
Satisfaction with quality of text messages,1 mean (SD)		4.7 (0.5)
Satisfaction with quantity of text messages,1 mean (SD)		4.5 (0.7)
Recommend program, n (%)	Definitely not	0 (0)
	Probably not	1 (2.2)
	No opinion	3 (6.5)
	Yes, probably	7 (15.2)
	Yes, absolutely	35 (76.1)

¹Satisfaction variables were measured using a five-point scale where one is “Not satisfied at all” and five is “Very satisfied.”

The week 16 survey also asked participants to share what they liked, did not like, or felt could be improved about the intervention. The comments were overwhelmingly positive in relation to the intervention. Twenty-five generally positive comments on the intervention overall were made, including liking the program overall and not wanting to change anything about the program. Seventeen comments were made about how the study financial incentives were appreciated. In relation to responses about the text message content, the messages themselves were well received (n = 10), found to be encouraging (n = 5), and a helpful reminder to not smoke (n = 3). However, some comments shared a view there could have been fewer messages (n = 10). Comments were made particularly appreciating the timing of the messages to coincide with Ramadan (n = 8). The tailoring of the content to be responsive to both culture and religion was also appreciated (n = 3).

The fact this program is based on my culture and religion, it encouraged me more than any other program I have been involved in the past.

Discussion

This study aimed to test the acceptability and feasibility of tailoring a text-messaging intervention to address smoking among Somali Muslim men during Ramadan. We showed that 50 Somali Muslim men were willing to enroll in the study and engage with the text messages, and demonstrated a 92% retention rate at follow up. This indicates recruitment is feasible and supports the idea that further studies targeting smoking during Ramadan are practical. Participants were overwhelmingly positive about the intervention. Participants felt it was tailored in response to their faith, particularly liking the relevance to Ramadan and the way in which the messages included religiously tailored content. While many text message interventions decrease in intensity over time,⁴² interventions may need to re-intensify as Ramadan concludes in order to help sustain abstinence or maintain motivation for quitting.

Data show a change in smoking behavior, with a significant reduction in CPD through the 16 weeks follow-up assessment. Fourteen percent of participants reported having quit and sustained that quit for 16 weeks. Participants also experienced increases in motivation and confidence in quitting, although this was not consistently sustained at follow-up. Significant improvements were also observed in relation to measures of self-reported anxiety and depression. It is noteworthy that 34% of participants stated they quit smoking during the Ramadan in the year before to this study. This may be due to the social desirability bias of reporting having quit during Ramadan, along with limited recall of behavior that from one year prior. It also indicates that while quitting smoking may happen during Ramadan, it is not often maintained, and our findings suggest there is potential to maintain sustained quit beyond Ramadan with the appropriate support.

This study has several limitations, including the absence of a control group which would help to clarify the impact of the intervention from the impact of Ramadan itself. Participants were enrolled from a single metropolitan area in the Midwestern United States and the intervention may not be equally applicable to smokers who identify as Muslim in other regions of the United States or internationally. In addition, participants enrolled in the pilot study had to be identify as Somali Muslim men who smoke, and therefore, may not yield results that can be generalized to smokers who identify as Somali Muslim women. Finally, the focus on feasibility meant that participants were not formally asked or required to set a quit date at the beginning of Ramadan, and the intervention effect might be different under those conditions. Further empirical work should investigate the efficacy of a combined religiously tailored text message interventions to support smoking reduction and cessation before, during and post‐Ramadan. Future studies could also be improved through additional biomarker measures of cessation, such as cotinine, and collecting data that allows a comparison of the effect of religiously tailored messages to that of health-related messages.

Ramadan presents a window of opportunity upon which to build smoking cessation interventions for Muslim men who smoke. These preliminary findings suggest that text messaging is a feasible and acceptable intervention strategy, and that religious tailoring was well received. Such an approach may offer potential for addressing smoking disparities among Muslim men who smoke.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.

Acknowledgments

We would like to acknowledge our community partners, WellShare International and the Islamic Civic Society of America (ICSA) and their staff.

Funding

This pilot trial was funded by ClearWay, Minnesota (NCE - RC 2017-0007). Research reported in this publication was also supported by NIH grant P30 CA77598 utilizing the Biostatistics and Bioinformatics Core shared resource of the Masonic Cancer Center, University of Minnesota and by the National Center for Advancing Translational Sciences of the NIH Award Number UL1TR002494.

Declaration of Interests

None declared.