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Tobacco Control in Vietnam
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Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Review Paper
Tobacco Control in Vietnam D.T. Tran a, R.O. Kosik b, G.A. Mandell c, Y.A. Chen c, T.P. Su c, A.W. Chiu c, A.P. Fan c,* a
Department of Nephrology and Endocrinology, Children’s Hospital, HoChiMinh City, Vietnam Santa Clara Valley Medical Center, San Jose, CA, USA c School of Medicine, National Yang-Ming University Taipei, Taiwan b
article info
summary
Article history:
Objectives: To investigate the use of tobacco in Vietnam.
Received 13 July 2011
Study design: Review study.
Received in revised form
Methods: Data were collected through a review of tobacco-related literature in Vietnam.
16 June 2012
Grey literature and web content from agencies such as the World Health Organization and
Accepted 19 November 2012
the US Centers for Disease Control and Prevention were consulted.
Available online 22 January 2013
Results: Tobacco smoking is still common in Vietnam, although numerous policies have been issued and implemented over the last two decades. Based on the most recent data
Keywords:
(2010), the prevalence of smoking among adults aged >15 years was 23.8%, with a higher
Smoke
percentage among males (47.4%) than females (1.4%). The prevalence of smoking among
Tobacco
students aged 13e15 was 3.8% (2007), with a similar gender pattern. The prevalence of
Vietnam
exposure to secondhand smoke is of concern, with 73.1% and 55.9% of adults reporting
Cigarette
exposure to secondhand smoke at home and at work or other places, respectively. Of the
MPOWER
adult respondents, 55.5% believed that smoking may cause lung cancer, stroke and heart disease. Most students (93.4%) and adults (91.6%) had seen anti-smoking media messages. Of the students, 56.4% had seen pro-cigarette advertisements on billboards, 36.9% had seen pro-cigarette advertisements in newspapers or magazines, and 8.2% had been offered free cigarettes by tobacco company representatives. The price of cigarettes decreased by approximately 5% between 1995 and 2006, whereas gross domestic product per capita increased by more than 150%. On average, smokers smoked 13.5 cigarettes per day, and spent US$86 on cigarettes per year. Despite such high levels of tobacco exposure in Vietnam, the total tax on cigarettes remains at 45% of the retail price. Furthermore, only 29.7% of smokers had been advised to quit by a healthcare provider in the past 12 months. Conclusion: Strong enforcement and evidence-based regulations which rounded on MPOWER are needed to help protect current smokers and non-smokers from the devastating effects of tobacco. ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. P.O. Box 22072, Taipei, Taiwan, ROC 100. Tel./fax: þ886 937 190763. E-mail address: [email protected] (A.P. Fan). 0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2012.11.012
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Introduction
Methods
Vietnam has one of the highest smoking rates in the world. In 2010, almost half of males (47.4%) and one in 70 females (1.4%) reported that they currently smoked some form of tobacco.1 Although the prevalence of smoking in Vietnam is lower than it was a decade ago (72.8% of men and 4.3% of women),2 the absolute number of smokers has not declined: 15.5 million Vietnamese smoked in 1997 compared with 15.3 million in 2010.1,2 Smoking also affects non-smokers, as 67.6% and 49% of adults have reported that they are exposed to secondhand smoke at home and work, respectively.1 Smoking has adverse health consequences for both smokers and secondhand smokers. Compared with non-smokers, odds ratios for periodontitis of 7.17 and 2.37 have been reported for heavy smokers (>5 pack-years) and light smokers (5 packyears) in Vietnam, respectively.3 Model projections of the prevalence of moderate to severe chronic obstructive pulmonary disease in those aged 30 years predict nearly 2 million cases.4 Lung cancer was the most common cancer in males from 1993 to 2007, with recent incidence rates of 27.30 per 105 in males and 10.50 per 105 in females.5 Population-based cancer mortality registration recorded 11,409 lung cancer deaths (8383 in males) in 2006, making lung cancer the second most common cause of cancer death in adults.6 Children are inevitable, and sometimes overlooked, victims of smoking. It has been reported that 70.5% of Vietnamese children aged <5 years were exposed to environmental tobacco smoking and 63.5% were exposed to indoor smoking. It is estimated that 44,000 excess hospital admissions for pneumonia each year among children aged <5 years are attributable to environmental tobacco smoking in Vietnam.7 Tobacco consumption also has a detrimental effect on the national economy. In 1998, it was estimated that the total expenditure on tobacco smoking was US$435.6 million. This could have been used to purchase 1.6 million tons of rice, and provide food for 10.6 million people for 1 year.8 In 2005, the costs of just three diseases (lung cancer, ischaemic heart disease and chronic obstructive pulmonary disease) attributable to tobacco use in Vietnam were approximately US$77.5 million, representing 4.3% of the country’s total healthcare expenditure.9 In 2000, the Government of Vietnam responded to the high prevalence of tobacco use with a National Tobacco Control Policy (NTCP) for the following 10 years. It aimed to reduce the smoking rate in men from 50% to 20%.10 In addition, over 15 decrees and decisions were issued along with international conventions and multilateral collaborations. For example, Vietnam signed the World Health Organization Framework Convention on Tobacco Control on 3 September 2003, and ratified it into law on 17 December 2004.11 However, the results have not been as promising as the government had hoped, with only a 2.6% reduction over the 10-year period. It is not clear whether the failure was due to inconsistent and poorly implemented policies, fast social changes or business strategies instituted by the tobacco companies. This paper provides a comprehensive overview of evidencebased data concerning implementation of the six measures of the MPOWER package.
An extensive review of the literature with no time limit was conducted using PubMed. Search terms were ‘tobacco’ or ‘smoking’ or ‘cigarette’ AND ‘Vietnam’, both in English and in Vietnamese. Only surveys that used a nationally representative, randomly selected sample of sufficient size were considered. Data from the websites of the World Health Organization and the US Centers for Disease Control and Prevention were gathered. In addition, academic and grey literature were obtained from government agencies, such as the Vietnamese Ministry of Health and the Vietnam Steering Committee on Smoking and Health. The references of collected articles were also reviewed to identify further related articles.
Results Seven national representative data sets were found: the Vietnam Living Standards Survey from 199312 and 199813; the Vietnam National Health Survey from 200114; the Vietnam Household Living Standards Survey from 200615; a study by Jenkins et al.2 from 1998; the Vietnam Global Adult Tobacco Survey1 from 2010; and the Vietnam Global Youth Tobacco Survey (students aged 13e15 years) from 2007.16 Other relevant papers have been presented under each MPOWER target. Table 1 summarizes tobacco control in Vietnam by MPOWER target.
Protecting people from second hand smoke The Law on the Protection of Peoples’ Health, passed in June 1989, was the first effort by the Government of Vietnam to recognize smoking as a public health issue, and to demonstrate the Government’s commitment to tobacco control. Article 15, Chapter II stated that ‘smoking is banned in halls, cinemas, theatres, and designated public places’.17 In August 2000, the NTCP was signed by the Prime Minister as an affirmation of the Vietnamese Government’s commitment to tobacco control. It prohibited smoking during meetings; on public transport; in offices, medical facilities, schools, kindergartens, cinemas and theatres; and in otherwise unspecified crowded places. Other goals included protecting the rights of non-smokers to breathe clean, smoke-free air and to reduce tobacco-related losses for individuals, families and society as a whole.18 In 2001, the Prime Minister established the Vietnam Committee on Smoking and Health, a steering committee for tobacco control.19 Decree No. 45/2005/NDeCP by the Prime Minister made important steps towards tobacco control, stating for the first time that a warning or a fine of 50,000e100,000 VND ($US3e6) would be levied for breaching a number of tobacco policies. Smoking cigarettes or pipe tobacco in public places e such as theatres, cinemas, meeting rooms, offices, hospitals, libraries, waiting rooms at railway stations, bus stations, airports, ports, on public transport or in other public places e was henceforth prohibited.20 In 2009, the Prime Minister signed the Ratification of the Action Plan for the Implementation of the WHO Framework
Table 1 e Summary of tobacco control in Vietnam by MPOWER and suggestions for future control. Objective
Government regulations
Offer help to quit tobacco use Easily accessible August 2000, National Tobacco Control Policy for 2000e2010 stated services to manage that ‘Encourage, organize and support measures of tobacco addictobacco dependence tion and rehabilitation research methods in accordance with the conditions of Vietnam’. To enhance training of health workers in methods of smoking cessation is suitable for all investors. The Government’s Decision No. 1315/QDeTTG dated 21 August 2009 on Ratification of the Action Plan for the Implementation of the WHO Framework Convention on Tobacco Control continued to support the development and effective implementation of smoking cessation programmes, and diversification of the methods of smoking cessation counselling. Must be integrated into national health and educational programmes and strategies, and involve health workers, educators and community workers. Issue permission for production, importation and use of pharmaceutical products for the treatment of tobacco addiction and apply preferential taxation policies to these products in accordance with the relevant government regulations. Promote research into and application of cessation methods appropriate to the socio-economic conditions of Viet nam. Allocate a budget for the development of cessation services from the state budget, international aid, and contributions from service users in the forms of user fees and health insurance premiums.
Suggestions
In 2007, 58.5% students aged 13e15 years exposed to smoke at home and 71.2% exposed to smoke in other places. In 2010, 73.1% of adults were secondhand smokers. In 2010, smoking in public places occurred quite commonly, including at 22.3% of schools, 23.6% of healthcare facilities, 34.4% of public transport, 38.7% of government buildings, 54.3% of universities, 84.9% of restaurants and 92.6% of bars/cafes/tea shops.
Strong law and regulation enforcement. Prohibit all indoor smoking.
In 2007, a survey in students aged 13e15 years found that 100.0% had ever received help to stop smoking. In 2010, only 27.2% of current and former smokers visited a healthcare provider for curative or preventive care or counselling services. Nicotine replacement therapy was used by 24.4% of respondents. Only 3% used counselling/advice.
Increase counselling. National smoking cessation programme.
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Protect people from tobacco smoke Completely smoke June 1989, Law on the Protection of Peoples’ Health stated that free environments ‘smoking is banned in halls, cinemas, theatres, and designated public places’. August 2000, National Tobacco Control Policy for 2000e2010 prohibited smoking during meetings, in offices, at medical facilities, at schools, in kindergartens, in cinemas, in theatres, on public transport, and in otherwise unspecified crowded places. 2005, Decree No. 45/2005/NDeCP of Prime Minister on Regulation on Sanctioning of Administrative Violations in the Health Sector stated that a warning or a fine of 50,000e100,000 VND (US$3e6) for smoking cigarettes or pipe tobacco in some public places. 2009, Ratification of the Action Plan for the Implementation of the WHO Framework Convention on Tobacco Control prohibited smoking in the above places, planned to prohibit all indoor public places from 2010, strict enforcement of penalties imposed for smoking violations in public places.
Facts
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Table 1 e (continued ) Objective
Government regulations
Warn about the dangers of tobacco High levels of Decree 119/2007/NDeCP on tobacco production and trade required awareness of the that all packets should be labelled with the label taking up 30% of the health risks of packet’s surface ‘Smoking can cause lung cancer’ or ‘Smoking can tobacco use cause chronic obstructive pulmonary disease’ in black text on white background; this took effect from 1 April 2008. The Government’s Decision No. 1315/QDeTTG dated 21 August 2009 on Ratification of the Action Plan for the Implementation of the WHO Framework Convention on Tobacco Control also supports the implementation of pictorial health warnings to warn about the harmful health effects of smoking. However, it does not clearly state the content and graphic presentation, or when it must be implemented.
Suggestions
92.4% of current smokers had noticed health warnings on cigarette packs. 66.7% of them had thought about quitting smoking because of those health warnings. 95.7% of adults agreed that smoking tobacco cause dangerous diseases. 95.6% of adults were aware that smoking caused lung cancer, stroke (70.3%) and heart attack (62.7%). However, only 55.5% of them believed that smoking caused all three of these diseases. 87.0% of adults agreed that secondhand smokers could get dangerous diseases due to the smoke/fumes. In 2007, 93.4% students aged 13e15 years had seen anti-smoking media messages; in 2010, 91.6% of adults had seen anti-smoking media messages.
Warning labels should cover at least 50% of packet display areas. Increase more precise as well as strong warning messages. Warning messages should be rotated. Pictorial warnings.
In 1995, 62.3% of respondents did not recall seeing or reading any cigarette advertising. In 2007, 56.4% of students aged 13e15 years had seen pro-cigarette advertisements on billboards, 36.9% had seen pro-cigarette advertisements in newspapers or magazines, and 8.2% had been offered free cigarettes by a tobacco company representative. In 2010, 16.9% of adults had noticed any form of tobacco advertising, sponsorship or promotion. Tobacco advertisements in shops were seen by the highest number of people (8.6%), followed by restaurants/cafes/tea shops (3.7%), on television (2.1%) and in cinemas (0.2%). 3.2% of people overall had noticed cigarette promotions on clothing or other items with a brand name or logo. 16.2% of non-smokers aged 15 years had noticed cigarette advertisements over the past 30 days. Non-smokers had seen cigarette advertisements in shops and restaurants/cafes/tea shops (8.3% and 3.5%, respectively). Current smokers were given free samples, coupons and free gifts/discounts on other products more often than non-smokers (1.5% vs 0.6%, 1.7% vs 0.8% and 1.8% vs 1.0%, respectively).
Strong law and regulation enforcement.
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Enforce bans on tobacco advertising, promotion and sponsorship Complete absence of In 1992, Directive 13-TTG of the Prime Minister banned tobacco tobacco advertising, advertising on mass media and required removal of erected signs/ promotion and panels with tobacco advertising. sponsorship In 2000, the National Tobacco Control Policy for 2000e2010 prohibited all forms of tobacco advertising and marketing activities. Strengthening the implementation of the strict ban on all forms of cigarette advertising, sponsorship and marketing by the Government’s Directive 12/2007/CTeTTG in 2007 and the Government’s Decision No. 1315/QDeTTG in 2009.
Facts
Surveillance, monitoring and evaluation Effective No specific requirement on effective surveillance. surveillance, monitoring and evaluation systems in place to monitor tobacco use
Price declined by approximately 5% between 1995 and 2006. In 1995, smokers smoked a mean of 9.6 cigarettes per day, and the equivalent of approximately 4.5 cigarettes for those who smoked water pipes exclusively. They spent an average of US$49.05 on cigarettes each year. In 2010, the average price for a packet of 20 cigarettes was only 5500 VND (US$0.29). In 2010, smokers smoked an average of 13.5 cigarettes per day, and they spent an average of US$86 on cigarettes each year.
Annually increase the special consumption tax so that prices of tobacco products would increase in excess of the growth rate of the economy. Add an effective specific tax, indexed to inflation. Need a specific water pipe tobacco excise tax. Establish special govern mental agency to help tobacco farmers and anti-smuggling. Also execute and manage tobacco control strategies.
1993e2006: 25e36% of the Vietnamese population were current smokers, predominantly males. The highest rates were recorded in 1995, with 72.8% male and 4.3% female current smokers. In 2010, 23.8% (15.3 million) of Vietnamese adults aged 15 years were current smokers: males, 47.4%; females, 1.4%. Of these current smokers, 81.8% were daily smokers. Most people smoke cigarettes (19.5% manufactured and 1.1% hand rolled) followed by water pipes (6.4%) and other smoked tobacco (0.1%). In 2007, 3.8% of students aged 13e15 years, predominantly male, were current smokers.
Periodically obtain nationally representative and population-based data on key indicators of tobacco use for youth and adults.
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Raise taxes on tobacco products Progressively less Before 1990, 5% revenue tax on tobacco enterprises. affordable tobacco From 1990 to 1998, special consumption tax of 52% or 70% on filtered products cigarettes produced mainly from imported materials or from domestic materials, respectively, and of 32% on non-filtered cigarettes and a tariff rate of 70% on imported cigars. From 1999 to 2005, a slight decrease of 5e7% in special consumption tax for all types of tobacco. From 1999, 10% value added tax was introduced for the first time. From 1 April 2000, Decision No. 175/1999/QDeTTG of the Prime Minister on the stamping domestic cigarette production was begun implementation In 2006, Vietnam imposed a uniform special consumption tax at 55% of the wholesale price across all cigarettes. This rate increased to 65% in 2008. However, water pipe tobacco, which is quite common, especially in rural areas, is not subject to taxation. The enterprise tax has decreased by nearly 25% in the past 18 years. In 1993, the rate decreased from 40% to 35%. In 1999, it was further decreased to 32%, and in 2004, it was eventually brought down to 28%. Imported cigarettes and cigars from the World Trade Organization’s ‘most favourite nations’ are taxed at a rate of 150% of the merchandise’s cost, insurance and freight (CIF) value and at a rate of 225% of the CIF value for cigarettes and cigars from other countries.
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Convention on Tobacco Control, prohibiting smoking in classrooms, kindergartens, medical facilities, libraries, cinemas, theatres, cultural houses, the in-house manufacturing sector and workplace, on public transport and where there is high risk of fire. It also planned to ban smoking in all indoor public places from 2010. Strict enforcement of sanctions was imposed for smoking violations in public places.21
Tobacco cessation support In 2010, more than two-thirds of smokers aged 15 years said that they planned to stop smoking some time in the future: 38.2% planned to quit in more than 1 year, 19.8% planned to quit within the next year, and 9.5% planned to quit within the next month. More male smokers were planning to quit than female smokers (68.5% vs 36.9%). More than half of the current and former smokers (55.3%) had been abstinent for less than 12 months. Nearly one-third (27.2%) of the current and former smokers had visited a healthcare provider for curative or preventive care or counselling services, and the figure was higher among women (36%). Less than one-third of smokers had been advised to quit smoking by a healthcare advisor when they visited a doctor or healthcare provider.1 Nicotine replacement therapy (24.4%) was the most common cessation method used by current smokers who had made a quit attempt in the past 12 months. Other methods (constituting <10%) were prescription medications (e.g. Bupropion, Varenicline), counselling/advice, traditional medicines, smokeless tobacco, etc.1 In 2007, a survey among students aged 13e15 years found that 75.4% wanted to stop smoking, 79.7% had tried to stop smoking during the past year, and 100.0% had received help to stop smoking.16,22
Education on the dangers of tobacco use In 2007, the Ministry of Health failed to adopt strong health warning measures, such as those covering at least 30% of the front and rear surfaces of tobacco packets. They used health warnings with words or pictorials, such as ‘Smoking causes lung cancer’, ‘Smoking is harmful to foetuses and infants’, ‘Smoking causes bleeding of the brain’, ‘Smoking causes chronic obstructive pulmonary disease’ and ‘Smoking causes bad breath and rotten teeth’.23 Decree 119/2007/NDeCP on tobacco production and trade only required all packets be labelled with the label taking up 30% of the packet’s surface and stating ‘Smoking can cause lung cancer’ or ‘Smoking can cause chronic obstructive pulmonary disease’ in black text on a white background.24 The Government started to support the implementation of pictorial coverage to warn the consumer about the harmful health effects of smoking, but specific content or graphic presentation, or the timetable over which this must be implemented were not mandated.21 In 2010, most smokers had noticed the health warnings on cigarette packets (93.3% males, 64.3 females). As a result of these warnings, two-thirds of the sample had thought about quitting smoking (67.6% males, 38.1% females). Regarding the specific smoking-related diseases, 95.6%, 70.3% and 62.7% of adults were aware that smoking may cause lung cancer, stroke and heart attack, respectively, but only 55.5% believed
that smoking may cause all three diseases.1 Eighty-seven percent of adults, including 82.2% of current smokers and 88.5% of non-smokers, agreed that non-smokers who inhale smoke/fumes released by tobacco smokers could be at risk of dangerous diseases due to the smoke/fumes.1 Meanwhile, according to the Vietnam Global Adult Tobacco Survey,25 the percentage of adults aged 15 years who had noticed anti-smoking information published by any form of media over the past 30 days was 91.6%. Television and billboards were the two most common forms of media through which people saw anti-smoking information. People living in rural and urban areas were equally likely to have seen antismoking information on television, which is the most popular form of media in Vietnam. The proportion of people who noticed anti-smoking information on the Internet was 12.0%, 8.3% and 13.1% for overall, current and non-smokers, respectively. Younger people (aged 15e24 years) were more likely to see anti-smoking information on the Internet than older people, regardless of whether they were smokers or not.
Tobacco advertising, promotion, and sponsorship Weak enforcement of the law In 1992, Directive 13-TTG by the Prime Minister banned tobacco advertising on mass media, and required removal of erected signs or panels with tobacco advertising.26 Just 3 years later, however, 62.3% of respondents did not recall seeing or reading any cigarette advertisements.2 In 2000, the NTCP prohibited all forms of tobacco advertising and marketing activities. It also prohibited domestic organizations receiving financial assistance from organizing cultural activities, arts and sports linked with tobacco advertising.10 However, in 2003, smokers were still able to see protobacco messages in newspapers and magazines. Tobacco company representatives were still able to offer cigarettes to both smokers and non-smokers.13 In 2007, pro-cigarette advertisements could be seen on billboards (56.4%) and newspapers/magazines (36.9%).11 More government directives were issued in 2007 and 2009 in an effort to strengthen bans on all forms of cigarette advertising, sponsorship and marketing.21,27 Unfortunately, in 2010, the percentage of the overall population, those aged 15e24 years, and those aged 25 years who noticed any form of tobacco advertising, sponsorship or promotion was still high (16.9%, 25.3% and 14.0%, respectively). Tobacco advertisements in shops were seen by the highest number of people (8.6%), followed by restaurants/cafes/tea shops (3.7%), on television (2.1%) and in cinemas (0.2%). Current smokers exhibited patterns similar to the overall population in terms of noticing cigarette advertising.25
Tobacco taxation Before 1990, tobacco enterprises were subject to a 5% revenue tax. From 1990 to 1998, tobacco products in Vietnam were subject to a special consumption tax: 52% on filtered cigarettes made from imported materials, 70% on filtered cigarettes made from domestic materials, 32% on non-filtered cigarettes and 70% on imported cigars.28 To get a sense of the relative weight of tobacco spending compared with other household expenses, in 1995, the average amount spent on cigarettes was US$49.05 per year.
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This represents 1.5 times the annual per-capita household expense for education (US$30.82), five times the annual percapita household expense for healthcare (US$9.65), and approximately one-third of the annual per-capita household expense for food (US$143.27).2 From 1999 to 2005, a slight decrease (5e7%) in special consumption tax was implemented for all types of tobacco in Vietnam, and a 10% value added tax (VAT) was implemented for the first time.29 In 2006, Vietnam imposed a uniform special consumption tax at 55% of the wholesale price across all cigarettes and cigars, regardless of the origin of the material used. This rate increased to 65% in 2008, while the VAT rate has not changed since it was introduced. Water pipe tobacco, which is particularly common in rural areas, is not subject to taxation.29 This could be because the industry is fragmented with no standard brands. Despite the introduction of new taxes, total taxes on tobacco in Vietnam remain low compared with countries with successful tobacco control programmes, where rates range from 65% to 80% of the final retail price (Table 2).30 The enterprise tax is a tax on tobacco companies’ profits. It has decreased by nearly one-quarter in the past 18 years. In 1993, the rate was dropped from 40% to 35%. In 1999, it was further decreased to 32%, and in 2004, it was reduced to 28%.29 Although the Vietnamese Government imposed many types of tax and higher taxes between 1995 and 2006, the cost of tobacco products has not increased. In fact, it has decreased by approximately 5%.29 For instance, the price of a packet of Vinataba (Vietnam’s most popular brand) was approximately VND 10,000 in 1996 (in 2006 VND) (US$0.63),2 but was priced at about VND 8500 (US$0.53) 10 years later. Meanwhile, the gross domestic product per capita increased sharply by more than 150% from US$288 in 1995 to US$731 in 2006.31 Today, the average price for a pack of 20 cigarettes is even lower (VND 5500, US$0.29).1 It should be noted that the inflation rate was 8.8% when the survey was conducted.32 In 2010, current smokers smoked an average of 13.5 cigarettes per day, and spent an average of US$86 on cigarettes each year.1 This amount of money represents twice the annual per-capita household expense for education (US$43), more than twice the annual per-capita household expense for healthcare (US$39), and approximately one-quarter of the annual per-capita household expense for food (US$340).34
Tobacco monitoring The most recent data (2010) indicated that 15.3 million adults aged 15 years (23.8%, higher percentage of males than females) currently smoke tobacco in Vietnam. The prevalence rates of current smokers were similar in urban and rural areas (23.3% vs 24.0%, respectively). Of the current smokers, 81.8% were daily smokers. The prevalence rates for current smoking increased with age: 26.1% and 0.3% for males and females, respectively, aged 15e24 years, and 59.5% and 2.9% for males and females, respectively, aged 45e64 years. The average number of cigarettes smoked per day by daily cigarette smokers was 13.5 overall, 13.6 for men and 10.9 for women.1 The higher prevalence of smoking in males compared with females has been noted for the last two decades.2,12e14,35 The highest rates were recorded in 1995, with 72.8% of males and 4.3% of females smoking. Rates decreased to 49.2% in males
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and 1.5% in females in 2006. The pattern of current smoking was unchanged by age, with lower rates seen among both males (21.5e38.7%) and females (0.2e0.5%) aged 15e25 years, increasing to 68.9e84.1% for males aged 35e44 years, and 3.6e17.9% for females aged 65 years.2,12e14,35 In 2007, the prevalence of current smokers in students aged 13e15 years was 3.8% (6.5% in boys and 1.5% in girls).16,22
Discussion The Vietnamese Government has issued numerous decrees and directives in tobacco control; however, there have been no strict regulations at all levels of Government, indicating a lack of determination by the Central Government. Meanwhile, the objectives set out for tobacco control could be unrealistic without thorough review and evaluation of the societal situation. For example, the NTCP set a goal to reduce the smoking rate in men from 50% to 20%,10 but only achieved a reduction of 3% in 10 years. It appears that strong leadership combined with scientificbased measures which rounded on MPOWER is needed. Women who engage in smoking are subject to wide societal disapproval, and are thought to have questionable moral values, while for men, smoking is a natural and accepted social norm, particularly at social gatherings.36 Although the proportion of female smokers is much lower than that of male smokers, female smokers seem to be less interested in quitting (36.9% vs 68.5%). As a result, preventing the initiation of smoking by women, especially young women, is extremely important.36e38 Therefore, future tobacco control policies should be built on normative influences and gender specifics. In addition, policy should consider the potential influence of women regarding their husbands’ smoking behaviour; 15.3% of men who had quit smoking attributed their success to advice from their wives.39 Despite the large number of people who want to quit smoking in Vietnam, relevant programmes have remained scarce1 and those that do exist are inadequate. In current practice, smoking cessation programmes are generally integrated into other programmes, leading to insufficient budget and human resources. A national smoking cessation programme would be very helpful and should include costeffective measures aimed to promote tobacco cessation such as physician counseling.40 Although citizens demonstrated a high level of knowledge about the adverse consequences of smoking, the results show that thorough comprehension of this problem was limited: 92.4% of current smokers had noticed health warnings on cigarette packets, but only 66.7% of them thought about quitting smoking due to those health warnings. Therefore, media and public education campaigns should be enhanced. Increased pictorial warning labels with precise and strong warning messages may help.41,42 The Government could use diverse methods for taxation. For example, increasing the special consumption tax would increase the price of tobacco products. A recent assessment estimated that a 10% increase in the price of cigarettes can lead to a decrease in consumption of at least 5%.29 Policies that increase tax would receive overwhelming support from the Vietnamese people: 71.3% of adults, 71.9% of men and 70.8% of women.43
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Table 2 e MPOWER research results for the Vietnam Global Adult Tobacco Survey (GATS) and Vietnam Global Youth Tobacco Survey (GYTS). GATS Year 2010 Tobacco monitoring and the institution of prevention policies Currently smoke tobacco (%) Overall 23.8 Males 47.4 Females 1.4 Currently smoke cigarettesa (%) Overall 19.9 Males 39.7 Females 1.2 Currently smoke tobacco products other than cigarettes (%) Overall 6.4 Males 13 Females 0.1 Secondhand smoke At home (%) All people 73.1 Non-smokers 67.6 At work or other places (%) All people 55.9 Non-smokers 49 Tobacco cessation support Smokers who made a quit attempt in the past 12 months (%) Overall 55.3 Males 55.6 Females 44.4 Current smokers who plan to or are thinking about quitting smoking next month (GATS)/want to stop smoking (GYTS) (%) Overall 9.5 Males 9.6 Females 5.3 Smokers advised by a healthcare provider to quit in the past 12 months, or those who have ever received help stopping smoking (GYTS) (%) Overall 29.7 Males 30.2 Females 20.3 Education on the dangers of tobacco use Adults who believe smoking causes serious illness 95.7 Adults who believe smoking causes stroke, heart attack and lung cancer 55.5 Adults who believe exposure to tobacco smoke causes serious illness in non-smokers 87.0 Adults who believe cigarettes are addictive 94.4 Have been taught in class, during the past year, about the dangers of smoking Have discussed in class, during the past year, the reasons why people their age smoke Think smoke from others is harmful to them Tobacco advertising, promotion, and sponsorship: weak enforcement of the law Adults who noticed cigarette marketing in stores where cigarettes are sold 8.6 Adults who noticed any cigarette advertisements, sponsorship or promotions 16.9 Adults who noticed anti-cigarette smoking information on the television or radio 87.2 Saw pro-cigarette advertisements on billboards in the past 30 days Saw pro-cigarette advertisements in newspapers or magazines in the past 30 days Have an object with a cigarette brand logo Have been offered free cigarettes by a tobacco company representative Saw anti-smoking media messages in the past 30 days Tobacco taxation Median amount spent on 20 manufactured cigarettes (one pack) 5500 VND (US$0.29) Median yearly cigarette expenditure per current cigarette smoker 1,096,000 VND Average cost of 100 manufactured cigarettes as a percentage of per-capita gross 2.7% domestic product Adults who support increasing taxes on tobacco products Overall 71.3 Males 71.9 Females 70.8
GYTS 2007
3.3 5.9 1.2 3.8 6.5 1.5
58.5
71.2
79.7
75.4
75.4
73.3% 45.5% 85.0%
56.4% 36.9% 11.3% 93.4%
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Table 2 e (continued ) GATS Tax (% of retail price) Total Excise VAT Import duty and other taxes
GYTS
45 36 9 0
a Current smoker was defined by asking ‘During the past 30 days, on how many days did you smoke cigarettes’ for GYTS and ‘Do you currently smoke tobacco daily or occasionally’ for GATS.
Increasing tobacco taxes would generate higher tax revenue for the Government. The extra revenue could then be used to create some special governmental agencies aiming to reduce the country’s reliance on the tobacco industry. The agencies could fund programmes that support poor farmers who wish to give up tobacco cultivation to find new vocations, to help cigarette factory workers learn new skills to find jobs in other sectors, and so forth. Some governmental agencies should also have a role in strengthening anti-smuggling measures in Vietnam. Downsizing of the tobacco industry would only affect a small percentage of the workforce, while improving many socio-economic problems in Vietnam. However, specific methods to cut the businesses is a complicated issue that needs thorough planning. Vietnamese leaders, who tend to rely on their own systems too much, could benefit a great deal from other sources in strategic planning. The failure of the NTCP is an example of the Government’s inability to execute policy initiatives effectively on its own. Therefore, consulting experts who have extensive experience in tobacco control, inside and outside of Vietnam, should be undertaken. Ideally, some special governmental agencies, as mentioned above, should be created to execute and manage tobacco control strategies. Implementation of these strategies should be evaluated and revised regularly by taking account of the results and analyses from nationally representative and population-based data in order to ensure specific policies that are still effective, and to ensure that the relevant resources are not being wasted. Furthermore, independent evaluations should be undertaken to assess all aspects of the policies in an objective manner. Ensuring that independent evaluators do not have any tie to the Government and administration is vital. Additionally, better coordination between the ministries and relevant governmental agencies is needed to avoid duplication of tasks. All of this would also ensure that the plans are not just implemented, but those in charge and in control of the resources are held responsible for their actions. Similar obstacles exist in almost all large developing countries with a complicated governmental structure. Therefore, lessons from Vietnam are likely to provide useful reference for other countries pursuing tobacco control strategies.
Acknowledgements Ethical approval None sought.
Funding This study is supported by the Ministry of Education Grant MOE 99QC038.
Competing interests None declared.
references
1. MOH, University HM, GSO, CDC, WHO. Global Adult Tobacco Survey (GATS) Viet Nam. Hanoi: Ministry of Health of Vietnam, Hanoi Medical University, General Statistics Office, Centers for Disease Control and Prevention, World Health Organization; 2010. 2. Jenkins CNH, Dai PX, Ngoc DH, Kinh HV, Hoang TT, Bales S, et al. Tobacco use in Vietnam. Prevalence, predictors, and the role of the transnational tobacco corporations. J Am Med Assoc 1997;277:1726e31. 3. Do GL, Spencer AJ, Roberts-Thomson K, Ha HD. Smoking as a risk indicator for periodontal disease in the middle-aged Vietnamese population. Commun Dentist Oral Epidemiol 2003;31:437e46. 4. Regional COPD Working Group. COPD prevalence in 12 AsiaPacific countries and regions: projections based on the COPD prevalence estimation model. Respirology 2003;8:192e8. 5. Vuong DA, Velasco-Garrido M, Lai TD, Busse R. Temporal trends of cancer incidence in Vietnam, 1993e2007. Asian Pacif J Cancer Prev 2010;11:739e45. 6. Ngoan le T, Lua NT, Hang LT. Cancer mortality pattern in Viet Nam. Asian Pacif J Cancer Prev 2007;8:535e8. 7. Suzuki M, Yanai H, Matsubayashi T, Yoshida L-M, Tho LH, Minh TT, et al. Association of environmental tobacco smoking exposure with an increased risk of hospital admissions for pneumonia in children under 5 years of age in Vietnam. Thorax 2009;64:484e9. 8. Minh NT, Kinh HV, Lam NT, Hien NTT, Ngoc VTB. Financial burden of smoking on households in Vietnam. J Prac Med 2006;533:101e8. 9. Hana Ross DVT, Phu Vu Xuan. The costs of smoking in Vietnam: the case of inpatient care. Tob Control 2007;16:405e9. 10. Government of Vietnam. National tobacco control policy 2000e2010. Hanoi: Government of Vietnam; 2000. 11. World Health Organization. WHO report on the global tobacco epidemic, 2009. In: Implementing smoke-free environments. Geneva: WHO; 2009. 12. General Statistics Office. Vietnam Living Standard Survey (VLSS), 1992e1993. Hanoi: General Statistics Office; 1994. 13. General Statistics Office. Vietnam Living Standard Survey (VLSS), 1997e1998. Hanoi: General Statistics Office; 2000.
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14. Ministry of Health. Vietnam National Health Survey (VNHS), 2001e02. Hanoi: Ministry of Health; 2003. 15. General Statistics Office. Result of the Vietnam household living standards survey 2006. Hanoi: General Statistics Office; 2006. 16. Van Minh H, Hai PT, Giang KB, Nga PQ, Khanh PH, Lam NT, et al. Effects of individual characteristics and school environment on cigarette smoking among students ages 13e15: a multilevel analysis of the 2007 Global Youth Tobacco Survey (GYTS) data from Vietnam. Glob Public Health 2011;6:307e19. 17. Vietnam National Assembly. Law on the protection of peoples’ health. Hanoi: Vietnam National Assembly; 1989. 18. Government of Vietnam. Government resolution on ‘National Tobacco Control Policy’ 2000e2010. Hanoi: Government of Vietnam. Available at: http://www.vinacosh.gov.vn/%3mPage %3d06P20F01; 2000 [last accessed 31.03.11]. 19. Prime Minister. Decision 467/QDeTTG of the Prime Minister. Hanoi: Government of Vietnam; 2001. 20. Government of Vietnam. Decree No. 45/2005/NDeCP of Prime Minister on regulation on sanctioning of administrative violations in the health sector. Hanoi: Government of Vietnam; 2005. 21. Government of Vietnam. Decision No. 1315/QDeTTG of the Prime Minister on ratification of the action plan for the implementation of the WHO Framework Convention on Tobacco Control. Hanoi: Government of Vietnam; 2009. 22. Viet Nam Committee on Smoking and Health. Vietnam factsheet e Global Youth Tobacco Survey. CDC. Hanoi: Viet Nam Committee on Smoking and Health; 2007. 23. Ministry of Health. Decision 02/2007/QD-BYT on promulgating the regulation on hygiene and safety of tobacco products. Hanoi: Ministry of Health; 2007. 24. Government of Vietnam. Decree 119/2007/NDeCP on tobacco production and trade. Hanoi: Government of Vietnam; 2007. 25. Centers for Disease Control and Prevention. GSPS. Atlanta, USA: CDC. Available at: http://www.cdc.gov/tobacco/global/ gsps/introduction/index.htm; 2009 [last accessed 31.03.11]. 26. Directive 13-TTG of Prime Minister on strengthening the implementation of the policy guidance prohibits the import and circulation of foreign cigarettes on the market of our country. Hanoi: Government of Vietnam; 1992. 27. Government of Vietnam. Prime Minister Directive No 12/2007/ CTeTTG of the Prime Minister on strengthening tobacco control activities in Vietnam. Hanoi: Government of Vietnam; 2007. 28. Huyen BTM. Tobacco tax policy in Vietnam e tobacco tax workshop. Hanoi: Ministry of Finance; 2003.
29. Guindon GE, Hien Nguyen TT, Kinh Hoang V, McGirr E, Trung Dang V, Lam Nguyen T. Tobacco taxation in Vietnam. Paris: International Union Against Tuberculosis and Lung Disease; 2010. 30. Doran CM, Byrnes JM, Higashi H, Truong K. Revenue implications to the Vietnamese government of using taxes to curb cigarette smoking. Addict Behav 2010;35:1089e93. 31. World Bank. Vietnam GDP per capita 2012. The World Bank Group: Washington, USA. Available at: http://data.worldbank. org/indicator/NY.GDP.PCAP.CD/countries%3fpage%3d3; 2012 [last accessed 07.04.12]. 32. Ha DA, Chisholm D. Cost-effectiveness analysis of interventions to prevent cardiovascular disease in Vietnam. Health Policy Plann 2010;26(3):210e22. 34. General Statistics Office. Summary results of the Vietnam household living standard survey 2010. Hanoi: Government of Vietnam; 2011. 35. General Statistics Office. Result of the Viet Nam household living standards survey, 2006. Hanoi: General Statistics Office; 2007. 36. Morrow M, Ngoc DH, Hoang TT, Trinh TH. Smoking and young women in Vietnam: the influence of normative gender roles. Soc Sci Med 2002;55:681e90. 37. Minh HV, Hai PT, Giang KB, Kinh LN. Prevalence of and susceptibility to cigarette smoking among female students aged 13 to 15 years in Vietnam, 2007. Prev Chron Dis 2010;7:A11. 38. Page RM, Huong NT, Chi HK, Tien TQ. Social normative beliefs about smoking in Vietnamese adolescents. Asia-Pacific J Public Health 2010;24(1):68e81. 39. Trong LN, Thuy TT, Phong DN, et al. Vietnam national prevalence of smoking survey. Hanoi: Ministry of Health, Vietnam committee on smoking and health; 1999. 40. Higashi H, Barendregt JJ. Cost-effectiveness of tobacco control policies in Vietnam: the case of personal smoking cessation support. Addiction 2012;107:658e70. 41. Borland R. Tobacco health warnings and smoking-related cognitions and behaviours. Addiction 1997;92:1427e35. 42. Hammond D, Fong GT, McNeill A, Borland R, Cummings KM. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey. Tob Control 2006;15:19e25. 43. Bryce JCD, Darnton-Hill I, Pelletier D, Pinstrup-Andersen P, Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: effective action at national level. Lancet 2008;371:510e26.
Available online at www.sciencedirect.com
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Review Paper
Tobacco Control in Vietnam D.T. Tran a, R.O. Kosik b, G.A. Mandell c, Y.A. Chen c, T.P. Su c, A.W. Chiu c, A.P. Fan c,* a
Department of Nephrology and Endocrinology, Children’s Hospital, HoChiMinh City, Vietnam Santa Clara Valley Medical Center, San Jose, CA, USA c School of Medicine, National Yang-Ming University Taipei, Taiwan b
article info
summary
Article history:
Objectives: To investigate the use of tobacco in Vietnam.
Received 13 July 2011
Study design: Review study.
Received in revised form
Methods: Data were collected through a review of tobacco-related literature in Vietnam.
16 June 2012
Grey literature and web content from agencies such as the World Health Organization and
Accepted 19 November 2012
the US Centers for Disease Control and Prevention were consulted.
Available online 22 January 2013
Results: Tobacco smoking is still common in Vietnam, although numerous policies have been issued and implemented over the last two decades. Based on the most recent data
Keywords:
(2010), the prevalence of smoking among adults aged >15 years was 23.8%, with a higher
Smoke
percentage among males (47.4%) than females (1.4%). The prevalence of smoking among
Tobacco
students aged 13e15 was 3.8% (2007), with a similar gender pattern. The prevalence of
Vietnam
exposure to secondhand smoke is of concern, with 73.1% and 55.9% of adults reporting
Cigarette
exposure to secondhand smoke at home and at work or other places, respectively. Of the
MPOWER
adult respondents, 55.5% believed that smoking may cause lung cancer, stroke and heart disease. Most students (93.4%) and adults (91.6%) had seen anti-smoking media messages. Of the students, 56.4% had seen pro-cigarette advertisements on billboards, 36.9% had seen pro-cigarette advertisements in newspapers or magazines, and 8.2% had been offered free cigarettes by tobacco company representatives. The price of cigarettes decreased by approximately 5% between 1995 and 2006, whereas gross domestic product per capita increased by more than 150%. On average, smokers smoked 13.5 cigarettes per day, and spent US$86 on cigarettes per year. Despite such high levels of tobacco exposure in Vietnam, the total tax on cigarettes remains at 45% of the retail price. Furthermore, only 29.7% of smokers had been advised to quit by a healthcare provider in the past 12 months. Conclusion: Strong enforcement and evidence-based regulations which rounded on MPOWER are needed to help protect current smokers and non-smokers from the devastating effects of tobacco. ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. P.O. Box 22072, Taipei, Taiwan, ROC 100. Tel./fax: þ886 937 190763. E-mail address: [email protected] (A.P. Fan). 0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2012.11.012
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Introduction
Methods
Vietnam has one of the highest smoking rates in the world. In 2010, almost half of males (47.4%) and one in 70 females (1.4%) reported that they currently smoked some form of tobacco.1 Although the prevalence of smoking in Vietnam is lower than it was a decade ago (72.8% of men and 4.3% of women),2 the absolute number of smokers has not declined: 15.5 million Vietnamese smoked in 1997 compared with 15.3 million in 2010.1,2 Smoking also affects non-smokers, as 67.6% and 49% of adults have reported that they are exposed to secondhand smoke at home and work, respectively.1 Smoking has adverse health consequences for both smokers and secondhand smokers. Compared with non-smokers, odds ratios for periodontitis of 7.17 and 2.37 have been reported for heavy smokers (>5 pack-years) and light smokers (5 packyears) in Vietnam, respectively.3 Model projections of the prevalence of moderate to severe chronic obstructive pulmonary disease in those aged 30 years predict nearly 2 million cases.4 Lung cancer was the most common cancer in males from 1993 to 2007, with recent incidence rates of 27.30 per 105 in males and 10.50 per 105 in females.5 Population-based cancer mortality registration recorded 11,409 lung cancer deaths (8383 in males) in 2006, making lung cancer the second most common cause of cancer death in adults.6 Children are inevitable, and sometimes overlooked, victims of smoking. It has been reported that 70.5% of Vietnamese children aged <5 years were exposed to environmental tobacco smoking and 63.5% were exposed to indoor smoking. It is estimated that 44,000 excess hospital admissions for pneumonia each year among children aged <5 years are attributable to environmental tobacco smoking in Vietnam.7 Tobacco consumption also has a detrimental effect on the national economy. In 1998, it was estimated that the total expenditure on tobacco smoking was US$435.6 million. This could have been used to purchase 1.6 million tons of rice, and provide food for 10.6 million people for 1 year.8 In 2005, the costs of just three diseases (lung cancer, ischaemic heart disease and chronic obstructive pulmonary disease) attributable to tobacco use in Vietnam were approximately US$77.5 million, representing 4.3% of the country’s total healthcare expenditure.9 In 2000, the Government of Vietnam responded to the high prevalence of tobacco use with a National Tobacco Control Policy (NTCP) for the following 10 years. It aimed to reduce the smoking rate in men from 50% to 20%.10 In addition, over 15 decrees and decisions were issued along with international conventions and multilateral collaborations. For example, Vietnam signed the World Health Organization Framework Convention on Tobacco Control on 3 September 2003, and ratified it into law on 17 December 2004.11 However, the results have not been as promising as the government had hoped, with only a 2.6% reduction over the 10-year period. It is not clear whether the failure was due to inconsistent and poorly implemented policies, fast social changes or business strategies instituted by the tobacco companies. This paper provides a comprehensive overview of evidencebased data concerning implementation of the six measures of the MPOWER package.
An extensive review of the literature with no time limit was conducted using PubMed. Search terms were ‘tobacco’ or ‘smoking’ or ‘cigarette’ AND ‘Vietnam’, both in English and in Vietnamese. Only surveys that used a nationally representative, randomly selected sample of sufficient size were considered. Data from the websites of the World Health Organization and the US Centers for Disease Control and Prevention were gathered. In addition, academic and grey literature were obtained from government agencies, such as the Vietnamese Ministry of Health and the Vietnam Steering Committee on Smoking and Health. The references of collected articles were also reviewed to identify further related articles.
Results Seven national representative data sets were found: the Vietnam Living Standards Survey from 199312 and 199813; the Vietnam National Health Survey from 200114; the Vietnam Household Living Standards Survey from 200615; a study by Jenkins et al.2 from 1998; the Vietnam Global Adult Tobacco Survey1 from 2010; and the Vietnam Global Youth Tobacco Survey (students aged 13e15 years) from 2007.16 Other relevant papers have been presented under each MPOWER target. Table 1 summarizes tobacco control in Vietnam by MPOWER target.
Protecting people from second hand smoke The Law on the Protection of Peoples’ Health, passed in June 1989, was the first effort by the Government of Vietnam to recognize smoking as a public health issue, and to demonstrate the Government’s commitment to tobacco control. Article 15, Chapter II stated that ‘smoking is banned in halls, cinemas, theatres, and designated public places’.17 In August 2000, the NTCP was signed by the Prime Minister as an affirmation of the Vietnamese Government’s commitment to tobacco control. It prohibited smoking during meetings; on public transport; in offices, medical facilities, schools, kindergartens, cinemas and theatres; and in otherwise unspecified crowded places. Other goals included protecting the rights of non-smokers to breathe clean, smoke-free air and to reduce tobacco-related losses for individuals, families and society as a whole.18 In 2001, the Prime Minister established the Vietnam Committee on Smoking and Health, a steering committee for tobacco control.19 Decree No. 45/2005/NDeCP by the Prime Minister made important steps towards tobacco control, stating for the first time that a warning or a fine of 50,000e100,000 VND ($US3e6) would be levied for breaching a number of tobacco policies. Smoking cigarettes or pipe tobacco in public places e such as theatres, cinemas, meeting rooms, offices, hospitals, libraries, waiting rooms at railway stations, bus stations, airports, ports, on public transport or in other public places e was henceforth prohibited.20 In 2009, the Prime Minister signed the Ratification of the Action Plan for the Implementation of the WHO Framework
Table 1 e Summary of tobacco control in Vietnam by MPOWER and suggestions for future control. Objective
Government regulations
Offer help to quit tobacco use Easily accessible August 2000, National Tobacco Control Policy for 2000e2010 stated services to manage that ‘Encourage, organize and support measures of tobacco addictobacco dependence tion and rehabilitation research methods in accordance with the conditions of Vietnam’. To enhance training of health workers in methods of smoking cessation is suitable for all investors. The Government’s Decision No. 1315/QDeTTG dated 21 August 2009 on Ratification of the Action Plan for the Implementation of the WHO Framework Convention on Tobacco Control continued to support the development and effective implementation of smoking cessation programmes, and diversification of the methods of smoking cessation counselling. Must be integrated into national health and educational programmes and strategies, and involve health workers, educators and community workers. Issue permission for production, importation and use of pharmaceutical products for the treatment of tobacco addiction and apply preferential taxation policies to these products in accordance with the relevant government regulations. Promote research into and application of cessation methods appropriate to the socio-economic conditions of Viet nam. Allocate a budget for the development of cessation services from the state budget, international aid, and contributions from service users in the forms of user fees and health insurance premiums.
Suggestions
In 2007, 58.5% students aged 13e15 years exposed to smoke at home and 71.2% exposed to smoke in other places. In 2010, 73.1% of adults were secondhand smokers. In 2010, smoking in public places occurred quite commonly, including at 22.3% of schools, 23.6% of healthcare facilities, 34.4% of public transport, 38.7% of government buildings, 54.3% of universities, 84.9% of restaurants and 92.6% of bars/cafes/tea shops.
Strong law and regulation enforcement. Prohibit all indoor smoking.
In 2007, a survey in students aged 13e15 years found that 100.0% had ever received help to stop smoking. In 2010, only 27.2% of current and former smokers visited a healthcare provider for curative or preventive care or counselling services. Nicotine replacement therapy was used by 24.4% of respondents. Only 3% used counselling/advice.
Increase counselling. National smoking cessation programme.
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Protect people from tobacco smoke Completely smoke June 1989, Law on the Protection of Peoples’ Health stated that free environments ‘smoking is banned in halls, cinemas, theatres, and designated public places’. August 2000, National Tobacco Control Policy for 2000e2010 prohibited smoking during meetings, in offices, at medical facilities, at schools, in kindergartens, in cinemas, in theatres, on public transport, and in otherwise unspecified crowded places. 2005, Decree No. 45/2005/NDeCP of Prime Minister on Regulation on Sanctioning of Administrative Violations in the Health Sector stated that a warning or a fine of 50,000e100,000 VND (US$3e6) for smoking cigarettes or pipe tobacco in some public places. 2009, Ratification of the Action Plan for the Implementation of the WHO Framework Convention on Tobacco Control prohibited smoking in the above places, planned to prohibit all indoor public places from 2010, strict enforcement of penalties imposed for smoking violations in public places.
Facts
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Table 1 e (continued ) Objective
Government regulations
Warn about the dangers of tobacco High levels of Decree 119/2007/NDeCP on tobacco production and trade required awareness of the that all packets should be labelled with the label taking up 30% of the health risks of packet’s surface ‘Smoking can cause lung cancer’ or ‘Smoking can tobacco use cause chronic obstructive pulmonary disease’ in black text on white background; this took effect from 1 April 2008. The Government’s Decision No. 1315/QDeTTG dated 21 August 2009 on Ratification of the Action Plan for the Implementation of the WHO Framework Convention on Tobacco Control also supports the implementation of pictorial health warnings to warn about the harmful health effects of smoking. However, it does not clearly state the content and graphic presentation, or when it must be implemented.
Suggestions
92.4% of current smokers had noticed health warnings on cigarette packs. 66.7% of them had thought about quitting smoking because of those health warnings. 95.7% of adults agreed that smoking tobacco cause dangerous diseases. 95.6% of adults were aware that smoking caused lung cancer, stroke (70.3%) and heart attack (62.7%). However, only 55.5% of them believed that smoking caused all three of these diseases. 87.0% of adults agreed that secondhand smokers could get dangerous diseases due to the smoke/fumes. In 2007, 93.4% students aged 13e15 years had seen anti-smoking media messages; in 2010, 91.6% of adults had seen anti-smoking media messages.
Warning labels should cover at least 50% of packet display areas. Increase more precise as well as strong warning messages. Warning messages should be rotated. Pictorial warnings.
In 1995, 62.3% of respondents did not recall seeing or reading any cigarette advertising. In 2007, 56.4% of students aged 13e15 years had seen pro-cigarette advertisements on billboards, 36.9% had seen pro-cigarette advertisements in newspapers or magazines, and 8.2% had been offered free cigarettes by a tobacco company representative. In 2010, 16.9% of adults had noticed any form of tobacco advertising, sponsorship or promotion. Tobacco advertisements in shops were seen by the highest number of people (8.6%), followed by restaurants/cafes/tea shops (3.7%), on television (2.1%) and in cinemas (0.2%). 3.2% of people overall had noticed cigarette promotions on clothing or other items with a brand name or logo. 16.2% of non-smokers aged 15 years had noticed cigarette advertisements over the past 30 days. Non-smokers had seen cigarette advertisements in shops and restaurants/cafes/tea shops (8.3% and 3.5%, respectively). Current smokers were given free samples, coupons and free gifts/discounts on other products more often than non-smokers (1.5% vs 0.6%, 1.7% vs 0.8% and 1.8% vs 1.0%, respectively).
Strong law and regulation enforcement.
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Enforce bans on tobacco advertising, promotion and sponsorship Complete absence of In 1992, Directive 13-TTG of the Prime Minister banned tobacco tobacco advertising, advertising on mass media and required removal of erected signs/ promotion and panels with tobacco advertising. sponsorship In 2000, the National Tobacco Control Policy for 2000e2010 prohibited all forms of tobacco advertising and marketing activities. Strengthening the implementation of the strict ban on all forms of cigarette advertising, sponsorship and marketing by the Government’s Directive 12/2007/CTeTTG in 2007 and the Government’s Decision No. 1315/QDeTTG in 2009.
Facts
Surveillance, monitoring and evaluation Effective No specific requirement on effective surveillance. surveillance, monitoring and evaluation systems in place to monitor tobacco use
Price declined by approximately 5% between 1995 and 2006. In 1995, smokers smoked a mean of 9.6 cigarettes per day, and the equivalent of approximately 4.5 cigarettes for those who smoked water pipes exclusively. They spent an average of US$49.05 on cigarettes each year. In 2010, the average price for a packet of 20 cigarettes was only 5500 VND (US$0.29). In 2010, smokers smoked an average of 13.5 cigarettes per day, and they spent an average of US$86 on cigarettes each year.
Annually increase the special consumption tax so that prices of tobacco products would increase in excess of the growth rate of the economy. Add an effective specific tax, indexed to inflation. Need a specific water pipe tobacco excise tax. Establish special govern mental agency to help tobacco farmers and anti-smuggling. Also execute and manage tobacco control strategies.
1993e2006: 25e36% of the Vietnamese population were current smokers, predominantly males. The highest rates were recorded in 1995, with 72.8% male and 4.3% female current smokers. In 2010, 23.8% (15.3 million) of Vietnamese adults aged 15 years were current smokers: males, 47.4%; females, 1.4%. Of these current smokers, 81.8% were daily smokers. Most people smoke cigarettes (19.5% manufactured and 1.1% hand rolled) followed by water pipes (6.4%) and other smoked tobacco (0.1%). In 2007, 3.8% of students aged 13e15 years, predominantly male, were current smokers.
Periodically obtain nationally representative and population-based data on key indicators of tobacco use for youth and adults.
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Raise taxes on tobacco products Progressively less Before 1990, 5% revenue tax on tobacco enterprises. affordable tobacco From 1990 to 1998, special consumption tax of 52% or 70% on filtered products cigarettes produced mainly from imported materials or from domestic materials, respectively, and of 32% on non-filtered cigarettes and a tariff rate of 70% on imported cigars. From 1999 to 2005, a slight decrease of 5e7% in special consumption tax for all types of tobacco. From 1999, 10% value added tax was introduced for the first time. From 1 April 2000, Decision No. 175/1999/QDeTTG of the Prime Minister on the stamping domestic cigarette production was begun implementation In 2006, Vietnam imposed a uniform special consumption tax at 55% of the wholesale price across all cigarettes. This rate increased to 65% in 2008. However, water pipe tobacco, which is quite common, especially in rural areas, is not subject to taxation. The enterprise tax has decreased by nearly 25% in the past 18 years. In 1993, the rate decreased from 40% to 35%. In 1999, it was further decreased to 32%, and in 2004, it was eventually brought down to 28%. Imported cigarettes and cigars from the World Trade Organization’s ‘most favourite nations’ are taxed at a rate of 150% of the merchandise’s cost, insurance and freight (CIF) value and at a rate of 225% of the CIF value for cigarettes and cigars from other countries.
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Convention on Tobacco Control, prohibiting smoking in classrooms, kindergartens, medical facilities, libraries, cinemas, theatres, cultural houses, the in-house manufacturing sector and workplace, on public transport and where there is high risk of fire. It also planned to ban smoking in all indoor public places from 2010. Strict enforcement of sanctions was imposed for smoking violations in public places.21
Tobacco cessation support In 2010, more than two-thirds of smokers aged 15 years said that they planned to stop smoking some time in the future: 38.2% planned to quit in more than 1 year, 19.8% planned to quit within the next year, and 9.5% planned to quit within the next month. More male smokers were planning to quit than female smokers (68.5% vs 36.9%). More than half of the current and former smokers (55.3%) had been abstinent for less than 12 months. Nearly one-third (27.2%) of the current and former smokers had visited a healthcare provider for curative or preventive care or counselling services, and the figure was higher among women (36%). Less than one-third of smokers had been advised to quit smoking by a healthcare advisor when they visited a doctor or healthcare provider.1 Nicotine replacement therapy (24.4%) was the most common cessation method used by current smokers who had made a quit attempt in the past 12 months. Other methods (constituting <10%) were prescription medications (e.g. Bupropion, Varenicline), counselling/advice, traditional medicines, smokeless tobacco, etc.1 In 2007, a survey among students aged 13e15 years found that 75.4% wanted to stop smoking, 79.7% had tried to stop smoking during the past year, and 100.0% had received help to stop smoking.16,22
Education on the dangers of tobacco use In 2007, the Ministry of Health failed to adopt strong health warning measures, such as those covering at least 30% of the front and rear surfaces of tobacco packets. They used health warnings with words or pictorials, such as ‘Smoking causes lung cancer’, ‘Smoking is harmful to foetuses and infants’, ‘Smoking causes bleeding of the brain’, ‘Smoking causes chronic obstructive pulmonary disease’ and ‘Smoking causes bad breath and rotten teeth’.23 Decree 119/2007/NDeCP on tobacco production and trade only required all packets be labelled with the label taking up 30% of the packet’s surface and stating ‘Smoking can cause lung cancer’ or ‘Smoking can cause chronic obstructive pulmonary disease’ in black text on a white background.24 The Government started to support the implementation of pictorial coverage to warn the consumer about the harmful health effects of smoking, but specific content or graphic presentation, or the timetable over which this must be implemented were not mandated.21 In 2010, most smokers had noticed the health warnings on cigarette packets (93.3% males, 64.3 females). As a result of these warnings, two-thirds of the sample had thought about quitting smoking (67.6% males, 38.1% females). Regarding the specific smoking-related diseases, 95.6%, 70.3% and 62.7% of adults were aware that smoking may cause lung cancer, stroke and heart attack, respectively, but only 55.5% believed
that smoking may cause all three diseases.1 Eighty-seven percent of adults, including 82.2% of current smokers and 88.5% of non-smokers, agreed that non-smokers who inhale smoke/fumes released by tobacco smokers could be at risk of dangerous diseases due to the smoke/fumes.1 Meanwhile, according to the Vietnam Global Adult Tobacco Survey,25 the percentage of adults aged 15 years who had noticed anti-smoking information published by any form of media over the past 30 days was 91.6%. Television and billboards were the two most common forms of media through which people saw anti-smoking information. People living in rural and urban areas were equally likely to have seen antismoking information on television, which is the most popular form of media in Vietnam. The proportion of people who noticed anti-smoking information on the Internet was 12.0%, 8.3% and 13.1% for overall, current and non-smokers, respectively. Younger people (aged 15e24 years) were more likely to see anti-smoking information on the Internet than older people, regardless of whether they were smokers or not.
Tobacco advertising, promotion, and sponsorship Weak enforcement of the law In 1992, Directive 13-TTG by the Prime Minister banned tobacco advertising on mass media, and required removal of erected signs or panels with tobacco advertising.26 Just 3 years later, however, 62.3% of respondents did not recall seeing or reading any cigarette advertisements.2 In 2000, the NTCP prohibited all forms of tobacco advertising and marketing activities. It also prohibited domestic organizations receiving financial assistance from organizing cultural activities, arts and sports linked with tobacco advertising.10 However, in 2003, smokers were still able to see protobacco messages in newspapers and magazines. Tobacco company representatives were still able to offer cigarettes to both smokers and non-smokers.13 In 2007, pro-cigarette advertisements could be seen on billboards (56.4%) and newspapers/magazines (36.9%).11 More government directives were issued in 2007 and 2009 in an effort to strengthen bans on all forms of cigarette advertising, sponsorship and marketing.21,27 Unfortunately, in 2010, the percentage of the overall population, those aged 15e24 years, and those aged 25 years who noticed any form of tobacco advertising, sponsorship or promotion was still high (16.9%, 25.3% and 14.0%, respectively). Tobacco advertisements in shops were seen by the highest number of people (8.6%), followed by restaurants/cafes/tea shops (3.7%), on television (2.1%) and in cinemas (0.2%). Current smokers exhibited patterns similar to the overall population in terms of noticing cigarette advertising.25
Tobacco taxation Before 1990, tobacco enterprises were subject to a 5% revenue tax. From 1990 to 1998, tobacco products in Vietnam were subject to a special consumption tax: 52% on filtered cigarettes made from imported materials, 70% on filtered cigarettes made from domestic materials, 32% on non-filtered cigarettes and 70% on imported cigars.28 To get a sense of the relative weight of tobacco spending compared with other household expenses, in 1995, the average amount spent on cigarettes was US$49.05 per year.
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This represents 1.5 times the annual per-capita household expense for education (US$30.82), five times the annual percapita household expense for healthcare (US$9.65), and approximately one-third of the annual per-capita household expense for food (US$143.27).2 From 1999 to 2005, a slight decrease (5e7%) in special consumption tax was implemented for all types of tobacco in Vietnam, and a 10% value added tax (VAT) was implemented for the first time.29 In 2006, Vietnam imposed a uniform special consumption tax at 55% of the wholesale price across all cigarettes and cigars, regardless of the origin of the material used. This rate increased to 65% in 2008, while the VAT rate has not changed since it was introduced. Water pipe tobacco, which is particularly common in rural areas, is not subject to taxation.29 This could be because the industry is fragmented with no standard brands. Despite the introduction of new taxes, total taxes on tobacco in Vietnam remain low compared with countries with successful tobacco control programmes, where rates range from 65% to 80% of the final retail price (Table 2).30 The enterprise tax is a tax on tobacco companies’ profits. It has decreased by nearly one-quarter in the past 18 years. In 1993, the rate was dropped from 40% to 35%. In 1999, it was further decreased to 32%, and in 2004, it was reduced to 28%.29 Although the Vietnamese Government imposed many types of tax and higher taxes between 1995 and 2006, the cost of tobacco products has not increased. In fact, it has decreased by approximately 5%.29 For instance, the price of a packet of Vinataba (Vietnam’s most popular brand) was approximately VND 10,000 in 1996 (in 2006 VND) (US$0.63),2 but was priced at about VND 8500 (US$0.53) 10 years later. Meanwhile, the gross domestic product per capita increased sharply by more than 150% from US$288 in 1995 to US$731 in 2006.31 Today, the average price for a pack of 20 cigarettes is even lower (VND 5500, US$0.29).1 It should be noted that the inflation rate was 8.8% when the survey was conducted.32 In 2010, current smokers smoked an average of 13.5 cigarettes per day, and spent an average of US$86 on cigarettes each year.1 This amount of money represents twice the annual per-capita household expense for education (US$43), more than twice the annual per-capita household expense for healthcare (US$39), and approximately one-quarter of the annual per-capita household expense for food (US$340).34
Tobacco monitoring The most recent data (2010) indicated that 15.3 million adults aged 15 years (23.8%, higher percentage of males than females) currently smoke tobacco in Vietnam. The prevalence rates of current smokers were similar in urban and rural areas (23.3% vs 24.0%, respectively). Of the current smokers, 81.8% were daily smokers. The prevalence rates for current smoking increased with age: 26.1% and 0.3% for males and females, respectively, aged 15e24 years, and 59.5% and 2.9% for males and females, respectively, aged 45e64 years. The average number of cigarettes smoked per day by daily cigarette smokers was 13.5 overall, 13.6 for men and 10.9 for women.1 The higher prevalence of smoking in males compared with females has been noted for the last two decades.2,12e14,35 The highest rates were recorded in 1995, with 72.8% of males and 4.3% of females smoking. Rates decreased to 49.2% in males
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and 1.5% in females in 2006. The pattern of current smoking was unchanged by age, with lower rates seen among both males (21.5e38.7%) and females (0.2e0.5%) aged 15e25 years, increasing to 68.9e84.1% for males aged 35e44 years, and 3.6e17.9% for females aged 65 years.2,12e14,35 In 2007, the prevalence of current smokers in students aged 13e15 years was 3.8% (6.5% in boys and 1.5% in girls).16,22
Discussion The Vietnamese Government has issued numerous decrees and directives in tobacco control; however, there have been no strict regulations at all levels of Government, indicating a lack of determination by the Central Government. Meanwhile, the objectives set out for tobacco control could be unrealistic without thorough review and evaluation of the societal situation. For example, the NTCP set a goal to reduce the smoking rate in men from 50% to 20%,10 but only achieved a reduction of 3% in 10 years. It appears that strong leadership combined with scientificbased measures which rounded on MPOWER is needed. Women who engage in smoking are subject to wide societal disapproval, and are thought to have questionable moral values, while for men, smoking is a natural and accepted social norm, particularly at social gatherings.36 Although the proportion of female smokers is much lower than that of male smokers, female smokers seem to be less interested in quitting (36.9% vs 68.5%). As a result, preventing the initiation of smoking by women, especially young women, is extremely important.36e38 Therefore, future tobacco control policies should be built on normative influences and gender specifics. In addition, policy should consider the potential influence of women regarding their husbands’ smoking behaviour; 15.3% of men who had quit smoking attributed their success to advice from their wives.39 Despite the large number of people who want to quit smoking in Vietnam, relevant programmes have remained scarce1 and those that do exist are inadequate. In current practice, smoking cessation programmes are generally integrated into other programmes, leading to insufficient budget and human resources. A national smoking cessation programme would be very helpful and should include costeffective measures aimed to promote tobacco cessation such as physician counseling.40 Although citizens demonstrated a high level of knowledge about the adverse consequences of smoking, the results show that thorough comprehension of this problem was limited: 92.4% of current smokers had noticed health warnings on cigarette packets, but only 66.7% of them thought about quitting smoking due to those health warnings. Therefore, media and public education campaigns should be enhanced. Increased pictorial warning labels with precise and strong warning messages may help.41,42 The Government could use diverse methods for taxation. For example, increasing the special consumption tax would increase the price of tobacco products. A recent assessment estimated that a 10% increase in the price of cigarettes can lead to a decrease in consumption of at least 5%.29 Policies that increase tax would receive overwhelming support from the Vietnamese people: 71.3% of adults, 71.9% of men and 70.8% of women.43
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Table 2 e MPOWER research results for the Vietnam Global Adult Tobacco Survey (GATS) and Vietnam Global Youth Tobacco Survey (GYTS). GATS Year 2010 Tobacco monitoring and the institution of prevention policies Currently smoke tobacco (%) Overall 23.8 Males 47.4 Females 1.4 Currently smoke cigarettesa (%) Overall 19.9 Males 39.7 Females 1.2 Currently smoke tobacco products other than cigarettes (%) Overall 6.4 Males 13 Females 0.1 Secondhand smoke At home (%) All people 73.1 Non-smokers 67.6 At work or other places (%) All people 55.9 Non-smokers 49 Tobacco cessation support Smokers who made a quit attempt in the past 12 months (%) Overall 55.3 Males 55.6 Females 44.4 Current smokers who plan to or are thinking about quitting smoking next month (GATS)/want to stop smoking (GYTS) (%) Overall 9.5 Males 9.6 Females 5.3 Smokers advised by a healthcare provider to quit in the past 12 months, or those who have ever received help stopping smoking (GYTS) (%) Overall 29.7 Males 30.2 Females 20.3 Education on the dangers of tobacco use Adults who believe smoking causes serious illness 95.7 Adults who believe smoking causes stroke, heart attack and lung cancer 55.5 Adults who believe exposure to tobacco smoke causes serious illness in non-smokers 87.0 Adults who believe cigarettes are addictive 94.4 Have been taught in class, during the past year, about the dangers of smoking Have discussed in class, during the past year, the reasons why people their age smoke Think smoke from others is harmful to them Tobacco advertising, promotion, and sponsorship: weak enforcement of the law Adults who noticed cigarette marketing in stores where cigarettes are sold 8.6 Adults who noticed any cigarette advertisements, sponsorship or promotions 16.9 Adults who noticed anti-cigarette smoking information on the television or radio 87.2 Saw pro-cigarette advertisements on billboards in the past 30 days Saw pro-cigarette advertisements in newspapers or magazines in the past 30 days Have an object with a cigarette brand logo Have been offered free cigarettes by a tobacco company representative Saw anti-smoking media messages in the past 30 days Tobacco taxation Median amount spent on 20 manufactured cigarettes (one pack) 5500 VND (US$0.29) Median yearly cigarette expenditure per current cigarette smoker 1,096,000 VND Average cost of 100 manufactured cigarettes as a percentage of per-capita gross 2.7% domestic product Adults who support increasing taxes on tobacco products Overall 71.3 Males 71.9 Females 70.8
GYTS 2007
3.3 5.9 1.2 3.8 6.5 1.5
58.5
71.2
79.7
75.4
75.4
73.3% 45.5% 85.0%
56.4% 36.9% 11.3% 93.4%
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Table 2 e (continued ) GATS Tax (% of retail price) Total Excise VAT Import duty and other taxes
GYTS
45 36 9 0
a Current smoker was defined by asking ‘During the past 30 days, on how many days did you smoke cigarettes’ for GYTS and ‘Do you currently smoke tobacco daily or occasionally’ for GATS.
Increasing tobacco taxes would generate higher tax revenue for the Government. The extra revenue could then be used to create some special governmental agencies aiming to reduce the country’s reliance on the tobacco industry. The agencies could fund programmes that support poor farmers who wish to give up tobacco cultivation to find new vocations, to help cigarette factory workers learn new skills to find jobs in other sectors, and so forth. Some governmental agencies should also have a role in strengthening anti-smuggling measures in Vietnam. Downsizing of the tobacco industry would only affect a small percentage of the workforce, while improving many socio-economic problems in Vietnam. However, specific methods to cut the businesses is a complicated issue that needs thorough planning. Vietnamese leaders, who tend to rely on their own systems too much, could benefit a great deal from other sources in strategic planning. The failure of the NTCP is an example of the Government’s inability to execute policy initiatives effectively on its own. Therefore, consulting experts who have extensive experience in tobacco control, inside and outside of Vietnam, should be undertaken. Ideally, some special governmental agencies, as mentioned above, should be created to execute and manage tobacco control strategies. Implementation of these strategies should be evaluated and revised regularly by taking account of the results and analyses from nationally representative and population-based data in order to ensure specific policies that are still effective, and to ensure that the relevant resources are not being wasted. Furthermore, independent evaluations should be undertaken to assess all aspects of the policies in an objective manner. Ensuring that independent evaluators do not have any tie to the Government and administration is vital. Additionally, better coordination between the ministries and relevant governmental agencies is needed to avoid duplication of tasks. All of this would also ensure that the plans are not just implemented, but those in charge and in control of the resources are held responsible for their actions. Similar obstacles exist in almost all large developing countries with a complicated governmental structure. Therefore, lessons from Vietnam are likely to provide useful reference for other countries pursuing tobacco control strategies.
Acknowledgements Ethical approval None sought.
Funding This study is supported by the Ministry of Education Grant MOE 99QC038.
Competing interests None declared.
references
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