From Table 3, it is apparent that the available evidence comes largely from the international literature, with few studies from Vietnam, an easy justification of critics of reform:
…one of their [tobacco industry] arguments is that the research data we have are not from Vietnam. For some research, we based [our assumptions] on literature reviews from other countries, so they say that they are not applicable to Vietnam. (VPHA; quote from interview)
Indeed, the level of demand for local evidence among stakeholders appears to have been used to discount efforts by VINACOSH to provide exposure to relevant data from countries within the region with experience in tobacco:
Recently, we invited representatives from the National Assembly, the MOH, local and foreign organizations, including Australia and Thailand [to an information session on Tobacco Harm Prevention Law]. The delegates from foreign countries shared their experience in tobacco control, but the National Assembly members were more interested in specific information from Vietnam. (NAO; quote from interview)
In the following sections, we examine the positions of stakeholders with respect to each policy instrument in the draft Tobacco Harm Prevention Law in light of the availability of local and international evidence and their strengths (background characteristics of stakeholders and their overall perceptions on tobacco issues were reported elsewhere (Higashi et al., 2011a)).
Interventions with overall stakeholders support
Both key informant interviews and National Assembly surveys confirm policy makers' perceptions that health education and communication through mass media and other means are central to tobacco control initiatives: ‘Mass media communication represents the largest part of tobacco control activities’ (MOH-TE; quote from interview). The draft law dedicates a whole chapter specifically for this item, reflecting its importance. No interviewees were opposed to the dissemination of health messages over the media, with even representatives of the ministries responsible for the economic management of the tobacco industry offering ‘…support promoting health education to reduce demand for tobacco’ (MTI; quote from interview).
The National Assembly survey revealed that 95% of the respondents believed the mass media communication to be effective, and expressed high levels of support, despite the absence of local evidence or strong evidence overall on its effectiveness as a stand-alone intervention. Although the support may stem from the known synergistic effect if combined with other interventions, the popularity of mass media strategies seems rather intuitive, supported on the basis of ‘felt’ effectiveness, a perception shared by VINACOSH itself: ‘Recently we just have had only one campaign running over many months, but I think the impact is high and effective, so we would like to have more campaigns’ (VINACOSH; quote from interview).
Similarly, smoke-free environments have overall support from the stakeholders interviewed and were reported to be popular among the general public:
Support for smoke free [areas] is very high from the public, from workers, and even from leaders of the agencies… 90–95% all support smoke free policy implementation. (HBC; quote from interview)
Despite the ambiguities surrounding the effective implementation of existing smoke-free environment legislation discussed earlier, the high support could likely be attributable to other factors, such as an emerging consensus around the rights of non-smokers to a smoke-free environment.
Personal smoking cessation support, including brief advice by health professionals and various pharmacological therapies, was rarely raised by stakeholders as a tobacco control strategy, unless specifically prompted. However, when asked, there was general support for smoking cessation support and no opposition was identified. The failure to raise this strategy may reflect the questionable feasibility of implementation due to lack of adequate existing infrastructure and service delivery mechanisms in Vietnam.
While these three interventions receive general support, there is limited objective evidence indicating the successful implementation in Vietnam due to the lack of local evidence on the effectiveness as well as the limited capacity for implementation. On these three interventions, evidence, or the lack of it, clearly does not necessarily determine the position of stakeholders, even among the tobacco control advocates, and other criteria appear to define support for one intervention over others in this context.
Interventions with less support from stakeholders
The government budget allocated to tobacco control activities has been increasing over time (Table 2) yet remains small compared with funds currently provided by international development agencies (VINACOSH; interview). Given the uncertainty associated with international funding, tobacco control advocates are eager to establish a foundation to secure sustainable funds. However, the establishment of a health promotion foundation is generally greeted with scepticism by most stakeholders, other than MOH and National Assembly members. The MTI and the Ministry of Finance (MOF) are particularly concerned about imposing an additional earmarked tax on tobacco products and the potential difficulties associated with managing such a mechanism (MTI and MOF; interview). Because of a lack of understanding of what the foundation might offer in terms of health promotion, and a limited exposure to similar organisational models, difficulties are anticipated even by the tobacco control advocates.
It is not that easy. We just have one foundation for environmental protection… but environment is seen as a very big issue, not like tobacco [which is not perceived as a big issue]. So… (VINACOSH; quote from interview)
The National Assembly survey results revealed somewhat contradictory views that 84% of the respondents believed that a health promotion foundation would work well and 74% supported its establishment. While the benefit of additional funds for health promotion from tobacco excise revenue has face validity, its feasibility and impact on tobacco consumption is largely unknown. In this situation, the lack of evidence means that stated positions essentially reflect the existing perceptions of stakeholders.
While support for the establishment of a health promotion foundation was ambiguous, two interventions were consistently resisted by stakeholders: the increase of excise tax and pictorial health warning messages on cigarette packs. While the current excise tax, 65% for all tobacco products, is not high compared with other countries in the region (WHO, 2008b), increasing tobacco excise tax is opposed by most stakeholders: ‘At National Assembly workshops, the opinions of different stakeholders are still diverse, but many of the participants do not agree to consider any tax increase’ (NAO; quote from interview).
The perceived impact of tax increases on its revenue is of great concern to the government. In fact, experience from other countries in the region, including Thailand, showed that higher tobacco taxation actually increased revenue (WHO, 2010a), a position that was further reinforced by a local modelling study in Vietnam (Doran et al., 2010). Nonetheless, 32% of respondents from the National Assembly are sceptical that this would be the case for Vietnam, a position reflected in interviews across most ministries, with even MOH reiterating the cautionary mantra: ‘We have to balance the tax level to secure the revenue’ (MOH-TE; quote from interview).
Caution around the implementation of pictorial warning labels has been spuriously justified by the potential of the warnings to shape purchaser behaviours towards illegally imported cigarettes, to the disadvantage of state-owned producers, as one of the respondents mentioned:
If we affix pictorial warning labels, the consumers will shift to products without such warnings imported from other countries, which also increases smuggling. (MTI; quote from interview)
As has been shown, the focus of arguments opposing these strategies revolves around economic concerns. First, the tobacco industry employs a significant number of people, with expected loss of employment with decreased production of tobacco products. Smuggling is expected to increase with these two interventions, compounding loss of employment in the formal economy. These concerns are particularly relevant to high-ranking officials: ‘To convince the National Assembly and the government, the MOH will have to show evidence on tobacco harm and socio-economic impact’ (NAO; quote from interview).
Here, the availability and strength of evidence on the effectiveness of interventions were not entirely aligned with the perceptions and positions of stakeholders. There seems to be a discounting of available evidence that challenges assumptions around the potentially negative socioeconomic impact of tobacco control. Although it is true that local evidence to challenge such concerns is deficient, so is evidence to support such apprehensions.
Second, it was shown from the National Assembly survey that there is a gap between the perception of the effectiveness of interventions and what the available evidence suggests. Thirty nine per cent of the respondents expressed some degree of scepticism over the effectiveness of excise tax increase in reducing smoking, in contrast to the finding that tax increase has the strongest international, and even local, evidence on its effectiveness in reducing demand for tobacco in Vietnam. Yet, a health promotion foundation was considered effective by the majority of respondents in the National Assembly survey, although it is not even clear what constitutes effectiveness.
Here, it becomes apparent that the availability and strength of evidence is not sufficient to influence the positions of policy makers: while recent evidence adds substantially to an understanding of the implications of tobacco control, it is not yet sufficiently comprehensive, and it does not adequately address the economic concerns of those ministries with a dominant financial brief.