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Keywords:

  • tobacco;
  • policy analysis;
  • evidence;
  • decision making

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. ACKNOWLEDGEMENTS
  9. REFERENCES
  10. APPENDIX

The Ministry of Health (MOH) in Vietnam is currently drafting the Tobacco Harm Prevention Law. The government requested the MOH to provide evidence on the strategies proposed in the draft law as part of its submission to the National Assembly. This study examines the availability and strength of evidence and its relationship to policy stakeholders' positions towards policy instruments proposed in the law.

Several qualitative methods were employed including documentary analysis, key informant interviews, focus group discussion and a key stakeholders' survey.

Contradictory findings were identified over the role of evidence. While there is high demand for local evidence, the availability and strength of evidence are not always aligned with stakeholders' positions with respect to different strategies. Stakeholders' positions are shaped by competing interests on the basis of their perceptions of the socioeconomic implications and health consequences of tobacco control. Claims of limited availability of evidence are often used to justify the maintenance of the status quo, a position that is seen to protect the state-owned tobacco industry and state revenue. Local evidence of the impact of tobacco on population health is argued to be ‘one-sided’ and evidence of selected interventions discounted.

Compelling and comprehensive local evidence, including those addressing economic concerns, is acutely needed in order to proceed with the current legislation process. For evidence to play a critical role, it needs to engage those ministries responsible for the tobacco industry itself and the economic development. Copyright © 2012 John Wiley & Sons, Ltd.


INTRODUCTION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. ACKNOWLEDGEMENTS
  9. REFERENCES
  10. APPENDIX

Vietnam has been in economic transition since the inception of the Doi Moi (renovation) policy in 1986 with major liberalisation of the market. Gross domestic product per capita has grown more than 10-fold over the last two decades from $90 in 1990 to $1160 in 2010, with Vietnam now considered a middle-income economy (IMF, 2011). However, Vietnam retains a socialist political system where the majority of major enterprises, including tobacco, remain state owned.

Population health has improved remarkably over the last decades, and health indicators, including maternal mortality ratio and infant mortality rates, perform better than other countries in the region at similar socioeconomic development levels (WHO, 2008a). However, smoking constitutes a significant public health threat to Vietnam, in a country where over half the male adults smoke (GSO, 2000; MOH, 2003; GSO, 1994). The increasing recognition of the threat of smoking on health has prompted the government of Vietnam to take action, particularly since the launch of the National Tobacco Control Policy 2000–2010 (Government of Vietnam, 2000). However, effective implementation of tobacco control strategies has been a challenge. The currently drafted Tobacco Harm Prevention Law (MOH, 2009) aims to strengthen the legal base of tobacco control policy to ensure enforcement and implementation. The Vietnam Steering Committee on Smoking and Health (VINACOSH), which coordinates tobacco control activities under the Ministry of Health (MOH), has been requested by the government to provide scientific evidence on the strategies proposed in the draft Tobacco Harm Prevention Law as part of its submission to the National Assembly. In response to this requirement, collaborative research between the Health Strategy and Policy Institute, the research arm of the MOH, and the University of Queensland has examined the cost-effectiveness of tobacco control interventions in Vietnam (Vietnam Evidence for Health Policy (VINE) Project, 2009; Higashi et al., 2011b; Higashi and Barendregt, 2011).

Evidence informed decision making has been increasingly advocated in the health policy domain as part of a move towards more transparent decision making (Dobrow et al., 2004). Proponents often see the relationship between evidence and policy, or practice, as a linear process whereby scientific findings would move from the ‘research sphere’ to the ‘policy sphere’, unambiguously guiding policy makers in their decision-making process. However, this is rarely the case in reality. This paper first reviews the evolvement of tobacco control policy in Vietnam. It then examines each element of the draft Tobacco Harm Prevention Law, documenting the availability and strength of evidence, both local and international, and explores the relation between policy makers' positions and that evidence.

METHODS

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. ACKNOWLEDGEMENTS
  9. REFERENCES
  10. APPENDIX

This study builds on previous epidemiological and economic analyses of tobacco control interventions for Vietnam (Doran et al., 2010; Higashi et al., 2011b; Higashi and Barendregt, 2011) by constructing arguments based on findings and issues identified from those studies. The analytic framework employs a case study approach by referring to the policy triangle framework proposed by Walt and Gilson (1994), incorporating four elements in the policy analysis: actors, content, context and process. While this paper explores the evidence base of ‘contents’ of the proposed Tobacco Harm Prevention Law as they serve as inputs to the legislation ‘process’, it will be discussed in light of the positions of various ‘actors’ and, to some extent, political ‘context’. A framework proposed by Grindle and Thomas (1991) that suggests a bipolar characterisation of policy as either ‘crisis’—those issues perceived as requiring urgent, decisive action to ensure political stability—or ‘politics-as-usual’—those more routine policy issues that do not generate the same sense of priority and may be engaged over a longer time frame—will be used to supplement the analysis in explaining the differing responses of stakeholders.

Three approaches formed the core of this study: literature review and documentary analysis, key informant interviews and a focus group discussion, and a survey of selected members of the National Assembly. Figure 1 provides a schematic depiction how each method relates to the different components and aims of this study.

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Figure 1. Relationships between methods and study aims

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The literature review examined tobacco control policy, policy analysis, evidence on available tobacco control interventions and the political system with reference to policy making in Vietnam. Literature on evidence of effectiveness of each intervention was obtained from our previous analyses on cost-effectiveness (Higashi et al., 2011b; Higashi and Barendregt, 2011) and identified by searches on PubMed, Medline, Google and Google Scholar with various combination of key words including ‘tobacco control’, ‘policy analysis’, ‘Vietnam’, ‘communist state’, ‘developing country’ and ‘political system’. In addition to the peer reviewed scientific literature, government reports, donor reports and legislative documents on political context and tobacco smoking in Vietnam were obtained and reviewed.

In consultation with VINACOSH, key informants were identified using an ‘event-based’ sampling approach (Marsden, 2005; Knoke and Yang, 2008) by using the legislation process for the Tobacco Harm Prevention Law (Figure 2) as the ‘event’ to identify the stakeholders who were critical to the policy process and needed to be interviewed in order to provide a comprehensive understanding of the process. This process identified 12 critical actors across different sectors and hierarchical levels for interview on the basis of their roles in the policy process (Table 1). The interviews were semi-structured, aimed at exploring the role of each stakeholder and their position in the development of Tobacco Harm Prevention Law, respondents' perceptions of proposed policy instruments and the tensions between stakeholders with competing agendas. Interviews were completed between February and March 2010 (by H. H., T. A. K. and A. D. N.) in English or in Vietnamese. The duration of each interview session was 40–80 min, with the use of a common interview question guide. In order to maintain consistency between interviews conducted by different researchers, the first interview session with the MOH was conducted under the attendance of all three interviewers to establish a common understanding of how to proceed with the subsequent interviews. Despite introductions through VINACOSH, responsible for liaising with other ministries on the Tobacco Harm Prevention Law, informants from the state-owned Vietnam National Tobacco Corporation (VINATABA) declined to be interviewed.

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Figure 2. Legislation process of Tobacco Harm Prevention Law

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Table 1. Stakeholders identified for the key informant interviews
StakeholderRepresented interests
  1. NB: The abbreviations in italics represent the informants in the interviews and focus group discussion and denote quotes from the interviewees in the text.

National Assembly Office (NAO)Legislative branch
Government Office (GO)Executive branch
Department of Propaganda and Training, Communist Party (DPT)Party
Bureau of Treatment and Examination, MOH (MOH-TE)Ministry (public health)
Bureau of Legislation, MOH (MOH-L)Ministry (health-related law)
Vietnam Committee on Smoking and Health (VINACOSH)Ministry (tobacco control)
Ministry of Trade and Industry (MTI)Ministry (industry, economics)
Ministry of Finance (MOF)Ministry (revenue, budget)
Vietnam National Tobacco Corporation (VINATABA)State-owned tobacco industry
Vietnam Public Health Association (VPHA)Academic public health, civil society
World Health Organization (WHO)Multilateral agency
HealthBridge Canada (HBC)International NGO

In addition, one 60-min focus group discussion was held with six staff members of the MOH aimed at further elaborating on their perceptions of the strategies, potential obstacles, and opportunities to progress with the Tobacco Harm Prevention Law. All interviews and discussions were recorded and transcribed into Vietnamese or English, depending on the language used for each session, and were summarised in English. Thematic analyses were conducted on textual data, assisted by the ATLAS.ti 6.1 programme (ATLAS.ti, 2010).

In 2009, VINACOSH was invited by the National Assembly to provide information sessions on the Tobacco Harm Prevention Law to members of the National Assembly and their staff in Hanoi and in one northern province. The evaluation process linked to these information sessions provided an exceptional opportunity to access the perceptions of a number of difficult-to-access higher-ranking officials on tobacco control. A self-administered questionnaire was distributed as part of the evaluation of the sessions with 67 (65%) and 35 (50%) participants responding for the first and second sessions, respectively. The questionnaire comprised structured and semi-structured questions related to tobacco control policy and the proposed legislation including overall understanding of tobacco as a public health issue, perceptions on the available evidence surrounding tobacco control activities and position on the proposed tobacco control legislation (see Appendix for the questionnaire forms). Ethics clearance was obtained from the School of Population Health Research Ethics Committee at the University of Queensland.

RESULTS

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. ACKNOWLEDGEMENTS
  9. REFERENCES
  10. APPENDIX

The evolution of tobacco control policy and legislation

The evolution of tobacco control policy in Vietnam is summarised in Table 2. The initiative to address tobacco as a public health issue can be traced back to 1989 when the MOH set up the Steering Committee on Tobacco Control (Ly et al., 2006). However, a comprehensive package of tobacco control activities had to wait until the inception of the National Tobacco Control Policy in 2000 (Government of Vietnam, 2000). Although the targets set in the policy appeared somewhat ambitious, it clearly demonstrated the government's recognition of the tobacco epidemic as a significant public health issue.

Table 2. The evolution of tobacco control initiatives in Vietnam
YearGlobal eventsInstitutional arrangementsPolicies, decrees, decisions
  1. Source: Shafey et al. (2009), WHO (2007), Guindon et al. (2010), key informant interviews.

19881st World No Tobacco Day  
1989 SCTC established under MOHSmoking banned in selected public places
1990GLOBALink inaugurated Import and distribution of foreign cigarettes banned
1992  Tobacco advertisement banned in mass media and public places
1994International Non-Governmental Coalition Against Tobacco foundedRestructuring of SCTC 
1995  Tobacco Control National Action Plan 1995–1999
1998WHO Tobacco Free Initiative established  
2000Framework Convention Alliance formed Resolution No. 12/2000/NQ-CP (National Tobacco Control Policy 2000–2010)
Decision 2019/2000/QD-BYT (health warning on cigarette packs)
2001Southeast Asia Tobacco Control Alliance formedSCTC upgraded to VINACOSHDirection No. 08/2001/CT-BYT (strengthening tobacco control in the health sector)
Direction No. 36/2001/CT-BGD&DT (strengthening tobacco control in education and training sector)
Decree 76/2001/ND-CP (regulating tobacco manufacturing and trade)
2002  Direction No. 14/2002/CT-BVHTT (strengthening tobacco control in culture and information sector)
Direction No. 04/2002/CT-BTM (strengthening the inspection and control on smuggling)
Decree 66/2002/ND-CP (regulation on goods that can be brought in duty free, including tobacco)
2003Vietnam signed FCTC  
2004Vietnam ratified FCTC Decree 175/2004/ND-CP (fines for violations in the area of trade)
2005FCTC entry into force Direction No. 02/2005/CT (strengthening tobacco control in the transportation sector)
Decree 45/2005/ND-CP (fines for violations of health regulations)
Circular No. 19/2005/TT-BVHTT (guidelines for implementation of the advertising bans)
2006 VINACOSH budgetDecree 89/2006/ND-CP (regulating the printing of packages of goods)
VND 100mExcise tax standardised at 55%
2007Vietnam joins World Trade OrganizationVINACOSH budgetDecision 02/2007/QD-BYT (strengthening health warning on cigarette packs)
VND 200mDirection 12/2007/CT-TTg (strengthening overall tobacco control activities)
Decree 119/2007 ND-CP (replaced 76/2001/ND-CP, strengthening health warning on cigarette packs)
2008FCTC 3rd anniversaryVINACOSH budgetCigarette pack warning message strengthened
VND 500mExcise tax increased to 65%
2009 VINACOSH budgetDecision 1315/QD-TTg (FCTC action plan)
VND 800m
2010FCTC 5th anniversary Decree No. 75/2010/ND-CP (sanctions for violations of advertising and promotion)

Following the establishment of the national policy, tobacco control interventions have been expanded in Vietnam, particularly after 2004 when Vietnam ratified the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) (WHO, 2003). The FCTC is the first ever treaty negotiated under the auspices of WHO and entered into force on 27 February 2005. Over 170 member states have signed the treaty to date, a manifestation of the global awareness and commitment towards tackling the tobacco smoking epidemic. The FCTC is designed to expand national and international coordination to combat the tobacco epidemic. Following Vietnam's early ratification in 2004, tobacco control messages have continued to be broadcasted on mass media, a total advertisement ban on tobacco products has been enacted, the government has introduced a fine system to support smoking bans in public places and smoke-free models have been developed for various settings (SEATCA, 2008). The rules on health warnings on cigarette packs have been strengthened to be more conspicuous and informative, and the tobacco tax rate has increased overall over the last two decades, despite fluctuations (SEATCA, 2008).

However, the tobacco industry is largely state owned in Vietnam, ranking third, after oil and alcohol, among the major tax revenue sources to the government. Nonetheless, following the inception of the national policy, the government has capped investments in tobacco production and prohibited new production initiatives (Government of Vietnam, 2007).

The current proposal for the Tobacco Harm Prevention Law is the culmination of a lengthy process of policy development. The MOH has been taking the lead in drafting the Tobacco Harm Prevention Law in collaboration with various ministries and agencies. In order to facilitate the legislation process, VINACOSH has been commissioned to provide local evidence on the proposed strategies and interventions in the draft law, a clear priority for policy makers:

I think internationally there is ample evidence, but not in Vietnam. Sometime Vietnamese think that we should have evidence from Vietnam. I myself think it is not always necessary, but the policy makers want to see what happens in Vietnam. (VINACOSH; quote from interview)

However, despite this legislation process of tobacco control being led by the MOH, the Ministry of Trade and Industry (MTI) has now established a committee to prepare a parallel Tobacco Production and Business Law, focusing on tobacco production and consumption, with the intention of subsuming the Tobacco Harm Prevention Law and appropriating the lead role in tobacco control from MOH:

…the Tobacco Harm Prevention Law is part of ours. The law alone is not adequate, so we believe it is not suitable. …We proposed to integrate the two laws [Tobacco Production and Business Law and Tobacco Harm Prevention Law] into a comprehensive tobacco control law. (MTI; quote from interview)

This strategy is not without precedent. In 2001, soon after the National Tobacco Control Policy was launched, MTI issued decree 76/2001/ND-CP to regulate tobacco manufacturing and trade (Table 2), asserting the primacy of MTI control over tobacco production.

Proposed strategies in the Tobacco Harm Prevention Law and availability of evidence

The draft Tobacco Harm Prevention Law (MOH, 2009) incorporates five broad strategies for tobacco control, largely consistent with the FCTC, although with varying strength and availability of evidence regarding their effectiveness in reducing tobacco consumption in Vietnam. The law is primarily aimed to consolidate and provide legal support to existing tobacco control strategies, and, although it includes some new provisions, the contents are largely linked to previously issued decrees and decisions (Table 2). Chapter I of the draft law reiterates the state governance principle in tobacco control and outlines the principles of the law. Chapter II specifically addresses the need for effective communication and education on tobacco control. Chapter III regulates production and trade of tobacco products. Chapter IV refers to strategies that reduce demand for tobacco consumption. Chapter V suggests strategies for effective and sustainable implementation of tobacco control activities. Having undertaken an analysis of available evidence for these strategies, Table 3 provides a summary of evidence available internationally and in Vietnam, including cost-effectiveness rankings from our previous analyses (Higashi et al., 2011b; Higashi and Barendregt, 2011).

Table 3. Interventions included in the draft Tobacco Harm Prevention Law ranked by strength of available supporting evidence
Draft Tobacco Harm Prevention LawFCTCEvidence on effectiveness [reference]Strength of evidenceaCost-effectiveness (ranking)b
LocalInternational
  1. a

    We referred to Australian Research guidelines for the assessment of strength of evidence (NHMRC, 2000),with preference placed on local evidence.

  2. b

    Higashi et al. (2011b); Higashi and Barendregt (2011).

  3. c

    ThaiHealth (2011).

  4. d

    VicHealth (2011).

  5. e

    ITC Policy Evaluation Project (2009).

  6. f

    National Cancer Institute (2008).

  7. g

    IARC (2009).

  8. h

    Stead et al.(2008a, 2008b); Cahill et al. (2008); Hughes et al. (2010).

  9. i

    Hoang et al. (2006).

  10. j

    Laxminarayan and Deolalikar (2004).

  11. k

    WHO (2010b).

Chapter V: Establishment of a health promotion foundationNANoneExperience from ThailandcNot clear with what constitutes appropriate evidenceNA
Experience from AustraliadNo local evidence
Chapter III: Pictorial warning labelArticle 11: Packaging and labelling of tobacco productsNoneInternational Tobacco Control Policy Evaluation ProjecteFirm evidence yet to be establishedCost-effective (first)
No local evidence
Chapter II: Education and communicationArticle 12: Education, communication, training and public awarenessNoneNational Cancer Institute (USA)fMixed evidence for stand-alone approach, reasonable if combined with others.Cost-effective (fourth)
No local evidence
Chapter IV: Smoke-free policyArticle 8: Protection from exposure to tobacco smokeNoneInternational Agency for Research on CancergReasonable evidence from high-income countries, mixed/lack of evidence from low/middle-income countriesCost-effective:
public places (third)
No local evidence (and enforcement is a challenge in Vietnam)work places (fifth)
Chapter IV: Smoking cessation supportArticle 14: Demand reduction measures concerning tobacco dependence and cessationNoneCochrane ReviewshReasonable evidence with meta-analysisCost-effective:
No local evidence (and implementation is a challenge in Vietnam)physician advice (sixth)
Not cost-effective:
pharmacotherapy
Chapter I: Excise taxArticle 6: Price and tax measures to reduce the demand for tobaccoHoang et al.iWHO Technical ManualkStrong evidence internationallyCost-effective (second)
Laxminarayan and DeolalikarjReasonable local evidence available from Vietnam
Health promotion foundation

Although the establishment of a health promotion foundation is not an intervention per se, tobacco control advocates perceive it as a critical element of effective and sustainable implementation of tobacco control activities in Vietnam. This is not specifically included in the FCTC but has been proposed by the MOH and VINACOSH on the basis of other international models that generate funds for health promotion activities from cigarette sales. In the region, the initiative has been successful in Australia and Thailand in advancing tobacco control policy (e.g. buying out tobacco sponsorship from events) and scaling up health promotion activities (e.g. physical activities, mental health, etc.) (VicHealth, 2005; ThaiHealth, 2007), with VINACOSH exposed directly to the Thai experience. The lack of a linear link between this initiative and tobacco control makes it difficult to identify what would constitute ‘evidence’ of its effectiveness.

Pictorial health warning messages on cigarette packs

Health warning messages on cigarette packs have been in place in Vietnam since the inception of the National Tobacco Control Policy in 2000. Currently, cigarette packs include text warnings written in Vietnamese language (SEATCA, 2008), but pictorial warning labels have not yet appeared on cigarette packs. While the FCTC Article 11 requires all countries to affix health warning labels on cigarette packs, the employment of graphic pictorial message remains an option for each government. Despite this, the Vietnamese government made it mandatory in its FCTC action plan in 2009 (Government of Vietnam, 2009). Pictorial labels are potentially more effective than text alone messages. Studies comparing Canada, the USA, the UK, Australia and Mexico have ascertained that pictorial warnings are associated with higher awareness of health risks and intention to quit among cigarette smokers (ITC Policy Evaluation Project, 2009). Hammond et al. (2004) found that former smokers exposed to pictorial message, compared with text only, were more than two times as likely to cite warning labels as the motivating factor to quit smoking. However, pictorial warning labels are rather new even in the global tobacco policy domain, and the evidence of their true impact on smoking cessation has yet to be firmly established. In our modelling (Higashi et al., 2011b), pictorial warning labels have been calculated as the most cost-effective intervention for tobacco control in Vietnam (Table 3).

Mass media health education and communication

Media education is required by the FCTC under Article 12. Although it is potentially an effective intervention to reduce smoking, there is currently no local evidence available on the effectiveness of a mass media education in Vietnam, except for a post-campaign evaluation conducted in 2010 with surrogate outcome measures (i.e. recall of campaign and raised awareness on second-hand smoke) (World Lung Foundation, 2010). The effectiveness of this type of approach is generally difficult to evaluate because of confounding factors that vary depending on the duration and intensity of the interventions. International reviews provide mixed findings, yet with sound evidence on its synergistic effect if provided in combination with other interventions (e.g. smoking bans) rather than as a stand-alone strategy (Bala et al., 2008; Sowden and Arblaster, 1998; National Cancer Institute, 2008). Mass media communication ranks as the fourth most cost-effective intervention examined in Vietnam (Higashi et al., 2011b) (Table 3).

Smoke-free environment

The FCTC Article 8 requires the government to provide protection from exposure to tobacco smoke in public and work places. International reviews suggest that smoke-free policy is an effective intervention in reducing exposure to smoking, both through reduction in passive smoking and an increase in smoking cessation (Levy and Friend, 2003; IARC, 2009). However, similar to mass media communications, the evidence on its effectiveness can vary with the degree of enforcement, compliance and the definitions of public spaces that are to be designated smoke free. Although a smoke-free policy has been in place in Vietnam for more than a decade, there is currently no local evidence available on its effectiveness. Enforcement of smoke-free regulation is critical for its successful implementation and is often regarded as being far from sufficient in Vietnam: ‘Actually the challenge is enforcement. The regulation is fine, but enforcement is very weak’ (VINACOSH; quote from interview). A recent WHO report scored only 3 out of 10 for the degree of smoke-free compliance in Vietnam, which is one of the poorest scores in the Western Pacific region (WHO, 2011). Its re-inclusion in the draft law aims to give greater legal leverage for enforcement. In terms of cost-effectiveness standing (Higashi et al., 2011b), a smoking ban in public places ranks third, and a ban in workplaces the fifth most cost-effective interventions in Vietnam (Table 3).

Personal smoking cessation support

Provision of smoking cessation support, including brief advice by health professionals and various pharmacological therapies, are required by the FCTC Article 14. While the evidence on the effectiveness of smoking cessation interventions is unavailable from Vietnam, the international literature offers convincing evidence from a range of Cochrane Reviews (Table 3). The applicability of international evidence to Vietnam would be less of an issue because of the clinical nature of intervention with effectiveness not likely to vary according to social and political contexts. However, in the absence of family medicine in the primary healthcare system in Vietnam, the infrastructure for implementation of smoking cessation support is inadequate.

… for smoking cessation they [government] are supportive in general and there are no arguments against it. But how to mobilise the resources and how to organise such activities is a big question. (WHO; quote from interview)

In recognition of this current limitation, personal smoking cessation support is generally not considered cost-effective and feasible in Vietnam except for physician brief advice (Higashi and Barendregt, 2011) (Table 3).

Excise tax

Increasing the price of tobacco is widely regarded as the single most effective measure to decrease tobacco consumption (WHO, 2004), usually controlled in the form of excise tax. In Vietnam, ad valorem excise tax has been in place for some decades. The tax rate has been standardised at 65% since 2008 for all tobacco products. Although the rate has been increasing over time, the current value is still low compared with other countries in the region (SEATCA, 2008; WHO, 2008b). While tobacco excise is briefly addressed in Chapter I, an increase in tobacco excise has not been included in the draft Tobacco Harm Prevention Law, with MTI claiming policy jurisdiction over this initiative. Ironically, tax increase is one of few interventions for which reasonable local evidence on its effectiveness exists (Table 3) and is among strategies that tobacco control advocates would be eager to see in the Tobacco Harm Prevention Law. Hoang et al. found that the price elasticity of male smoking participation in Vietnam was −0.9 (i.e. a 1% increase of cigarette price will result in a 0.9% reduction of smokers), and the elasticity with respect to quantity was −0.5 (i.e. a 1% increase of cigarette price will result in a 0.5% reduction of cigarettes consumed). Further, the findings suggest that a tax increase would reduce tobacco consumption as well as increase government revenue, with Doran et al. (2010) confirming the dual benefit of a reduced smoking rate and an increase of government revenue. Excise tax is also one of the two most cost-effective interventions in Vietnam (Higashi et al., 2011b), the other being pictorial warning labels on cigarette packs (Table 3).

Stakeholders' positions in relation to available evidence

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.

DISCUSSION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. ACKNOWLEDGEMENTS
  9. REFERENCES
  10. APPENDIX

From our analyses, contradictions have been identified over the role of evidence in informing decision making. On one hand, there is a demand for strong local evidence in the legislative process of Tobacco Harm Prevention Law. On the other hand, the analysis revealed discrepancies between the policy position of stakeholders and available evidence and also between stakeholders' perceptions on the effectiveness of interventions and available evidence of their effectiveness. Clearly, the evidence of the effectiveness and cost-effectiveness of interventions is not the key driver in shaping the perceptions and positions of decision makers in relation to tobacco control policy in Vietnam, a position consistent with experience from some other countries (e.g. New Zealand (Thomson et al., 2007)), although more positive experiences do exist (e.g. South Africa (Ayo-Yusuf, 2011)).

What is clear is that differing stakeholders approach tobacco control with differing senses of urgency and priority. By referring to Grindle and Thomas' (1991) bipolar characterisation of policy as either ‘crisis’ or ‘politics-as-usual’, those stakeholders whose interests are dominated by the current revenue guaranteed by tobacco consumption apply a framing of ‘politics-as-usual’: policy issues that do not generate the same sense of priority as in ‘crisis’, and may be engaged over a longer time frame. In the less urgent framing of ‘politics-as-usual’ politics, bureaucratic interaction, self-interest or rivalry, typically dominates the decision-making process (Grindle and Thomas, 1991). Arguably, this is evident in competing tobacco legislation now being developed by the MTI, a strategic option that removes one of the most effective tobacco control instruments—tax excise—from the MOH Tobacco Harm Prevention Law.

The development and integration of two laws would potentially exacerbate the dilemma of high-ranking officials who must maintain the balance between economic and health issues. While MOH is responsible for committing to the FCTC requirements, MTI is in a position to meet the World Trade Organization (WTO) principles with the accession of Vietnam in 2007 (Table 2). These two initiatives may contradict each other in various aspects, particularly in relation to the ‘non-discrimination’ principle of WTO (2010). Mamudu et al. (2011) investigated the FCTC negotiation process to examine the stakeholder tension over this issue. The initial draft of FCTC included a trade provision that tobacco control ‘should not constitute a means of arbitrary or unjustifiable discrimination or a disguised restriction on international trade’ (Mamudu et al., 2011), which appeared to prioritise trade over health. Later, this principle was replaced by an article that put a priority on health over trade that was strongly advocated by an alliance of civil society. Such trade provision, however, was challenged not only by tobacco trading countries but also by WHO, which believed this article would unduly delay the negotiation process. Eventually, parties agreed with a compromised position of ‘silence’ by excluding any provisions on trade from the FCTC. Such a dramatic turnover of the relative position of FCTC with respect to WTO principles implies that the Tobacco Harm Prevention Law could be placed under a larger scrutiny of WTO principles rather than those of FCTC, should MTI assume a leading role.

Before concluding, this study has some limitations that are worth noting. The interviews were conducted by researchers from different backgrounds: foreign national with foreign affiliation, local national with local affiliation and local national with foreign affiliation. The different combinations of data collection teams may have had some influence on the stakeholders' attitudes and responses to the interview sessions. Herod (1999) discussed the pros and cons of being ‘insider’ or ‘outsider’ in the research process. Such positionalities have particular meanings in research involving interviews. An insider is advantaged in having better understanding of the local context and subject being studied and is in a position to better understand processes, histories and events as they unfold. On the other hand, an outsider tends to take things less for granted and would be more cautious in interpreting terms by probing into the details of the given concepts. The perceived impartiality of an outsider, who appears to be less of a threat on sensitive issues, may encourage the respondents to talk more openly. Given the different positionalities of researchers, the different compositions of interviewers in each session may have compromised consistency, although they may have allowed for opportunities to retrieve data from a wider dimension. Another limitation is the absence of interviews with VINATABA. Because of government ownership of tobacco industry in Vietnam, we believe that the industry's position advocated in negotiations with VINACOSH was able to be confirmed in discussions with their responsible government agency, the MTI. Nonetheless, a direct contact with representatives from the industry could have added invaluable information on the perceptions of tobacco producers.

CONCLUSIONS

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. ACKNOWLEDGEMENTS
  9. REFERENCES
  10. APPENDIX

The current situation is alarming for tobacco control policy advocates and poses a significant threat to the overall fate of the Tobacco Harm Prevention Law. In order to proceed with the legislation process towards its intended direction, compelling and comprehensive local evidence and strong advocacy are acutely needed. Although our analysis revealed that available evidence, or absence of it, is often used to justify stakeholders' positions, it is the lack of evidence addressing the economic concerns of MTI and MOF that enables such misuses. The high demand for local evidence identified from our analysis suggests that compelling evidence may influence key decision makers on tobacco control, although experience around tax excise suggests some caution in assuming this connection. If research evidence is to play a convincing role, it will need to engage those ministries responsible for the tobacco industry itself and for the economic development of Vietnam. The capacity to undertake the necessary body of research will stretch local capacity, and the government and the tobacco control community in general, both local and international, should seriously consider investing in capacity building and mobilisation of resources to generate comprehensive local evidence in fulfilling Vietnam's commitment towards the FCTC.

ACKNOWLEDGEMENTS

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. ACKNOWLEDGEMENTS
  9. REFERENCES
  10. APPENDIX

This work was supported by the Atlantic Philanthropies under the project of ‘Developing the Evidence Base for Health Policy in Vietnam’. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors would like to thank Mr Nguyen Hai Phong and Ms Nguyen Thi Minh Hieu from the Health Strategy and Policy Institute for their support on the interviews and focus group discussion. The authors declare that they have no competing interests.

REFERENCES

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  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. ACKNOWLEDGEMENTS
  9. REFERENCES
  10. APPENDIX
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APPENDIX

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. ACKNOWLEDGEMENTS
  9. REFERENCES
  10. APPENDIX

QUESTIONNAIRE TO EXPLORE OPINIONS OF NATIONAL ASSEMBLY ON SOME ISSUES RELATED TO REGULATIONS IN THE DRAFT LAW ON THE PREVENTION AND CONTROL OF TOBACCO HARMS

In order to explore the needs for evidence and identify priority policy issues for research to serve as a basis to formulate and approve the law on prevention and control of tobacco harms, the HSPI, in cooperation with Department of Treatment, Ministry of Health, is asking for opinions of the National Assembly members and representative agent of a member of the National Assembly on some issues related to regulations in the draft law on the prevention and control of tobacco harms.

Please kindly pay attention to and provide information by filling in this questionnaire!

(please check as appropriate)

  1. What is your position?
    1. A member of the National Assembly
    2. Representative agent of a member of the National Assembly
    3. Other, detail ……………………
  2. What level are you working for?(central, provincial, district, commune)…………………………
  3. What is your usual occupation?:……………………………………
  4. Have you ever heard/read the Draft law on prevention and control of tobacco harms?
    1. Yes
    2. No
  5. Where did you hear from?
    1. Ministry of Health
    2. National Assembly
    3. Other
  6. Have you ever discussed the Draft Law on prevention and control of tobacco harms?
    1. Yes
    2. No

Section A. How effective do you think the following policy options would be in decreasing smoking habit across population?

StatementVery effectiveEffectiveNot effectiveCould increase smokingUnsure
1. Carry out effective campaigns about the harmful effect of smoke on mass media     
2. Print big photographic and text health warnings on the package, covering at least 50% its area     
3. Issue and effectively implement the ban or limited usage of smoking images on movies and other forms of performances     
4. Issue and effectively implement the prohibition of smoking within all indoor offices (office with roof and/or surrounded walls), public indoor spaces and public transportation means.     
5. Prohibit all kinds of sponsor from tobacco companies     
6. Increase special consumption tax on tobacco products     
7. Impose a tax or fee (1–2% of retail price of tobacco products) to set up National Fund for Health Improvement and Tobacco Harms Control     

Section B: In your opinion, how available are the scientific evidences of the prevention and control of tobacco harms?

There are firm scientific evidences that smoking is harmful to community's health and socioeconomics. Please rate the following statements upon your agreement.

StatementAgreeDisagreeNeeds more evidenceUnsure
1. Smoking causes many serious diseases such as cancer, heart and lung diseases, and results in death    
2. Passive smoking (breath in smoke from other smoker) causes diseases and death    
3. Social—cost from smoking diseases outweighs tobacco's economic benefit    
4. Increase tax on tobacco products can reduce consumption    
5. Increased tobacco's tax will raise state revenue in spite of smuggling.    
6. To reduce smoking, photographic warnings (print on tobacco package) are more effective than texts warnings    
7. Promulgate on mass media about the harmful effects of smoke will reduce smoking rate.    
8. Number of deaths due to smoking is higher than the total number of deaths due to HIV/AIDS, TB and malaria.    
9. Small package (less than 20 sticks) will increase smoking in adolescent    

Section C. To prevent and control tobacco harms, do you support the following policy options?

 Totally supportSupport but need more evidenceWill not support until evidence is shownWill not support in any cases
1. Print photographic and text health warnings on cigarette package    
2. Restrict all kinds of sponsor from tobacco companies    
3. Issue and effectively implement the prohibition of smoking within all indoor offices (office with roof and/or surrounded walls), public indoor spaces and public transportation means.    
4. Increase tax on tobacco products    
5. Impose a tax or fee (1–2% of retail price of tobacco products) to set up National Fund for Health Improvement and Tobacco Harms Control    

Section D: What further evidence do you need to support the draft law on prevention and control of tobacco harms?

  1. Harmful effects of smoking on health and socioeconomic?

    ...............................................................................................................................................

  2. Treatment cost of smoking diseases?

    ...............................................................................................................................................

  3. Increase tax on tobacco products

    ...............................................................................................................................................

  4. Effect of mass media campaigns on the prevention and control of tobacco harms

    ...............................................................................................................................................

  5. National Fund for Health Improvement and Tobacco Harms Control

    ...............................................................................................................................................

  6. Other, (please detail)

    ...............................................................................................................................................

    ...............................................................................................................................................

    ...............................................................................................................................................

    ...............................................................................................................................................

  7. If possible, please indicate whether you are a smoker or not?

    a. Yes

    b. No

Thank you very much