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Tobacco use in Vietnam. Prevalence, predictors, and the role of the

transnational tobacco corporations

Article  in  JAMA The Journal of the American Medical Association · July 1997

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 Tobacco Use in Vietnam
Prevalence, Predictors, and the Role of the Transnational
Tobacco Corporations
Christopher N. H. Jenkins, MA, MPH; Pham Xuan Dai; Do Hong
Sarah Bales, MA; Susan Stewart, PhD; Stephen J. McPhee, MD
Objective.\p=m-\To describe tobacco use in Vietnam and the
impact of transnational tobacco corporations there.
Desig.\p=m-\In
cities, a multistage cluster design; in com-
munes, a systematic sample design, using face-to-face
interviews in all sites.
Set ing.\p=m-\Hanoi, Ho Chi Minh City, and 2 rural communes
in Vietnam.
Particpants.\p=m-\Random samples totaling 2004 men and
women aged 18 years or older.
Main Outcome Measures.\p=m-\Prevalenc and correlates of
tobacco smoking, amount and duration of smoking, age at ini-
tiation, quitting behavior, knowledge of health hazards of and
attitudes toward smoking, and cigarette brand smoked, pre-
ferred, and recognized as most widely advertised.
Results.\p=m-\Smoking prevalence among men (n=970) was
72.8% and 4.3% among women (n=1031). Male smokers
had smoked a mean of 15.5 years; the median age at initia-
tion was 19.5 years. Among male smokers, 16% smoked
non-Vietnamese cigarettes. More than twice as many (38%),
however, said that they would prefer to smoke a non-
Vietnamese brand if they could afford the cost. Among those
who recalled any cigarette advertising (38%), 71% recalled a
non-Vietnamese brand as the most commonly advertised.
Male smokers who were significantly more likely to smoke
non-Vietnamese brands lived in the south, were engaged in
blue collar or business/service occupations, earned higher
incomes, and lived in urban areas.
Conclusions.\p=m-\Vietnam has the highest reported male
smoking prevalence rate in the world. Unless forceful steps
are taken to reduce smoking among men and prevent the
uptake of smoking by youth and women, Vietnam will face a
tremendous health and economic burden in the near future.
Implementation of a comprehensive national tobacco control
campaign together with international regulation will be the
keys to the eradication of the tobacco epidemic in Vietnam
and throughout the developing world.
JAMA. 1997:277:1726-1731
From Suc Khoe La Vang! (Health Is Gold!), Vietnamese Community Health Pro-
motion Project, Division of General Internal Medicine, Department of Medicine, Uni-
versity of California, San Francisco (Mr Jenkins and Dr McPhee); National Center for
Human and Social Sciences, Institute of Sociology, Hanoi, Vietnam (Mr Pham);
Health Information and Education Center, Ho Chi Minh City Department of Health,
Ho Chi Minh City, Vietnam (Drs Do and Truong); Hanoi Trade College (Mr Hoang);
Department of Economics, University of California, Berkeley (Ms Bales); Northern
California Cancer Center, Union City (Dr Stewart); and the Institute for Health Policy
Studies, University of California, San Francisco (Dr McPhee).
Presented in part at the fifth conference of the Asian Pacific Association for the
Control of Tobacco, Chiang Mai, Thailand, November 23, 1995.
Corresponding author: Christopher N. H. Jenkins, MA, MPH, Suc Khoe La Vang!
(Health Is Gold!), Vietnamese Community Health Promotion Project, Division of Gen-
eral Internal Medicine, University of California, San Francisco, 44 Montgomery, Suite
850, San Francisco, CA 94104 (e-mail: chrisj@itsa.ucsf.edu).
Downloaded From: http://jama.jamanetwork.com/ by a University of California - Davis User on 07/10/2014
Ngoc, MD; Hoang Van Kinh; Truong Trong Hoang, MD;
WORLDWIDE, cigarette smoking causes 3 million deaths
annually, with two thirds of these deaths occurring in the
developed world.1 Cigarette smoking is an important risk
factor in the development of cancer, lung disease, coronary
heart disease, stroke, and birth defects and by the year 2020
is expected to kill more people than any single disease.2"4 As
smoking declines in the West, per capita cigarette consump¬
tion rates are growing in the developing world.5 Unless steps
are taken to reduce smoking rates, it is anticipated that in the
year 2025 the worldwide death toll due to smoking will climb
to 10 million per year, with 7 million of those deaths occurring
in the developing world.1
In the Asian countries of the Pacific Rim, the prevalence
of cigarette smoking is uniformly high among men. Among
women, smoking rates are low. In China, for example, 61% of
men and 7% of women smoke; in Indonesia, 53% of men and
4% of women smoke.5·6 In comparison, in the United States
26% of men and 24% of women smoke.7 With declining ciga¬
rette consumption in their domestic markets, transnational
tobacco corporations (primarily Philip Morris Companies and
RJR Nabisco Holdings Corporation in the United States and
B.A.T. Industries PLC [British-American Tobacco] in the
United Kingdom) are seeking new markets overseas through
exports, acquisitions, and joint ventures.8 In recent years, the
US Trade Representative has forced open Asian markets to
sales of US cigarettes with the threat of retaliatory trade
sanctions.8,9 Tobacco corporation revenues from international
tobacco operations regularly outpace those from domestic
sales.1012 In the United States, cigarette exports have grown
260% in the 10 years from 1986 to 1996, and 40% of US tobacco
exports are sold in Asia.13
Reliable data for cigarette smoking prevalence in Vietnam
are not available. Vietnam, a country with a population of 72.5
million, ranks as one of the poorest countries in the world with
an annual per capita income of $200.14 However, recent market-
oriented economic reforms have stimulated annual growth
rates of 8% or more.15 The tobacco industry has proven to be
profitable for the Vietnamese government: in 1994, corporate
and excise taxes on tobacco accounted for 3.2% ($110 million)
of the national budget.16 Tobacco provides employment for
almost 15 000 workers in cigarette production and more than
100000 farmers in tobacco cultivation, accounting for less
than half of 1% of both the industrial and agricultural labor
forces. Although import of non-Vietnamese cigarettes has
been banned since 1990, illegal imports are estimated to fill
10% of the domestic demand. In addition, Vietnam relies on
legally imported tobacco leaf to fulfill 25% to 30% of its ciga¬
rette production needs.17 In an attempt to stem the flow of
 illegal imports and increase tobacco tax revenues, in 1994
(shortly after the United States lifted its trade embargo
against Vietnam) the Ministry of Trade issued licenses to 3
transnational tobacco corporations (Rothman's of Pall Mall,
Philip Morris, and B.A.T.) to produce non-Vietnamese-brand
cigarettes in Vietnam in joint ventures with the Vietnam
National Tobacco Corporation, a state-managed tobacco en¬
terprise.18·19
In this article, we present the results of a survey that
describes tobacco use in Vietnam, knowledge of its hazards
and attitudes about .its use, and the impact transnational
tobacco corporations are having on tobacco use in Vietnam.
METHODS
We conducted face-to-face interviews with men and women
aged 18 years or older in 2 cities, Hanoi and Ho Chi Minh City,
and 2 rural communes, Phu Linh in the north and Phuoc Vinh
An in the south, each approximately 50 km distant from their
respective urban centers. The survey sites were chosen be¬
cause they are broadly representative of the country (Viet¬
nam's 2 largest cities, 1 in the north and 1 in the south, and
2 typical wet-rice agricultural communities). During the fall
of 1995, a total of 2004 interviews were conducted, approxi¬
mately 500 in each of the 4 sites. In cities, respondents were
selected using a multistage cluster sampling design. Both
cities are administratively divided into wards, which are fur¬
ther subdivided into blocks. In each city, 25 wards were
selected in a manner which ensured that the probability of a
ward being selected was proportional to its size. Using a
computer-generated random number, we chose 1 block in
each selected ward. For each selected block, sampling frames
were formed by obtaining lists from block captains of all
households living in the block. Since each block had approxi¬
mately 100 households, we used a sampling interval of 5 to
select a systematic sample of 20 households in each block.
In rural communes, households were randomly selected
from the complete list of households living in the commune
provided by the commune People's Committee. The total
number of households in each commune was divided by 500
in order to obtain a sampling interval, which was then used
to select a systematic sample of households for interview. In
both urban and rural sites, after enumerating all eligible
adults in the household, we selected the respondent using a
random-numbers table and conducted the interview. If the
selected respondent was not available after at least 3
attempts within 3 days, we interviewed the next oldest
household member. University students and community
health workers, trained by the investigators, served as
interviewers.
Survey items included sociodemographic information (age,
sex, occupation, years of education, marital status, income),
smoking behavior (smoking status, number of years smoked,
type and amount of tobacco smoked per day, brand of ciga¬
rette), expenditures on tobacco, quitting behavior and atti¬
tudes toward quitting, and knowledge of the health hazards
associated with smoking. Since it is expected that men should
smoke or be offered cigarettes in many social situations, we
asked if respondents agreed with these social norms. Ciga¬
rette smokers were asked what brand of cigarette they would
prefer to smoke if they had more money. Among those who
recalled any cigarette advertising, we asked what brand they
recalled being most advertised. The survey instrument was
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pilot tested and modified to accommodate differences in re¬
gional dialects.
Subjects were asked if they had ever smoked tobacco; if,
during the prior week, they had smoked tobacco; and if, even
though they had not smoked in the last week, they sometimes
smoked tobacco in social situations. Respondents were clas¬
sified as current smokers if they responded yes to the first
and second questions or to the first and third questions, as
former smokers if they responded yes to the first and no to
the second and third questions, and as never smokers if they
responded no to the first question. The age at which smokers
started to smoke was calculated by subtracting number of
years smoked from age. We assumed that 4 water-pipe wads
were equivalent to 1 cigarette. Per capita income was cal¬
culated by dividing household income by household size. Viet¬
namese dong were converted to US dollars at the rate of
11000 dong per dollar.
Data analysis was performed with SUDAAN, a statistical
program for the analysis of complex survey data.20 After
pooling data from the 4 sites, data were weighted to national
population distributions by age, sex, and urban or rural sta¬
tus14 and to account for unequal selection probabilities owing
to differences in household size. In preliminary analyses of
sociodemographic characteristics and smoking behaviors, we
used t tests to test the significance of differences in means and
2 tests to test the significance of differences in proportions.
We then performed multiple logistic regression analyses to
control simultaneously for any differences in sociodemographic
factors that might have accounted for differences in smoking
behaviors. The regressions were performed to identify vari¬
ables among men significantly associated with current smok¬
ing, smoking non-Vietnamese-brand cigarettes, and prefer¬
ring non-Vietnamese-brand cigarettes.
RESULTS
Of the 2226 persons selected for interview, 214 were con¬
sidered ineligible due to illness (33), persistent absence (167),
or having moved away (14). Of the remaining 2012 persons,
2004 agreed to be interviewed, yielding a response rate of
99.6%. In the following analyses, 3 cases were dipped be¬
cause of missing age data.
Reflecting national distributions for age, sex, and urban or
rural residence, the mean age of the participants was 38.3
years (range, 18-92 years), women made up 51.5% of the
sample, and 78.1% of participants lived in rural areas. A
quarter of the participants were single, while the rest were
married or formerly married. Reported occupations were
classified as peasant (41.9%), blue collar (17.2%), business/
service (7.5%), white collar (7.9%), or not in the labor force
(25.5%). Participants reported means of 8.0 years of education
(SE, 0.1) and per capita income per month of $18.32 (SE,
$0.60).
More than a third of the respondents reported that they
were current smokers (Table 1). Smoking prevalence was
much higher among men than among women. Among men,
smoking was related to age (P<.001), peaking in the age
group of 35 to 44 years (84.1%) with younger men and older
men smoking at lower rates. Men belonging to each of the
following categories were more likely to smoke: peasant class,
living in a rural site, having fewer years of education, being
married, or having lower incomes. None of these associations
were statistically significant, however. Among women, there
 Table 1.—Smoking Prevalence for the Total Population and by Sex, All Forms
of Tobacco, Among All Survey Respondents, Vietnam
Total, % (95% CI)* Men,
% (95% CI) Women, % (95% CI)
Smoking Status (N=2001)_(n=970)_(n=1031)
Current smoker 36.0(33.1-38.9) 72.8(68.5-77.1) 4.3(2.6-5.9)
Former smoker 5.2 (3.2-7.2)_9.9(7.5-12.2)_1.2(0.3-2.1)
Never smoker 58.8 (55.9-61.7) 17.3 (13.3-21.3) 94.5 (92.7-96.4)
*CI indicates confidence interval.
was arelationship between smoking and age (P=.002). Smok¬
ing was rare among women younger than age 45 years, but
smoking prevalence rates increased moderately among older
women, peaking in the group aged 65 years or older at 17.9%.
Women who were significantly more likely to be smokers
were not in the labor force (P=.01), had fewer than 6 years
of education (P<.001), and were widowed (P<.001); there
was no significant association, however, between smoking
and urban or rural site of residence or household income.
Except where indicated, the following results presented are
for men, who accounted for 95% of the current smokers.
Most smokers smoked manufactured cigarettes (64.7%).
Another 8.9% smoked loose tobacco rolled into a cigarette,
14.9% smoked loose tobacco in a water pipe, and 11.4%
reported smoking both manufactured cigarettes and water
pipes. The vast majority of water-pipe smokers (92.6%) were
found in the rural survey site in the northern part of the
country.
Those who smoked cigarettes (manufactured or rolled,
n=526) smoked of 9.6 cigarettes per day (SE, 0.4);
a mean
6.7% reported smoking less than 1 cigarette per day and may
be considered occasional smokers. Although it might be ex¬
pected that consumption would increase with income, there
was no relationship between number of cigarettes smoked
per day and income. Among those who smoked water pipes
exclusively, the mean number of tobacco wads smoked per
day was 17.8 (SE, 1.3), the equivalent of about 4.5 cigarettes.
Current smokers (all forms of tobacco) reported smoking
a mean of 15.5 years (SE, 0.7). The median age at smoking
initiation was 19.5 years. Younger age cohorts generally
started smoking at younger ages: among those aged 25 to 34
years at the time of the survey, 78% had started smoking by
the time they reached age 24 years. However, among those
aged 35 to 44 years, only 65% had started smoking by age 24
years. In the group aged 45 to 54 years, the proportion fell to
44%, but rose somewhat among those aged 55 years or older
to 51%.
Among current smokers, 60.6% reported wanting to quit,
but 50.7% said they thought it would be difficult to do so.
Fewer than half of current smokers (43.7%) reported ever
trying to quit. Their mean number of attempts to quit was 2.1
(SE, 0.1). There were 121 former smokers who had quit
successfully (11.9% of ever smokers). Former smokers' most
frequently offered reasons for quitting were for their own
health (75.8%) or the health of their family (5.2%). Another
7.4% reported quitting for economic reasons; only 0.8% said
they quit because of government restrictions on smoking.
Among all respondents, levels of knowledge about the harm¬
ful effects of smoking on health were high. Nearly all agreed
that smoking harmed health (87.2%), smokers died at a younger
age than nonsmokers (80.6%), and environmental tobacco
smoke harmed health (78.9%). Although men and women did
not differ in their response to the second question, women
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Table 2.—Cigarette Brand Consumption, Preference, Recognition, and Cost*
Brand Now Brand Prefer Brand Most
Smoking, % to Smoke, % Advertised,% Price per
Brand_(n=664) (n=619)_(n=742) Pack, US $
Du Lieh_509_309_5_7_0.18
Vinataba_104_14J_137_0.55
Jet_103_21J3_3J3_0.50
555_2$_104_18 _1.05
Dunhill_1J_22_35_1_0.98
Marlboro_OÍS_22_9 _1.02
Other
non-Vietnamese 1.0 1.4 4.9
Other
Vietnamese 23.0 16.9 10.0
*Brand now smoked and preferred brand are reported for all cigarette smokers,
men and women. Brand most widely advertised Is reported for all respondents who
recalled any cigarette advertising, regardless of smoking status. Jet, 555, Dunhill, and
Marlboro are non-Vietnamese brands produced domestically. Prices for packs of 20
cigarettes were determined by calculating the average of prices obtained after sam¬
pling at 3 different vendors in Hanoi at the time of the survey. Ellipses indicate data
not applicable.
were significantly more likely than men to acknowledge that
both smoking (P=.004) and environmental tobacco smoke
(P=.008) harm health. For all 3 questions, nonsmokers were
more likely than smokers to acknowledge the health hazards
of smoking (P<.001).
Among all respondents, most agreed that cigarettes should
not be smoked during public meetings (80.9%). However,
slightly more than half felt that cigarettes should be smoked
at weddings or funerals (51.81%), guests in the home should
be invited to smoke (54.9%), and when meeting friends, one
should offer cigarettes (51.6%). In all situations, however,
men were significantly more likely than women to feel that
cigarettes should be smoked or offered (P<.001). Two thirds
of smokers, male and female (66.6%), agreed that their smok¬
ing bothered others; 62.1% of all respondents said they were
bothered when others smoked.
Most (62.3%) did not recall seeing or reading any cigarette
advertising (reflecting, perhaps, the fact that nearly all direct
cigarette advertising is banned in Vietnam). Among the 835
respondents who did, men (41.2%) were more likely to recall
advertising than women (22.7%), current smokers (40.3%)
recalled more than nonsmokers (26.1%), and those living in
cities (65.0%) recalled more than those living in rural areas
(21.6%). Rates of recall of cigarette advertising declined with
increasing age (P=.005), but rose with increasing income
level (P<.001) and years of education (P<.001). Among oc¬
cupational groups, recall rates were highest among those in
white collar (51.0%) or business and service occupations
(50.6%); only 21.8% of peasants recalled advertising. Those
not yet married were more likely to recall advertising than
those who had ever been married (P<.001).
The cigarette brands most commonly smoked and most
preferred were domestic brands (Table 2). Non-Vietnamese
brands (Jet, 555, Dunhill, Marlboro, and other brands) ac¬
counted for only 16% of brands currently smoked. More than
twice as many (38%) said that they would prefer to smoke a
non-Vietnamese brand if they could afford the cost. Among
those who recalled cigarette advertising, non-Vietnamese
brands were recalled by a wide majority (71%) as the most
commonly advertised. The brand which captured the great¬
est percentage of the market (50.9%), domestically produced
Du Lieh (Tourist), was only recognized by 5.7% as the most
widely advertised brand.
 Table 3.—Multiple Logistic Regression Analysis of Predictors of Current Smoking (All Forms of Tobacco), Smoking Non-Vietnamese-Brand Cigarettes, and Pre¬
ferring Non-Vietnamese-Brand Cigarettes, Vietnam, Men*

Current Smoker, Smokes Non-Vietnamese Brand, Prefers Non-Vietnamese Brand,

OR (95% CI)* (n=970) OR (95% CI) (n=533) OR (95% CI) (n=533)
ge, y
18-24 1.6(0.6-4.5) 7.0(1.0-50.4) 14.9(4.1-53.9)
25-34 3.8(1.5-9.3) 5.0 (0.8-30.0) 14.2(4.0-50.1)
35-44 4.9(2.0-12.0) 1.7(0.3-10.5) 7.5(2.1-26.2)
45-54 3.1 (1.3-7.6) 4.2 (0.5-32.6) 6.3(1.8-21.7)
55-64 2.4(1.0-5.7) 0.8(0.1-5.4) 2.1 (0.5-9.9)
ï65 Referent Referent Referent
Occupation
Not in labor force 0.7(0.3-1.5) 3.9 (0.6-25.8) 2.3 (0.8-6.5)
Blue collar 0.8(0.4-1.6) 10.0(2.5-40.5) 1.8(0.8-4.0)
Business/service 0.9 (0.3-2.3) 23.2(3.3-164.1) 2.2 (0.7-7.5)
White collar 0.4 (0.2-0.9) 3.9 (0.5-29.7) 1.2(0.4-3.1)
Peasant Referent Referent Referent
Residence
Urban 1.1 (0.6-1.8) 1(3.6-21.9) 3.1 (1.5-6.6)
Rural Referent Referent Referent
Region
South 0.7(0.4-1.3) 256.8(40.4-1633.1) 6.3(2.9-13.5)
North Referent Referent Referent
Education, y
0-5 3.4(1.2-9.4) 0.1 (0.0-1.2) 0.1 (0.0-0.3)
6-8 2.3(1.0-5.3) 0.3 (0.0-2.3) 0.2(0.1-0.7)
9-11 2.5(1.1-5.9) 0.3(0.1-2.3) 0.3(0.1-1.1)
12-15 2.5(1.1-5.4) 0.4(0.1-2.1) 0.3(0.1-1.1)
:16 Referent Referent Referent
Per capita monthly income, dongt
Refused to answer 1.2(0.6-2.5) 0.3(0.1-1.2) 1.7(0.7-4.2)
8000-112 000 1.0(0.5-2.1) 0.1 (0.0-0.8) 1.1 (0.4-3.0)
113000-179000 0.6(0.4-1.2) 0.1 (0.0-0.5) 0.9 (0.4-2.2)
£180 000 Referent Referent Referent
Marital status
Married 1.2(0.6-2.2) 0.5(0.2-1.2) 0.6(0.3-1.2)
Not married Referent Referent Referent

*The analysis of the current-smoker category Is based on all men and includes all forms of tobacco; analyses of the "smokes non-Vietnamese brand" and "prefers
non-Vietnamese brand" categories are based on all male cigarette smokers of manufactured and rolled cigarettes. OR indicates odds ratio; and CI, confidence interval.
tTo convert dong to US dollars, divide by 11 000.

Domestic cigarette brands ranged in price from $0.14 to
$0.55 per pack. Non-Vietnamese brands were considerably
more expensive, ranging in price from $0.55 to $1.05 per pack.
Loose tobacco for water pipes cost less than manufactured
cigarettes. A 5-g packet, enough for 20 water-pipe wads, cost
only $0.05. Loose tobacco and the use of a communal water
business/service or blue collar occupations and living in the
urban survey sites. Those with lower incomes were less likely
to smoke non-Vietnamese brands. In the final regression, the
strongest predictor of preferring to smoke non-Vietnamese
brands was younger age. The OR of preferring non-Viet¬
namese brands was 14.9 (95% CI, 4.1-53.9) for those aged 18

pipe are commonly offered free of charge to patrons of res¬
taurants, noodle stands, and coffee shops in the north.
On average, cigarette smokers spent $49.05 on cigarettes
each year. This amount was lVà times their annual per capita
household expense for education ($30.82), 5 times their annual
per capita household expense for health care ($9.65), and about
a third of their annual per capita household expense for food
($143.27). As might be expected, the amount of money spent
on cigarettes rose significantly with a rise in income (P<.001)
and with the number of cigarettes smoked per day (P<.001).
In the multiple logistic regression analyses (Table 3), we
found among men, those more likely to smoke were aged from
25 to 54 years (age groups 25-34, 35-44, and 45-54 years) and
had less than a college education. White collar workers were
less likely to smoke. In the second regression, living in the
southern survey sites was overwhelmingly associated with
smoking non-Vietnamese-brand cigarettes (odds ratio [OR],
to 24 years and 14.2 (95% CI, 4.0-50.1) for those aged 25 to 34
years. Other predictors included being aged 35 to 44 years or
aged 45 to 54 years and being from an urban or southern
survey site. Those who were less educated, with fewer than
9 years of education, were less likely to prefer non-Vietnam¬
ese brands.
COMMENT
Compared with smoking prevalence rates reported by the
World Health Organization (WHO) for 87 countries for which
national data are available,5 Vietnam has the highest smoking
prevalence rate for men in the world. Smoking rates among
Vietnamese women, on the other hand, are among the world's
lowest. We should caution that more reliable national smok¬
ing prevalence data might have been obtained from a national
probability sample. However, as noted above, survey sites
were chosen because they are broadly representative of the

256.8; 95% confidence interval [CI], 40.4-1633.1). Other pre¬ country, and the data were weighted to reflect national popu¬
dictors of smoking non-Vietnamese brands were working in lation distributions.

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 Based on the smoking prevalence rates reported here and
Vietnamese population data for 1994, there are approximately
15.5 million smokers in Vietnam. Reports from developed coun¬
tries indicate that about half of all lifetime smokers will die from
tobacco-related diseases; half of these deaths will be prema¬
ture, occurring between the ages of 35 and 69 years.1 Using this
evidence, we can project that approximately 7 325 000 Viet¬
namese (about 10% of the population) will die from tobacco use
and that about 3 660 000 of these persons will die prematurely.
Furthermore, if children start to smoke at the rates their par¬
ents smoke, more than 5 million of those younger than 15 years
in 1995 will die prematurely from smoking-related diseases.
Vietnamese male smokers smoked fewer cigarettes (9.6
per day) than the mean number reported worldwide for both
more developed countries (22 per day) and less developed
countries (14 per day).5 In addition, they started smoking
when they were somewhat older than their counterparts in
other parts of the world, where the median age at initiation
is often younger than 15 years.5 An older age at initiation
combined with a life expectancy of only 60 years for men14
means Vietnamese smokers are exposed to fewer years of
smoking than smokers in more developed countries where life
expectancy is longer. These factors may mean that the tobacco-
related mortality estimates for Vietnam above are overstated.
Even if we reduce these estimates by half, however, they still
portend an ominous future of tobacco-related death, disabil¬
ity, and associated lost productivity and health care costs.
Furthermore, if age at smoking initiation decreases and life
expectancy increases, we can expect that the toll on human
life taken by tobacco will be greater in the future.
Contributing to the public health toll on cigarette smokers
and their families is the proportion of a smoker's income that
is spent on cigarettes. Money spent on cigarettes is money not
spent to meet vital, life-sustaining needs. The mean expen¬
diture for cigarettes could have bought 136 kg of rice at 1995
prices ($0.36/kg), nearly enough to feed 1 person for 1 year.
Although state subsidies for food, health care, and education
were common before 1989, the policy Dot Mot (Renovation)
and the ending of financial support from the former Soviet
Union have led to severe cutbacks in recent years.15 By 1995,
for example, consumers paid for more than 80% of their own
health care expenses.21
Water-pipe smoking is a popular custom among rural men,
especially in the north. The relative health effects of water-
pipe smoking, compared with cigarette smoking, are unknown.
In cigarette equivalents, the quantity of tobacco smoked per
day by water-pipe smokers is less than half that smoked by
cigarette smokers. This fact alone may mean that water-pipe
smoking is less hazardous to health, but this issue bears
further research.
In recent years, smoking cigarettes has been an integral
part of government meetings and commercial negotiations at
all levels. Cigarette packs or cartons are often offered as
"gifts" to higher authorities in exchange for favors. Accord¬
ing to a popular maxim about gaining approval from a gov¬
ernment official, "If you offer a cheap, domestic brand you will
be greeted with silence; if you offer 555 brand, you will get
whatever you want." The large number of respondents who
agreed that cigarettes should not be smoked during meetings
were likely reflecting government regulations issued in 1995
banning such activity. It remains to be seen to what degree
these regulations will be enforced. The great level of support
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reported for smoking in other social situations is testimony
to the widespread social acceptability of smoking and its
integral role in the social culture of Vietnam.
Without prior smoking data, it is not possible to know the
direction of trends in Vietnam. Others have demonstrated
that tobacco consumption in the less-developed countries is
significantly related to prosperity.22 It can be expected that
as disposable income increases in Vietnam, smoking will in¬
crease. Our own data show a trend toward younger age at
initiation. If this trend continues, rates among youth will
increase in the future.
Experience in other Asian countries has demonstrated that
the entry of transnational tobacco corporations and their
aggressive marketing increase tobacco consumption.23-25 In
the data we report, the rate of smoking non-Vietnamese-
brand cigarettes in Vietnam was relatively low. However,
future trends may be discerned in the higher rate of smokers
expressing a desire to smoke these brands if they could afford
them and the overwhelming recognition commanded by non-
Vietnamese brands in the advertising market. Non-Viet¬
namese-brand cigarettes have established their largest mar¬
ket niche in the urban south, perhaps a legacy of taste
preferences established during the US presence there before
1975. Furthermore, it is noteworthy that it was the younger
urban men who were more likely to notice tobacco advertis¬
ing and want to smoke non-Vietnamese brands if they could
afford them. It is these segments of the population that have
been most successfully targeted by the transnational tobacco
corporations to date.
Currently, social norms preclude younger women from
smoking. In younger cohorts, smoking is widely considered
unfeminine, unattractive to the opposite sex, and a sign of
loose morals.26 Among older women, these taboos fall away.
Although the female smoking rate is now low, especially
among younger women, this rate may rise as women enter
the industrial workforce, as their incomes rise, and, espe¬
cially, if transnational tobacco corporation advertising tar¬
gets women more successfully.
Although cigarette advertising has been banned in the
print, electronic, and outdoor media in Vietnam, the trans¬
national tobacco corporations promote their products aggres¬
sively through point-of-purchase advertising, sponsorship of
sports and cultural events, and the provision of logo-bearing
baseball caps, T-shirts, umbrellas, and other merchandise in
exchange for empty cigarette packs. Young women are hired
to distribute free samples in restaurants, hotels, karaoke
bars, and sports arenas. The manufacturers of Dunhill ciga¬
rettes provide $470000 in aid annually to develop profes¬
sional soccer in Vietnam.27 In addition, Dunhill sponsors tele¬
vision broadcasts of Saturday night soccer, slipping through
an advertising ban by showing only its logo with the slogan
"The Best Taste in the World," without showing the actual
cigarette itself.
Typically, as non-Vietnamese cigarettes garner more of
the market share in developing countries, domestic tobacco
companies intensify their marketing to remain competitive.9,25
Entry of the transnationals into the Vietnamese tobacco mar¬
ket, for example, has prompted domestic manufacturers to
develop new copycat brands. One state-owned tobacco fac¬
tory has come out with 333 brand cigarettes with gold foil
packaging, which carefully imitates British-American Tobac¬
co's 555; another new domestic brand, Boy Boy Boy, features
 packaging with images of a Vietnamese Marlboro man, com¬
plete with cowboy hat.
Special attention should be focused on the transnational
tobacco corporations in order to monitor and control their
activities. Exporting countries, which have made admirable
progress in recent years in controlling tobacco at home, should
take steps to ensure that they do not permit the export of the
tobacco epidemic to countries such as Vietnam or the rest of
the developing world. In the exporting countries, a combi¬
nation of legislative initiatives and consumer action is needed.
In the United States, for example, Congress can restrict the
activities of the US trade representative in promoting US
tobacco interests overseas, place a surtax on corporate prof¬
its derived from international tobacco sales, revoke corporate
tax exemptions for cigarette advertising expenses of over¬
seas operations, and force tobacco corporations to observe
abroad the more restrictive sales, advertising, and promotion
controls which apply in their domestic markets. Consumers
can organize boycotts of tobacco conglomerates, refusing to
buy nontobacco products controlled by the parent corpora¬
tion. Stockholders, particularly institutional stockholders such
as university endowments or retirement plans, can divest
their portfolios of tobacco stock holdings. In the past, boy¬
cotts and divestment have been used effectively to stop the
marketing of infant formula in the developing world and to
weaken the apartheid regime in South Africa.
On an international level, exporting countries can initiate
the development of an international convention for compre¬
hensive, global tobacco control, with set timetables for imple¬
mentation of plans to control international sales, advertising,
and smuggling of cigarettes. Without such an international
agreement, it is unlikely that any single exporting nation will
take regulatory actions that put their own tobacco corpora¬
tions at a competitive disadvantage in the international mar¬
ket. Such a convention was called for in 1996 by the World
Health Assembly, WHO's governing body.28
In Vietnam, health education efforts appear to have suc¬
ceeded in conveying the message that smoking and even
secondhand smoking are hazardous to health. This knowl¬
edge, however, has not resulted in substantial numbers of
smokers quitting. Unless forceful steps are taken to reduce
smoking among men and prevent the uptake of smoking by
youth and women, Vietnam will face a tremendous health and
economic burden in the near future. Health education and
information campaigns should be tailored for rural commu¬
nities, where most of the population—and most smokers—
live. Smoking bans, already in place, need to be more strictly
enforced. Advertising bans should be modified to include
point-of-purchase advertising, the offer of free samples, and
sponsorship of sporting and cultural events. Prominent health
warnings should be required on all cigarette packs. To dis¬
courage the initiation of smoking, especially by youth, taxes
on cigarettes should be raised and sales of cigarettes to mi¬
nors should be banned. Implementation of such a compre-
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stats by a University of California - Davis User on 07/10/2014
hensive national tobacco control campaign together with in¬
ternational regulation as outlined by WHO will be the keys
to the eradication of the tobacco epidemic in Vietnam and
throughout the developing world.
This research was supported by the University of California Pacific Rim
Research Program.
We would like to thank Judith Mackay, FRCP, Asian Consultancy on To¬
bacco Control, Hong Kong, for her helpful review of the manuscript.
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