27 Tobacco Use in Southeast Asia

8/12/2019 27 Tobacco Use in Southeast Asia

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Debra EfroymsonMenchi G. Velasco

The Collaborative Funding Program forSoutheast Asia Tobacco Control Research

Tobacco Use inSoutheast Asia:

Key Evidences forPolicy Development

Financial support fromThe Rockefeller Foundation and

Thai Health Promotion Foundation

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SoutheastAsiaTobaccoControlAlliance(SEATCA)

Under

The

Collaborative

Funding

Program

for

Tobacco

ControlResearch

Tobacco Use in Southeast Asia:Key Evidences for Policy Development

DebraEfroymson

andMenchiG.Velasco

Financialsupport

from

TheRockefellerFoundationand

ThaiHealthPromotionFoundation(ThaiHealth)

May2007

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2

TABLEOFCONTENTS

Page

Acknowledgement

3

IntroductiontoSEATCAResearchonTobacco 4

TobaccoandPoverty: LessonsfromCambodiaandVietnam 6

DemandAnalysisandTobaccoTaxesinVietnamandMalaysia 9

ASEANFreeTradeAreaandTobacco:ARegionalSummary 12

HealthCostsofTobacco 14

SociodemographicandPsychologicalTrendsofYouthSmoking 17

Knowledge,Attitudes,andPractice:TobaccoUseamongHealth

Professionals,MedicalStudentsandMonks

20

AnalysisofSmokingBehaviorinCambodia 23

WomenandTobacco:SmokefreeHomesinCambodia,Malaysiaand

Vietnam

26

WomenandTobacco:ReasonsforUse,andPreventionStrategiesin

Cambodia,MalaysiaandThailand

29

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3

Acknowledgement

TheSoutheastAsiaTobaccoControlAlliance(SEATCA)wishestospeciallythank

Ms.DebraEfroymson,ofHealthBridge(formerlyPathCanada)regionalofficein

Bangladesh,andMs.MenchiG.Velasco,inputtingallthesetogether.Wearealso

thankfultoTheRockefellerFoundationandtheThaiHealthPromotion

Foundation(ThaiHealth)fortheirfinancialsupport.

Weacknowledge the technicalsupportextended toSEATCAand researchersby

the regional and international research faculties in the development of the

researchprotocols,notablyProf.FrankChaloupka,Dr.HanaRoss,Dr. Jonathan

Samet andDr.FrancesStillman.

Finally,we

are

also

grateful

to

all

the

researchers

in

the

region,

whose

works

are

includedinthesummarizedfactsheets. Theyare:

1) AlSadat,NabillaA.M.,UniversityofMalaya,Malaysia2) Austria,MyrnaS.,DeLaSalleUniversity,Philippines3) Charoenca,Naowarut,MahidolUniversity,Thailand4) ChheaChhordaphea,NationalCentreforHealthPromotion(NCHP),

MinistryofHealth,Cambodia

5) DaoNgocPhong,HanoiSchoolofPublicHealth(HSPH),Vietnam6) Foong,Kin,UniversitiSainsMalaysia,Malaysia7) Hairi,Farizah,UniversityofMalaya,Malaysia8) HoangVanKinh,TradeUniversity,Vietnam9) Khor,YokeLim,UniversitiSainsMalaysia,Malaysia10)NgoLeThu,VietnamSteeringCommitteeonSmokeandHealth

(VINACOSH),Vietnam

11)PhaukSamrech,LIDEEKhmer(LeagueofKhmerStudentsfromAbroad),Cambodia

12)Pongpanich,Sathirakorn,ChulalongkornUniversity,Thailand13)Saad,Ilyas,Indonesia14)SanSanAye,MinistryofHealth,Myanmar15)Sanguanprasit,Boosaba,MahidolUniversity,Thailand16)Sarntisart,Isra,ChulalongkornUniversity,Thailand17)SengSouern,NationalInstituteofStatistics(NIS),Cambodia18)SoreachSereithida,WomensDevelopmentAssociation(WDA),Cambodia19)VichitVadakan,Nuntavarn,ChulalaongkornUniversity,Thailand20)VuPhamNguyenThanh,InstituteofSociology,Vietnam21)VuXuanPhuandDangVuTrung,HanoiSchoolofPublicHealth(HSPH),

Vietnam

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4

IntroductiontoSEATCAResearchonTobacco

SeveralSEATCApolicyrelevantresearchoneconomicsandepidemiologyoftobacco

wereconductedinthecountriesofCambodia,Malaysia,ThailandandVietnam.And

oneresearch

each

on

trade

and

tobacco

was

conducted

in

Indonesia,

Myanmar

and

thePhilippines.Allthesetoevidentlyshowtheburdensoftobaccouseinhouseholds,

ingovernmentbudget, innon smokers, inyouthandeven tohealthprofessionals

who are supposed tobe rolemodels. To showburdens of tobacco use thatfar

outweighgains,and thus, tobaccocontrolwillbe legislatedand strictlyenforcedat

countrylevel.

These recent SEATCA research on tobacco covers a wide range of issues, from

smokingamongmonksandwomenconvincingtheirhusbandsnottosmokeintheir

homes,toissuesoffinancialburdensoftobacco,taxation,smuggling,andfreetrade.

Butthe

results

all

point

in

the

same

direction:

the

responsibility

of

governments

to

takestrongeractiontoreducetheharmcausedbytobacco.

Someofthespecificissuesraisedintheresearchinclude:

Smoking leads to large economic losses for the entire society and imposesbig

burdenonbothgovernmentandhouseholdsbudgets.

Tobacco spending can represent a considerable portion of household

expenditures, and a significant sum of money nationwide. Tobacco use

contributes significantly to poverty. Tobacco control activities could help toeliminatehungerandtoreducepoverty.

Taxrevenuesare likely to increaseascigarette taxesareraised.Thedecrease in

quantitiesconsumedwouldbemorethancompensatedforbyanincreaseinthe

taxrate,andhealthcoststotreatsmokingrelateddiseaseswouldalsodecline.

Raising tobacco taxes represents a winwinwin situation, as it will improve

health,contributetopovertyalleviation,andincreasegovernmentrevenue.Low

taxesoncigarettescontribute to theiraffordability,andyouthand thepoorare

mostaffected

by

price

increases.

Governmentrevenuefromthetobaccoindustryisnotenoughtofinancethecost

of smokingrelated diseases. Therefore, the government needs to increase the

tobaccotax.

Highratesofsmokingamong influentialgroups insociety,suchasmonksand

health practitioners, are a matter of concern in tobacco control. Efforts to

understand the reasons for the high smoking rateswill assist in programs to

achieveareduction.

Womens

tobacco

use

is

currently

still

much

lower

than

it

is

for

men.

This

reflects

the social, cultural,and traditionalbeliefs thatdiscourage them from smoking.

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5

However,womenarenegativelyaffectedbymenstobaccouse,intermsofhealth

effects to the smokerandother familymembers,anddiversionofmoney from

basicneeds.

Creatingasmokefreehomerequiresathreeprongedapproach,i.e.preventing

the initiationof tobaccouse (inhomeswhere therearenosmokers),promotingquit attempts among the young and adults (in homes with smokers), and

eliminating nonsmokers exposure to secondhand smoke (in homes with

smokers).

Pervasive tobacco advertising evenwhere it is prohibitedby lawplays a

significantroleinencouragingpeopleofallagesandbothsexestosmoke.

Theretentionofmessagesfromcigarettepackagesisfairlyhigh.

Finally, smokefree places contribute to a sense that tobacco smoking is

unacceptable.

Policymakers, researchers, health professionals, health advocates and others can

come together to decide how to address the tobacco epidemic. Through such

collaborative efforts, policy relevant research evidences in hand, and through a

strong commitment to themeasures that havebeen proven effective in reducing

tobaccouse,SoutheastAsiacan lead theworld incombating the tobaccoepidemic

andincreasingthehealth,wealth,andwellbeingofitscitizens.

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6

TobaccoandPoverty: LessonsfromCambodiaandVietnam1

Highlights:

1) AnalysisofthefinancialburdensofsmokingonhouseholdsinCambodiaand

Vietnam

2) TobaccouseimposesrelativelyhighburdensinbothCambodiaandVietnam,

andcontributestoinequality.

3) Thepoortendtospendalargerportionoftheirexpendituresontobacco,they

aremoreaffectedbytobaccousethantherich.Themoneywastedontobacco

makesthemevenpoorerthantheyseem,andcontributestowideningthegap

betweentherichandpoor.

4) Smokers inVietnamburn theamountof tobaccoequivalent to6,000billion

Vietnamesedong (VND)orUS$416.7millioneachyear.Thissumofmoneycanbuy1.6milliontonsofrice,whichissufficienttofeed10.6millionpeople

ayear.

5) SmokersinCambodiaspend6,248billionRielsorUS$69.44millionannually,

this equivalent to the price of 274,304 tons of high quality rice, 1,388,382

bicyclesor27,778largewoodenhousesintheprovinces.Thiswastedamount

couldalsoeasilyfilladeficitinthenationalbudgetandbeagoodsourceof

financingformanyofthecountrysreconstructionandsocialprojects.

Recommendations

from

the

research

are:

Effortsareneededtoreducetobaccoconsumption,forpovertyandequityas

well as improved health. To achieve significant reductions in tobacco use,

particularly among the poor, an increase in tobacco taxes is needed; in

addition,allpromotionoftobaccoproductsshouldbestrictlybanned.

Tobaccocontrolshouldbeincorporatedintopovertyalleviationstrategies;the

associationbetweentobaccouseandpovertyshouldbebroadlypublicized.

Itmaybe useful to raise awareness of the risk of tobacco use on family

economicwellbeing.

One

efficient

mechanism

is

through

pictorial

messages

oncigarettepacks,whichcouldincludeeconomicaswellashealthmessages.

1Thisfactsheetdrawsonthefollowingresearch: 1)PhaukSamrech,LIDEEKhmer(LeagueofKhmer

Students fromAbroad),Cambodia.Tobacco,PovertyandSocioeconomicStatus inCambodia;2)Seng

Souern and Tith Vong,National Institute of Statistics (NIS), Cambodia. TheAnalysis of Smoking

BehaviorSurvey inCambodia,2004;3)HoangVanKinh,NguyenThacMinh,NguyenThiThuHien

(TradeUniversity),TradeUniversity,NguyenTuanLam(WHO),andVuThiBichNgoc(Instituteof

Finance),Vietnam.FinancialBurdenofSmokingonHouseholdsinVietnam.

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8

aremore likely to use tobacco than the rich, and spend a larger portion of their

expenditureson tobacco, theyaremoreaffectedby tobaccouse than the rich.The

moneywastedontobaccocontributestowideningthegapbetweenrichandpoor.

InVietnam, tobacco spending causesmany households to fallbelow the poverty

line. Tobacco spending does not contribute to improving household livingstandards, but rather reduces household disposable income. After separating

tobaccospendingfromtotalhouseholdexpenditures,1.5%ofthepopulationwhose

livingstandardsusedtobeabovethefoodpovertylinefallintothecategoryoffood

poorhouseholds.Iftheamountspentontobaccowasinsteadusedtopurchasefood,

then11.2%offoodpoorpeoplewouldbeabletoemergefrompoverty.

Tobaccospendingthuscontributestopoverty intwoways: tobaccoexpenditure is

welfarereducing,andatthesametimereduceswelfareenhancingexpendituresfor

education,health ornutrition.Tobacco spending also contributes towidening the

gapbetween therichand thepoor,because thepoorhavehigherratesofsmoking

andspendahigherproportionoftheirincomeontobacco.

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9

DemandAnalysisandTobaccoTaxesinVietnamandMalaysia4

Highlights:

1) Imposingauniformhightaxof65%ontobaccoinVietnamwillresultinarise

of 16 32% in prices of lowpriced cigarettes, a decrease of about 27% intobacco consumption,and an increaseofmore than 11% in the tobacco tax

revenueof thegovernment.So imposingauniformhigh taxon tobacconot

onlybenefitsthepoor,butalsodoesnothurtthegovernmentbudget.

2) InMalaysia, a 10% increase in pricewould result in a 3.8% reduction in

cigaretteconsumptionoverthelongrunifannualtobaccotaxincreaseswere

made.An increase in cigarette excise tax from the current levelofRM1.60

(US$0.42)perpacktoRM2.00(US$0.53)perpackwouldincreasetheaverage

cigarettepriceby5.9%andreduce theconsumptionby2.25%.Thisreduced

consumptionwould translate tobetween174and179 fewer tobacco related

deaths per year among the adult population. At the same time, the

government would collect additional RM 437million (US$116million) in

cigaretteexcisetaxes,oralmost23%morecomparedtowhatitwillotherwise

collect.

Recommendationsfromtheresearchare:

InVietnam,theresaneedtostrengthenthenationaltobaccocontrolstrategy

includinggovernmentmeasuresandpubliceducationprogramsforthepoor

households.

Tobaccocontrolprogramsshouldbeexpandedtocovermoreextensivelythe

southernregionsofVietnamitsruralandisolatedareas,wherethehighest

smoking rate ismoreprevalent, and at the same timeaddressing theother

regionsofthecountrywithrelativelylowersmokingrates.

Annual cigarette tax increase in Malaysia that will result in a winwin

situation:animprovedpublichealthandanincreaseingovernmentrevenues.

Additional government revenues from proposed annual tax increase in

Malaysiacan

be

used

to

help

smokers

in

their

cessation

efforts

and

to

support

tobaccofarmerstoswitchtoalternativecrops

Imposing taxeson tobacco isoneof themostefficientandeffectivemeasures that

can be implemented to reduce tobacco use.5 Simply raising the tax on tobacco

4 This fact sheet draws on the following research: 1)HoangVanKinh,Hana Ross,David Levy,

NguyenThacMinhandVuThiBichNgoc,Vietnam.TheHealthandEconomic ImpactsofaUniform

HighTobaccoTax inVietnam;and2)AlSadat,NabillaA.M.,UniversityofMalaya,Malaysia,Hana

Ross,ZarihahZain,Haniza,MA,MohammedSyedAlJunid,Mohamed IzhamMohamed Ibrahim.

DemandAnalysisofTobaccoConsumptioninMalaysia.5Chaloupka,FJ,Hu,T,Warner,KE,Jacobs,R,andYurekli,A. TheTaxationofTobaccoProducts, inP.

JhaandF.Chaloupka(eds.),Tobaccocontrolindevelopingcountries2000,pp.237272.

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10

products achieves a significant decline in use,while also increasing government

revenues.InVietnam,smokersof lowpricedcigarettesaccountedfora largeshare

oftotalcigaretteconsumption.Mostconsumersoflowpricedcigaretteswerepoor.

Theyspenta largerproportionof theirhouseholddisposable incomeoncigarettes

thanricher

smokers;

consequently,

they

bore

the

largest

relative

economic

burden

fromtobaccouse.

ResearchinVietnamshowedthatimposingauniformtaxof65%ontobaccowould

result in an increaseof1632% in thepriceof lowpriced cigarettes, adecreaseof

about 27% in tobacco consumption, and an increase of more than 11% in the

governmentstobaccotaxrevenue.Thatis,imposingauniformlyhightaxontobacco

wouldnotonlybenefitthepoor,itwouldalsoincreasegovernmentincome.6

TheMalaysian study showed that a 10% increase inpricewould result in a 3.8%

reductionincigaretteconsumptionoverthelongrunifannualtobaccotaxincreases

weremade.Asimulationmodelrevealedthatanincreaseincigaretteexcisetaxfrom

the current levelofRM1.60 (US$0.42)perpack toRM2.00 (US$0.53)perpack in

2006wouldincreasetheaveragecigarettepriceby5.9%andreducetheconsumption

inthatyearby2.25%.Thisreducedconsumptionwouldtranslatetobetween174and

179fewertobaccorelateddeathsperyearamongtheadultpopulation.Atthesame

time, thegovernmentwouldcollectadditionalRM437million (US$116million) in

cigaretteexcisetaxes,oralmost23%morecomparedtowhatitwillotherwisecollect

in 2005. In both cases, therefore, demand analysis showed that taxation is an

effectivemethodofreducingconsumptionwhileincreasinggovernmentrevenue.

TheMalaysian researchers further estimated that the incomeelasticityof cigarette

demandinMalaysiawas+1.0,meaningthata10%increaseinincomewouldleadto

a10% increase incigarettedemand.Therefore, itcanbeexpected that the tobacco

epidemicinMalaysiawillspreadwithincomegrowthifnostringenttobaccocontrol

measuresaretaken.

The results of the Vietnamese research indicate that tax revenues are likely to

increaseastaxesareraisedfordomesticunfilteredanddomesticfilteredcigarettesto

theleveloftheexistingrateforforeignfilteredcigarettes.Thedecreaseinquantities

consumedwould

be

more

than

compensated

for

by

an

increase

in

the

tax

rate.

That

is,healthandeconomicconcernscanbemetwithoneaction:consumptiondeclines

butrevenuesincrease.

Cigarette tax increases inMalaysiawould result inawinwin situation: improved

publichealthandanincreaseingovernmentresources.Ideally,thesenewlyobtained

resourceswouldbeused tohelpsmokers toquitsince theycame from thosewho

have themostdifficultygivingup theirsmokinghabit.Theycouldalsobeused to

supporttobaccofarmerstoswitchtoalternativecrops.

6Sinceconductingthisresearch,thetaxstructureinVietnamchangedtoauniformtaxof55%.

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While this fact sheet focuses onjust two countries Vietnam andMalaysia the

informationpresented isapplicableelsewhereaswell.Keeping tobacco taxes low

whetheroveralloronlyonthetypesoftobaccomostusedbythepoorest inorder

toavoidharming thepooreconomicallycouldbeseenasanodd formofsubsidy,

onewhich

encourages

abehavior

that

governments

are

otherwise

trying

to

discourage.Since thepoorare the leastable toaffordspendingmoneyon tobacco,

there is a great incentive to discourage their tobacco use. Raising tobacco taxes

representsawinwinwinsituation,asitwillimprovehealth,contributetopoverty

alleviation,andincreasegovernmentrevenue.

Twokeyargumentsmaybeputforwardagainstincreasingtobaccotaxes:thatthey

willcontribute tosmuggling,and that theywillharm thosemostaddictedamong

thepoor.The firstargument iseasilycounteredby the information indicating that

taxationlevelsarenotresponsibleforsmuggling,andthatotheractions(increasing

penalties,usingtaxpaidmarkings,andincreasingpoliceenforcement)arefarmoreeffectiveat reducing smuggling than reducing taxes.As for the secondargument,

since thepooroverallwillreduce their tobaccouseand thus theirexpenditureson

tobacco ifpricesgoup, itmakesnosense tokeepprices lowonadeadlyproduct,

therebyencouraging itsuse.Finally,concernsoverpossiblenegativeconsequences

tohighlyaddicteduserscanbeassuagedinmorehelpfulways,suchasbyspending

someoftheincreasedtaxationrevenuesoncessationassistancetothepoororother

programstoimprovetheirwellbeing,ratherthantosubsidizetheiraddiction.>>


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ASEANFreeTradeAreaandTobacco:ARegionalSummary7

Importantconclusionsandpolicyimplications:

The CEPT scheme relatively favors imported cigarettes. Future smoking

controlmeasureswillfacetougherresistancefromforeigntobaccoproducers.

An increase inexcisetax isthebestwaytoprotectASEANsmokers.Higher

excise taxeswill reduce thedecrease inprices, the increase indemand,and

the increase in health costs. Governments should increase cigarette excise

taxesatahigherratethanthefallintariffs.Otherwise,themainbeneficiaryof

AFTAwillbeforeigncigaretteproducers.

Decreases in the relative price of cigarettes over time encourage smoking;

governments should thus regularly increase excise tax rates. Excise tax

indexationwith

inflation

can

be

an

effective

instrument

to

ensure

rising

actual

costofcigarettesandcontinuingreductionindemand.

Excluding tobacco from theAFTACEPTscheme is thebestsolution forall

ASEANcountries.TheinclusionoftobaccointheAFTAsCEPTschemeisan

importantlessonforallcountries.

In Indonesia, loyalty to domestic brands protects local smokers, but the

Indonesiancigarettemarketisatargetforforeigncigaretteproducers.Ifprice

reductionislargeenough,Indonesianswillswitchtoimportedcigarettes.

Price

control

will

not

generate

a

change

in

cigarette

demand

but

may

have

adverse effects since the governments foregone tax revenue will go to

cigarette producers and importers, especially in Thailand. Producers and

importers may use additional profit for political lobbying, nonprice

promotion,andotheractivitiesthatoffsetsmokingcontrolmeasures.

Argumentsinfavoroffreetradearenotapplicabletotobacco.Lowercigaretteprices

that follow the establishment of free trade areas would allow more cigarette

consumption;consequently, thehealthcostofsmokingand thenumberof tobacco

relateddeathswouldrise,whiletobaccotaxrevenuewouldlikelybereduced.

UndertheASEANFreeTradeArea(AFTA),membercountriesagreed toeliminatetradebarriersonmostgoodsandservicesamongthemselves,includingtobaccoand

tobaccoproducts,whilecontinuing toapplybarriersagainst the restof theworld.

Taking into account the income and price impacts, the overall impact of trade

7Thisfactsheetdrawson the followingresearch:1)Sarntisart, Isra,Centre forDevelopmentPolicy

Studies (CDePS),FacultyofEconomics,ChulalongkornUniversity,Thailand.AFTAandTobacco:A

Regional Summary; 2) Saad, Ilyas, Indonesia. Likely Impacts of AFTA on Cigarette Consumption:

IndonesianCase;3)Austria,MyrnaS.,DeLaSalleUniversity, Philippines.TheEconomicandHealth

Impact ofTradeLiberalization inAFTA: theCaseof thePhilippines,2006;4)SanSanAye,Ministryof

Health,Myanmar,ImpactsofTobaccotoHealthandtheEconomyinRelationtoAFTA:Myanmar,2006;

and5)Sarntisart,Isra,AFTAandTobaccoinThailand,2005.

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liberalizationoncigarettedemandislargestinlowincomecountries.

Tobaccoand cigaretteproductionplaysavery small role in theThaieconomy. In

2003,theThaipopulationwasslightlyover62millionandsmokingprevalencewas

about 25%. Thailand hasbeen a net importer of tobacco. The share of cigarette

imports from AFTA member countries, very low in the pre2000 period, hascontinuouslyincreasedandby2003representednearly81%oftobaccoimports.

TheimpactofAFTAonIndonesiansmokersislimitedbecauseofthedominanceof

clovecigarettes (kretek).Clovecigarettesrepresentnearly90%of theIndonesian

cigarettemarket.However, a simulation using a 10% decrease in cigarette prices

showsthatdemandwillincreaseby6.1%.Withtotalsmokersalreadymorethan132

million,smokingattributabledeathswillbestriking.Longtermhealthcostswillbe

asmuchasUS$21billion,muchlargerthanotherASEANcountries.

Withthe

openness

of

Myanmar

foreign

trade,

cheaper

foreign

cigarettes

have

penetratedtheMyanmarmarketandsmokingprevalenceratesarenowslightlyover

30%. The implementation of AFTA has further reduced the domestic prices of

importedcigarettes,meaningahugedeclineinrealtobaccopricesinrecentdecades.

In2005,anestimate showed that therewouldbeanearly2% increase incigarette

demandfollowingtheimplementationofAFTA,risingto3.9%in2008.Estimatesof

theincreasesindeathsare976in2025,945in2026,949in2027,and922in2028.

The Philippines analysis shows two alternative possibilities. First, the tariff rate

reduction from 11.67% to 5% in 2003 will decrease cigarette prices by 5.45%.

Consequently, demandwill increaseby 2.14% or 4.62million packs. Second, thegovernmentmaydecidetoincreasetheexcisetax,whichwillpartlyoffsettheimpact

ofAFTA. If the tariff rate is reduced to 5%,but the excise tax is increased, there

wouldbeonlya4.10%decrease inprice,anda1.61% increase indemand (or less

than4millionpacks).

InThailand,analysisshowsthatadecrease in tariffratesontobaccowouldreduce

the taxburden on importers and the local producer (TTM), and adversely affect

government revenue. In the case of imports, total government revenuewouldbe

reducedbyapproximately11%ofthepreAFTAvalueornearly1,200millionBaht,

while cigarette importerswould earn 12%more profit. For TTM cigarettes, totaltobacco tax revenue would decreaseby over 7million Baht. If the government

decidedtolowertheretailpricesofbothtypesofcigarettes,demandwouldincrease

and imported cigarettes would gain more market share. Consequently, the

governmenttobaccorevenuewoulddecreasebyabout1,034millionbaht(US$25.85

million).Avery optimistic estimate shows that the enforcement ofAFTA in 2003

wouldcost theThaieconomyaround82millionbaht (more thanUS$2million) in

increaseddeaths.

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HealthCostsofTobacco8

Highlights:

1) InVietnam, the total cost or economic loss attributable toCOPD, Ischemic

HeartDisease, and LungCancer in 2005was 1,162billionVND (US$77.50million)

2) Vietnam spent about 1,161,829 million VND (US$77 million) on hospital

treatmentof threesmokingrelateddiseases(COPD,IschemicHeartDisease,

and Lung Cancer). This represented about 4.3% of total health care

expenditureandabout0.22%ofGDPin2005.

3) InThailand, the totalcostoreconomic lossattributable toCOPDandLung

Cancerin2003wasapproximately20.51billionbaht(US$514million),which

represents0.35

%

of

GDP

for

that

year.

This

also

accounted

for

8.36%

of

total

2003healthcareexpenditure.

4) The totalhealthcarecostfor top3diseases(COPD,CoronaryHeartDisease

andLungCancer)causedbysmokingconsistedoftotaldirectcostand total

indirectcostisequaltoBaht145,028.80/person/year(US$3,625.72)inThailand.


Establishapermanentmechanismtotracktobaccorelatedhealthcarecosts.

Policymakerscouldconsideranationalhealthcampaign tocoincidewitha

sharpriseintheratesoftaxoncigarettesandothertobaccoproducts.

Educate, encourage, and stimulate government, law enforcers, and the

population tobe aware of tobacco consumptionproblems and the need to

enforceexistinglawsandpolicies.Strongenforcementshouldbefollowedby

strongpunishmentofviolators.

Tobacco use is one of themost important contributors to premature deaths and

avoidablemorbidityinlowandhighincomecountries.Theeconomicconsequences

of tobaccouse includehigherhealth care costs, indirect cost like transportation to

and from health care facilities, and productivity losses due to morbidity and

premature mortality.9 Public costs of smoking represent a burden for the state

budget,whileprivatecostsofsmokingimposeaburdenonhouseholdsandreduce

theirspendingpower.

InThailand,theexpenditureforoneCOPDpatientfromsmoking/year in2003was

8Thisfactsheetdrawsonthefollowingresearch:1)VuXuanPhu,DangVuTrung,HanoiSchoolof

PublicHealth(HSPH),Vietnam),HanaRoss,InternationalTobaccoEvidenceNetwork(ITEN),USA,

Cost ofHospitalizationforThreeSmokingRelatedDiseases,Vietnam;and2)SathirakornPongpanich,

Ph.D.,CollegeofPublicHealth,ChulalongkornUniversity,Thailand.AComparativeAnalysisbetween

PresentandFutureTobaccoRelatedHealthCareCostsinThailand.9WorldBank,1999.Opcit.

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approximately baht 10,740.81 (US$268). Approximately 55% of COPD patients

acquireCOPDfromsmoking.ThetotalcostoreconomiclossofCOPDin2003was

approximately13.96billionbaht(US$350million),whichrepresents0.24%ofGDP

for that year. In addition, it also accounted for 5.7% of total 2003 health care

expenditurein

Thailand.

10

In1990figures,thetotalcostorexpenditureofpatientsbeingtreatedforCHDwas

approximately20,165millionbaht(US$504million),whichrepresents0.33%ofGDP

for that year and 8.27% of total 2003 health care expenditure.11 The total cost or

economic loss attributable to lung cancer in 2003was approximately 6.547billion

baht(overUS$164million),whichrepresents0.11%ofGDPand2.66%oftotal2003

healthcareexpenditure.

The tobacco industry contributes to government revenue in twoways. First, the

Thailand Tobacco Monopoly, the only cigarette producer, generally contributes

around3.5%4.5%ofgovernmentrevenue.In2003,thiswasslightlymorethanbaht

38 billion. The second part is tax revenue from imported tobacco and tobacco

products.In2003,thetotalgovernmentrevenuefromcigaretteswasaroundbaht43

billion more than 5% of total government revenue. But from an economic

perspective, tobacco taxes represent only a redistribution of existing resources.

Therefore, taxes collected on tobacco could be collected on alternative products

withoutreducingpeoplesspendingpower.

TheVietnam study confirms that smoking leads to large economic losses for the

entire

society

and

imposes

a

big

burden

on

both

government

and

household

budgets.Themajorityofpatientsinthisgroupwereintheirlate50s,primarilymale

(72%)andcurrentorformersmokers(66%).Thecostsassociatedwithhospitalization

of these patientswere large.On average, a patient stayed in a hospital 26 days;

averagecostsforoneinpatientepisodewere31,399,800VND,12,358,200VND,and

3,744,400VND (US$2,093,US$824, andUS$250) for ischemic disease, lung cancer

andCOPD,respectively.

Smoking increases the likelihood of getting a smokingrelated disease and of

incurringhighersocialcostswhenhospitalized.Asmokerwas81%morelikelythen

anon

smoker

to

incur

higher

social

costs

of

hospitalization.

Those

social

costs

of

smokingweresharedbygovernment,insurancecompaniesandhouseholds.

Themacro level analysis revealed that about 72.5% of social costs related to the

treatmentofthethreediagnosesinVietnamcouldbeattributedtosmoking.Vietnam

spendsabout1,161,829millionVND(US$77million)annuallyonhospitaltreatment

of threesmokingrelateddiseases.This representedabout4.3%of totalhealthcare

expenditureandabout0.22%ofGDPin2005.

10NationalHealthAccountofThailand200311NationalHealthAccountofThailand2003.

>>


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16

SmokingrelatedCOPDcreates thegreatest financialburden,costing societyabout

1,033,541millionVND(US$69million)peryear,followedbysmokingrelated lung

cancer(78,143millionVNDorUS$5.2million)andsmokingrelatedischemicdisease

(50,145 million VND or US$3.3 million). These costs fall most heavily on the

government,which

bears

51%

of

smoking

related

costs.

Families

and

insurance

sectorbear about 34% and 15% of these costs, respectively.Despite the alarming

resultswith respect to the economicburdenof smoking, the researchers conclude

thatthesecostsareactuallyseverelyunderestimated.

The Vietnamese study demonstrates that tobacco smoking has an enormous

economicimpactonVietnamesesociety,imposingcostsofatleast1,162billionVND

(US$77.5million) annually. The data indicate thatVietnammightbe in the early

stages of the tobacco epidemic, meaning that these costs will rise rapidly with

economicgrowthandincreasedsmokingratesamongwomen.However,thisthreat

canbe avoidedby adopting strong tobacco controlmeasures thatwill not onlyreducesufferingcausedbysmokerelateddiseases,butalsoleadtobettereconomic

performance.

Similarly, theThaistudydemonstrated thatgovernment revenue from the tobacco

industry is not enough to finance the cost of smokingrelated disease (SRD).

Therefore, the government needs to increase the tobacco tax and if it is still not

enough, itmayneed to increase revenueby taxing otherproducts to supplement

tobaccorevenuetopayforthesedifferences.>>


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17

SociodemographicandPsychologicalTrendsofYouthSmoking12

Highlights:

1) Factors, such as, age, sex, family problems, performance in school and

smoking status among friends, teachers, parents and family membersinfluencedstudentssmokingbehaviorandinitiation.

2) Mostofcurrentyoungsmokerswereabletoconvenientlypurchasecigarettes

atstores,althoughbylaw,itisprohibited.

3) Morefemalestudentsinurbanareassmokethaninruralareas.

4) Parentalcontrolandhighcostofcigarettespreventyouthsfromsmoking.

5) InVietnam,mostmale studentsknowabout thedangersof smokingbut is

invalidatedbecauseofteachersseensmokingintheuniversity.

6) In Thailand, 1/3 of the current young smokers added narcotic substances,

suchas,cannabistotheircigarettes.

7) In Malaysia, exposure to direct and indirect advertising is high and

advertisingmessagesappealtotheemotionsoftheyoung.


Designmultiyearmediacampaignsusingastrongsocialmarketing

approach.

Develop

cessation

programs

that

target

teens

before

addiction

begins.

Implementandenforcecomprehensiveadvertisingbans.

Expandandenforcesmokefreeareas.

Stronglyenforcenotobaccosalestominors.

Increasecigaretteprices.

Implement school and communitybased programs that adopt a social

influentialmodel,whichalsotargetsfamilialenvironments.

Theprohibitionofsmokinginschoolsshouldbemoreseriouslyimplemented

atlocalandnationalleveltomakeiteffective. Conduct

program

evaluation

of

preventive

and

control

measures.

SmokingratesarerisingamongyoungpeopleinThailand,Vietnam,andMalaysia.

A Thai study of secondary and vocational school children aged 12 and 19 years

foundasmokingprevalenceof6.8%in2003.Smokingratesamong15to19yearolds

12This fact sheetdrawson the following research: 1)VichitVadakan,Nuntavarn,Aekplakorn,W,

Tanyanont,W,andPoomkachar,H.,ChulalongkornUniversity,Thailand.PrevalenceofSmokingand

Related Factors in School Students, Thailand 2003; 2) Vu PhamNguyen Thanh et al., Institute of

Sociology,Vietnam.PerceptionsofTobaccoandSmokingamongMaleYouthinVietnam.2003;3)Foong,

Kin, and Khor, Yoke Lim, Universiti Sains Malaysia. Tobacco Advertising and Smoking amongst

Adolescents:AQualitativeStudyinMalaysia.2003.

>>


19/35

18

doubledbetween1999 (6.35%)and2003 (15.6%).Substantial increaseswere found

amongbothsexes.

Astudyof1,200Vietnamesemalestudentsaged16to23yearsoldinHanoiCityand

PhuLy town found that43.2%ofyoungpeoplehadexperimentedwith smoking.

Oneinthreemalessmokedatleastonecigarettedaily.Mostyoungpeopleinitiatedsmokingwhile still in their teens (age 1318).MostThaiandVietnamese students

smoked less than 10 cigarettes daily and preferred localbrands.On average, the

smokersspentaboutUS$0.50perday.

The reasons given for smoking among young people in Thailand, Vietnam and

Malaysiawereverysimilar.Peer influenceandcuriositywere themost frequently

reported reasons for smoking uptake. Smoking initiation often occurred while

socializingwithfriends.Imitatingadultssuchasparents,oldersiblings,andteachers

wereoftencited.

Smokingwas commonly perceivedby the students as ameans of relaxation, to

enhanceonesimage,andtocontrolbodyweight.MaleyouthinVietnamsaidthey

smokedwhenbored,duringsocialgatherings,andwhenstressed.Femalestudents

were more likely to smoke when they experienced family problems and were

influencedbymale friends. Thai adolescent smokers felt that smoking enhanced

maturity,masculinity,andmadeteenslookmoreattractiveandcool.

Thai adolescents with family problems, poor academic performance, poor

relationship with parents, who were school violators, and/or who had smoking

adultsintheirenvironmentweremorelikelytosmokethanyouthwhodidnotfaceany of these issues. Knowledge about health effects bore little relationship to

smokingbyyoungpeople.

Most adolescent smokers in each of the three countries purchased their own

cigarettesandwereneverrefusedbysellers.Cigarettesweresoldas loosesticks in

mostplaces.

Generally, knowledge about the harmful effects of smokingwas high.More than

80%oftheThai,Vietnamese,andMalaysianyouthknewthatsmokingwasharmful

tothehealthofsmokersandnonsmokers,andthatsmokingwasaddictive.

Exposuretobothdirectandindirecttobaccoadvertisingwashigh.InThailand,70%

ofadolescents reportedhaving seencigaretteadvertising in stores,while25%had

noticed such advertising in newspapers and/or other printedmedia. Almost all

Vietnamese students had seen characters smoking in movies. Direct cigarette

promotionwasalsowidespreadinallthreecountries.

Factors in the broader social and physical environment such as accessibility to

tobaccoproductsaswellasadvertisingandpromotionofsuchproductswerealso

likelytohavecontributedtothepervasivenessofyouthsmoking.

Thetobaccoindustryhasrepeatedlydeniedthattheytargetyouththroughintensive

>>


20/35

19

marketingandadvertising.However,evidencerevealed that the industryhasvery

successfully createdapositive imageof tobaccouseamongadolescents.Messages

conveyedbyadvertisingimagesappealedtothisyoungpopulation.Adolescentsin

MalaysiaandThailandbelievedthatsmokersaremoremature,stylistic,attractiveto

theopposite

sex,

and

macho.

This

suggests

that

cigarette

advertising

has

most

likely

increasedtheperceivedsocialvalueofsmokingamongyoungpeopleandwaslikely

tohaveinfluencedtherateofadolescentsmoking.

Easyaccessandwidespreadavailabilityofcigarettessignificantlycontributedtothe

high rateof smokingamongadolescents.Ofparticular concern is the finding that

tobacco use can potentially lead to other risk behaviors such as use of illicit

substances,suggesting that tobaccomightbeagatewaydrug.Onethirdofcurrent

adolescentsmokersintheThaistudyhaveexperimentedwithnarcoticsubstances.

Adults are rolemodels that children emulate; thus, cessation programs targeting

adultsmokerswouldindirectlyinfluencethelikelihoodofsmokingamongchildren

andadolescentsthroughreductioninnegativerolemodels.

Measuresthatdenormalizesmokingareimportanttoenhancenegativeperceptions

about smoking, that is, that smoking isnotwidespread and that it isnot socially

acceptabletosmoke.

Bychangingyouthsattitudesandbeliefs toward tobacco,stronger tobaccocontrol

policiesarelikelytoreducecigaretteconsumptionbyyouths,whichinturnislikely

totranslateintoadecreaseinthefutureburdenoftobacconationallyandglobally. >>


21/35

20

Knowledge,Attitudes,andPractice:

TobaccoUseamongHealthProfessionals,

MedicalStudentsandMonks13

Highlights:

1) QuitrateinhealthprofessionalsandmedicalstudentsinVietnamislow.

2) 45%ofmalemedicalstudentsand35.6%ofmalehealthprofessionals(mostly

doctors and dentists) smoke. Female medical students and female health

professionalsaccountfor2%smokers.

3) 99%ofhealthprofessionalsand85%ofmedicalstudentswhoparticipatedin

thestudy,werefullyawareofthehazardsanddangersofsmoking.

4) Exposuretosecondhandsmokingoffamilymembersandfriends is smoking

predictorformedicalstudents

5) The national smoking prevalence inmonks is 37.2%, although lower than

previousstudies,isstillveryhigh.

6) 50%ofsmokingmonksarefromEastandSouthofThailand.

7) 1/3ofthemonkssurveyedhadknowledgeofsmokingbanintemples.

8) Worshippersalwaysincludecigarettesaspartoftheirofferingstothemonks.

9) Quitrateishighforformersmokersafterenteringthemonkhood.

Recommendationstoreducesmokinginhealthprofessionals:

Needforstricttobaccocontrolregulationsorpoliciesinallthehospitals.

Improve and promote health professionals as rolemodels non smokers to

theirpatientsandthepublic.

Recommendationstoreducesmokinginmedicalstudents:

Moreattentionshouldbegiven toearlysmokingprevention,whenmedical

studentsstartstudyingattheuniversity.

National tobacco control policies should include official and strongregulationsonnonsmokingareasandpenaltiesforviolations.Theseshould

bestrictlyenforcedinthemedicaluniversities.

Promotionofmedical students as rolemodelsfornonsmokingand thehealth

hazardsofsmoking.Medicalstudentsshouldbeinvolvedwhentheyentered

13This factsheetdrawson the followingresearch:1)DaoNgocPhong,NguyenVanHuy,DaoThi

MinhAn,HanoiSchoolofPublicHealth,Vietnam.TobaccoUseamongVietnameseMedicalStudentsand

Health Professionals. 2003; 2) Charoenca, Naowarut, Kungskulniti,, N, Kengganpanich, T,

Kusolwisitkul,W,Pichainarong,N,Kerdmongkol, P,Silapasuwan,P.,MahidolUniversity,Thailand.

SmokingprevalenceamongMonksinThailand,2003.

>>


22/35

21

theirfirstyearintheuniversities.

Recommendationstoreducesmokingamongmonks:

Involvemonksindevelopingtobaccocontrolprograms.

Continue education to raise awareness of smoking laws in religiousplaces

includingprohibitingworshippersofferingcigarettestomonks.

Encouragemonkstotakeanincreasingroleintobaccocontroladvocacy.

Providecessationservicesformonksandthepublic,startinginselectedwats

(temples).

IncorporatetobaccocontrolintoBuddhisteducationalprograms.

Since health professionals and monks are respected members of society whom

people are likely to emulate, their smokingbehavior is amatter of concern, yet

research has found high rates of smoking and limited success in quitting among

Vietnamesehealth

professionals

and

Thai

monks.

The rateofsmokingamongmalemedicalstudents is45%and inmalehealthcare

providers it is36%.Whilesmokingamongmales iscommon inVietnam,smoking

among female medical students and health care providers (2%) is a new

phenomenon.

Medicalstudents inVietnamestimated that theyspentanaverageofUS$3.60per

month on cigarettes, about 10% of their total cost of living. Threefourths of the

medicalstudentssurveyedhad tried toquitsmokingat leastonce.Approximately

twothirdsofthemhadintentionstoquitsmokingwithintheupcoming12months.

Healthprofessionalsdidnotshowmuchsuccesswithquitting.About70%ofthem

had tried (unsuccessfully) to quit for one week. Only 25% of the health care

providersexpressedan intentiontoquitsmokingwithinthenext6months.Onlya

verysmallpercentage(6%)hadsuccessfullyquit.

More than 85% of the medical students participating in the study expressed

awareness that smoking was harmful to the health of smokers. Belief that

secondhand smokewas harmful to other peoples healthwas even higher (91%).

Healthcareproviders(99%)alsohadaveryhighawarenessofthehazardsofboth

active andpassive smoking.Fourfifths of thehealth careprovidersbelieved that

patients ability to quitwould increase if theywere advisedby their health care

providerstodoso.Thereversewouldhappenifhealthcareprovidersweresmokers.

Medicalstudentswhodidnotbelieve in theharmsofsmokingwere9 timesmore

likelytosmoke.Thosewithapositiveattitudetowardssmokingwere4timesmore

likely tosmoke.Knowledgeabout thehealthhazardsofsmoking,on thecontrary,

didnotdetersmoking.Studentswhowereexposedtofamilymemberswhosmoked

dailywere5timesmorelikelytosmoke.Thoseexposedtononfamilymemberswho

smokeddailywereabouttwiceaslikelytosmoke.Televisionwasthemostcommon

sourceof

anti

tobacco

information.

Most health providers were interested in being trained in tobacco control

>>


23/35

22

methodologies.Theyrecommendedacomprehensiveapproach thatwould include

healtheducation,legislativepolicyandalawbanningsmokinginallhealthfacilities,

andtraininginantitobaccomeasures.

Knowledgeofthehealthrisksoftobaccouseisnotsufficienttochangeattitudesand

beliefs that are crucial elements for behavioral change, even among health careprofessionals.InVietnam,thereisanurgentneedistoestablishanationalpolicyof

smokefreehealth facilities,whichwoulddeterhealthprofessionals from smoking

andencouragequitting.Assistanceincessationcouldalsoproveuseful.

InThailand,researchfound that25%ofmonkswerecurrentsmokers,andanother

19%wereexsmokers;90%ofcurrent smokers initiated smokingprior toentering

monkhood;and75%ofmonkswhosmokedhadinitiatedsmokingattheageof17.

Reasonsforsmokingincludedtoreducestress,experimentation,torelieveboredom,

socialreasons,andtolookcool.Smokingwasfoundtobeassociatedwitholderage,

nonnovice status, longer period of monkhood, temple residence, and lower

education.

Onethirdofthemonksknewaboutthelawbanningsmokinginreligiousplacesin

Thailand.Experimentersandneversmokersweremoreknowledgeableaboutthese

regulations thanwere current and exsmokers.Approximately 90% of themonks

were aware that secondhand smoke causes diseases and that quitting smoking

wouldreducehealthrisks,while60%knewthatsmokingposedamajormorbidity

andmortalityriskformonks.Currentsmokershadsignificantlylowerknowledgeof

health

risks

related

to

smoking.

82%

felt

that

people

should

be

told

not

to

offer

cigarettestomonks.57%feltthatmonksshouldrefusecigarettesofferedtothemand

thatnonsmokingmonkshadabetterpublicimageandacceptancethanmonkswho

smoked. 80% would support a campaign to educate the public against offering

cigarettestomonks.Threequartersofcurrentsmokerssaidthattheywantedtoquit.

Halfhadattemptedtoquitwithintheprevious12monthperiod.

Lackofwill toquit,poorknowledgeofcessationmethods,andabsenceofadvice

were themain reasonsgiven for failure toquit. Smokingwithin the templeswas

common. Buddhist monks play an important role in setting normative activity

patternsamong

Thai

males

and

community

values

for

healthy

living.

Thus,

adopting

anosmokingpolicyinwatsandamongmonksgenerallyisvitaltoeffortstoreduce

male smoking in the general population. A policy of nonsmoking wats would

facilitatenovicestoquitsmokingandfurthereducationwithinthewatsshouldhelp

toreinforcethehealth,social,andreligiousbenefitsofbeingsmokefree.

>>


24/35

23

AnalysisofSmokingBehaviorinCambodia14

Highlights:

1) The overallprevalence age 20 + formales and females inCambodia is 53.9

percentand6.0percent,respectively.2) Theoverallprevalenceage20+formalesandfemalesinurbanis39.8percent

and5.2percent,respectively.

3) Theoverallprevalenceage20+formalesandfemalesinruralis56.2percent

and6.1percent,respectively.

4) Theaverageageofinitiationis20yearsofage.Therearedifferencesinmean

ageofinitiationaccordingtogeographicregion,educationallevel,etc.

5) About 10% of Cambodians begin to smoke at the age 1014, and this is

alarming.

6) Smokingprevalence

is

much

higher

among

both

men

and

women

who

had

notattendedschool.

Recommendationsfromtheresearch:

Research on tobacco use shouldbe undertaken regularly in Cambodia in

ordertomeasuretrendsinsmokingprevalence,consumption,spending,and

attitudes.

Tobaccocontrolresearchcapacityshouldbestrengthened.

Antitobaccocampaignsshouldbeextendedtoreduce theappealof tobacco

use,tomakepeopleawarethattobaccouseisanimportantcontributortothe

developmentofdiseaseanddeath, and tohighlight its contributions to theloss of family income (through spending on tobacco and treatment of

tobaccorelateddiseases).

Government should give serious consideration to all strategies aimed at

reducing tobacco use, especially policies and regulations that became

obligatory under the Framework Convention on Tobacco Control (FCTC),

suchas:

o Increasingtaxesandpricesonalltobaccoproducts;

o Banningallformsoftobaccoadvertising,promotionandsponsorship;

o Requiring tobacco packaging to include strong health warnings, andbanningmisleadingtermssuchaslightandmild;and

o Creationofsmokefreeareasinworkandpublicplaces.

Ingeneral,thelowerprevalenceofsmokingamongwomeninCambodiareflectsthe

social, cultural, and traditional barriers that discourage them from smoking.

Smokingprevalencewasmuchhigheramongbothmen (67.4%)andwomen(11%)

14Thisfactsheetdrawsonthefollowingresearch:SengSouernandTithVong,NationalInstituteof

Statistics(NIS),Cambodia,TheAnalysisofSmokingBehaviorSurveyinCambodia2004.

>>


25/35

24

whohadnotattendedschool.Smokingprevalencedecreasedgraduallyfromlower

tohighereducationallevelsforbothsexesandinbothruralandurbanareas.12%of

all smokersbegan smokingbefore the age of 15.More females thanmalesbegan

smokingbefore the age of 15 (18.5% versus 11%); less educatedmales started to

smokeearlier

than

did

more

educated

males.

Almosthalfof theurbanand ruralcurrent smokerswanted to stop smoking.The

percentage of thosewho indicated a desire to quit smoking nowwas quite low

comparedwithquittingatsomepoint in thefutureornotatall,anddesiretoquit

smokingwasmuchhigheramong theyoungersmokersandamong those living in

urbanareas. Thismayberelated tobetteraccess to informationon thedangersof

smokingamongthesegroups.

Almosthalfof themalesmokersreportedthat theyregretted that theyhadstarted

smoking.Forbothsexes,approximatelytwooutofthreecurrentsmokershadtried

at somepoint to quit smoking. Females in rural areas had tried the least to quit

smoking.Almost 97% of current smokerswho reported a current desire to stop

smokingand87%ofcurrent smokerswhodesired to stop smokingat somepoint

hadattemptedtodoso,buthadnotsucceeded.Providingcessationservicesmaybe

averyeffectivewaytohelpthesesmokers.

Occasional smokingwasmuchmore prevalent among the lower income groups,

probably because the poor are more pricesensitive and therefore smoke less

frequently than do the rich. Twothirds of current smokers reported preferring

light

or

mild

products.

This

preference

was

based

on

the

smokers

dangerous

misconception that light/mildproductswere lessharmful to theirhealth and that

theyhadabetterflavor.

Approximately 83% of all respondentswere aware that smoking tobacco caused

eitheragreatdealora fairamountofharm to theirhealth.Awareness levels

werelowestamongthoseinruralareas.

Radio advertisements were noticed by 84% of respondents within the previous

month, followedby televisionadvertisements (82%)andbillboardsand/orposters

(44%).Within the past sixmonths, about 10% of the respondents reportedbeing

exposed tooneormoreof the following:beinggiven freecigarettesamples,beinginvolvedincompetitionslinkedtocigarettes,orbeinggivenafreegiftthatcontained

cigaretteadvertising.Intermsofexposuretotobaccoadvertisingbyagegroup,the

20+agegroupreportedmoreexposurethandidthe519agegroup(12%versus7%).

Interestingly, 75% of the survey respondents felt that cigarette advertising should

notbeallowedinCambodia.

78.8%oftherespondentsindicatedbeingexposedtoanantitobaccocampaigninthe

past6months.

Unlikecigarette

smoking,

tobacco

chewing

was

more

common

among

women

than

amongmen,reportedat9.3%and0.7%,respectively.Almost22%offemaleswithno

>>


26/35

25

education in rural areas chewed tobacco compared to only 1.5% among highly

educatedfemalesinurbanareas.

Womenwho smoked or chewed considered itmodern, attractive, and away to

reduce stress. The negative or undesirable perceptions related to having bad

manners anddamaging thehealth.Fewrespondentsviewedwomens tobaccousepositively.Among respondents in the517agegroup,44%perceived thatwomen

who smoked and chewed tobacco havebadmanners and 34.9% that shewould

damage her health. Amongboth the 1844 and the 45+ age groups, almost half

thought it was badmanners to use tobacco, and onethird thought it damaged

health.

>>


27/35

26

WomenandTobacco:SmokefreeHomes15

inCambodia,MalaysiaandVietnam

Highlights:

1) Persuasionmessages should specify the diseases and severity that passive

smokingcauses,especiallyamongchildrenandwomen.

2) Themostconvincingreasonstogetsmokersnottosmokeinsidethehouseis

thatsmokingmayharmtheirchildrenshealth.

3) Messages shouldhighlight the roleof fathers in settingagoodexample for

childrenandtheimportanceoftheirwellbeing.

4) Examplesofsmokerswhohadbecomehealthierafterquitting,orofsmokers

whokeptsmokingandthengotsmokingrelateddiseases,canbehelpfulfor

personalcomparisons.

5) The culturallyacceptablemessages that aremost likely to succeed: clearly

state theadverseeffectsofsmoking,explain thesteps to stopsmoking,and

remind people that smoking is haram (forbidden) according to theMuslim

religion.

6) Successfulmessages must be short and precise and strategies gentle and

loving.Oneshouldofferfullmoralandfamilysupport.

7) The main barrier to developing culturallyacceptable messages for young

womentocreateasmokefreehomeliesinhumanwillnotinscience.

8) Barriers to persuasion include: the fathers addiction, his poor attitude

towardssmoking,andinappropriatepersuasiontechniques.

9) Supportive factors include an engaged mother, a good fatherdaughter

relationship,andinvolvementfromthefatherspeers.


Effective smoking cessation programs for adults that need to be widely

disseminatedandpromoted.

Development of other effective interventions in the reduction of smoking

ratesamongadults.

Thegovernmentshouldtakeactiontolimitthequantityoftobaccoavailable

15This factsheetdrawson the followingresearch:1)NgoLeThu,VietnamSteeringCommitteeon

Smoke and Health (VINACOSH) and Nguyen Thac Minh, Vietnam University of Commerce,

Vietnam, Creating SmokeFree Homes; 2) Soreach Sereithida,Womens Development Association

(WDA),Cambodia.InterventionStudytoDevelopCulturallyAcceptableMessagesorStrategiesforWomen

toTakeActionattheHouseholdorCommunityLevel;3)Hairi,Farizah,AnwarSuhaimi,NoranNaqiah

Hairi,NurAzhanaHairi,M.RohaizadZamri andTeoh LiYing,University ofMalaya,Malaysia.

DevelopingCulturallyacceptableMessagesTowardsaSmokefreeHomethroughYoungWomen.

>>


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27

forsaleandshoulddisseminateinformationaboutthebadimpactofsmoking

atthegrassrootslevel.

NGOs shouldpromote awareness about tobacco/smoking and its impact to

theremote,ruralcommunities.

NGOs should work closely with local authorities and other agencies tosupportsmokingcessation.

Research conducted recently in Cambodia, Vietnam, andMalaysia suggests that

gendernormsandtraditionalvaluesmakeitdifficultforwomentoinfluencetobacco

use among men. In Cambodia and Vietnam, male smoking is considered both

normal and culturally acceptable,while female smoking is generally less socially

acceptable.InMalaysia,thereisanincreasingtrendofyoungfemalesmokers.

Cambodian women and men all were aware of the harmful health effects of

smoking.Thewomenalsoexpressedconcernabouttheirhusbandsotherunhealthy

habits such as drinking alcohol. The reasons cited by these women for their

husbands smoking included addiction, habit, imitating a friend, and reducing

stress.Cambodianwomenmarried to smokerswere concerned about themoney

theirhusbandsspentonsmoking:Thesumthatmyhusbandspendsoncigaretteseach

weekcouldbuy78kgofrice.

BothVietnamesemenandwomenwereaware thatsmokingharms thehealth,but

fewwere awareof specificharmful effects.Lowerincomemen realized that their

spendingontobaccorepresentedasignificantdecreaseintheirabilitytoaffordother

householdexpenditures,

while

one

said

that

one

pack

of

acommon

cigarette

cost

the

sameastwokilogramsofrice.

Allof theMalaysian ruralyoungwomenparticipantsperceived thatsmokingwas

harmfultothehealthofthepersonwhosmokes.Youngurbanwomenseemedtobe

lessawareof theharmfuleffectsof smoking.According to theyoungwomen, the

amountofmoneytheirfathersspentontobaccovariedfromaslowas5%toashigh

as 65% of the total household expenditure. Almost all of the femaleMalaysian

participantswereworried that themoneyspenton tobaccowouldreduceessential

spending for food,health care, and education.Oneyoungwoman expressed that

spendingpart

of

the

familys

income

on

tobacco

is

aselfish

act.

All of theCambodianwomenbelieved that exposure to secondhand smokewas

harmful to theirhealth andwereafraid that theywouldget the samediseases as

theirhusbandswhosmoked.Vietnamesewomennotonlydidnotunderstandabout

theharmofpassivesmoking,somewerenotevensurewhatwasmeantbypassive

smoking.NeitherVietnamesemennorwomencouldspecifyanydiseasescausedby

passivesmoking.The term passivesmokerwasalsonotfamiliaramong therural

youngwomen inMalaysia.Nevertheless, theharmfuleffectsof tobaccoonpassive

smokerswereunderstood.Someof theurbanyoungwomenalsohadneverheard

aboutpassivesmokingordidnotknowtheexactmeaningoftheterm.

>>


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28

Most(80%)oftheparticipatingCambodianwomenhadtriedtoadviseorpersuade

their husbands not to smoke in the home. Few indicated that they had been

successful inconvincing theirhusbands toactuallyquit.This isdue inpart to the

womens lowstatus in thehome,withmenbeingused tomakingdecisionsrather

thantaking

their

wives

advice.

MostofthewomenparticipatingintheVietnamesestudysaidthattheyhadasked

theirhusbandstoquitsmoking,butthattheirhusbandshadnotheededtheiradvice.

DespitethefactthattheVietnamesemenwereawarethattheirsmokingharmedthe

healthofothers,mostof them still smoked inside thehouse.The lackof indepth

informationabouttheproblemsofsmokingsuggests theneedbothforbettermass

mediacampaigns,andforstrongerwarningsoncigarettepacks.Mensreluctanceto

hearadvicefromtheirwivessuggeststhatwomenmaynotbethebesttargetgroup

forchangingtheirhusbandsbehavior.

Only half of the youngMalaysianwomen participants had tried to advise their

father to smoke outside the house, usually unsuccessfully.TheMalaysian fathers

reportedthattheyusuallysmokedanywhereandwhenevertheywished.

This suggests thatmessagesincluding those on cigarette packsshould specify

diseasesandtheirseriousness,forbothactiveandpassivesmokers.Sincemenwere

more aware and concerned about the effect ofpassive smoking on their children

thanontheirwives,messagesaboutpassivesmokingshouldincludetheharmtoall

women,notjustpregnantwomen.Somesmokersmistakenlybelievedthatsmoking

water

pipes

is

far

less

harmful

than

smoking

cigarettes,

both

for

themselves

and

for

thoseexposed to thesmoke.Messagesshould thusmakeclear thatsmokingwater

pipesharmsactiveandpassivesmokersasmuchassmokingcigarettes.

Themainreason thatmengavefornotsmoking inside thehomewasconcernthat

smokecouldharm theirchildrenshealth,aswellaspressurenottodosobytheir

children.Messagesshouldremindsmokersabouttheirvitalroleandresponsibility

inprotectingtheirchildrenshealth,andshouldusechildrenasalliesinpersuading

mennottosmokeindoorsandtoquitsmoking.

Creatingasmokefreehomerequiresathreeprongedapproach:1)preventingthe

initiationof tobaccouse(inhomeswhere therearenosmokers),2)promotingquitattemptsamongtheyoungandadults(inhomeswithsmokers),and3)eliminating

nonsmokers exposure to secondhand smoke (inhomeswith smokers).Creating

smokefree homes requires commitment from the family, health care providers,

policymakers,andantitobaccoadvocates.

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WomenandTobacco:ReasonsforUse,

andPreventionStrategies16inCambodia,MalaysiaandThailand

Highlights:

Cambodia

1)Community people stongly disliked smoking among young women;

however,smokingamongoldwomenwaslessstigmatized.

2)Tobacco chewing practicedby oldwomenwas considered as a traditional

practiceanditwasconsiderednotrisky.

3)Inwomens perceptions, handrolled cigarettes are safe,while commercial

cigarettesareharmfulbecausetheindustrymayaddaddictivechemicals.

4)Communitywomendidnotknowabouttheimpactofsecondhandsmokeor

about the impact of smoking on the environment and on the household

budget.

5)Mostsmokersdidnotknowhowtoquitsmoking. Somehavetriedtoquiton

theirownwhiletheyweresick,buttheyrelapsed

Malaysia

6)Havingamotherwhosmokes is astrongriskfactorforsmoking initiation

andsignificantlypredictseverandcurrentsmoking.

7)Currentsmoking

was

7times

more

likely

among

young

women

whose

close

friendssmokeand25timesmorelikelyamongyoungwomenwhosemothers

smoke.

8)Social, physical and immediate environments contribute to smoking

experimentation.

9)Concern for personal health,wanting to set an example for children, and

parentaldisapprovalmotivatemostsmokerstoconsiderquittingsmoking.

10)Malaysiansocietysdisapprovalofsmokingandthecurrentwarninglabelson

cigarettepacks

do

not

motivate

more

than

70%

of

the

smokers

to

quit

16 This fact sheet draws on the following research: 1) Chhea Chhordaphea and Koeut Pichenda,

NationalCentreforHealthPromotion(NCHP),MinistryofHealth,Cambodia.HealthKnowledgeand

GenderAttitudes Related to Women and Tobacco Use in Kratie Province, Cambodia; 2) Sanguanprasit,

Boosaba,OranuchPacheun,andLakanaTermsirikulchai,MahidolUniversity,Thailand.Knowledge

andAttitudesRelatedtoWomenandTobaccoamongYoungThaiWomen;3)KhorYokeLim,FoongK.,

FarizahH., Zarihah Z., Rahmat A.,Maizurah O., Razak L., Tan Y.L., Universiti SainsMalaysia,

FactorsAssociated with Tobacco Use among Female College and University Students in Kuala Lumpur,

Malaysia;4)VichitVadakan,Nuntavarn,ChulalongkornUniversity,Thailand.PeerCommunicators:

BridgingCommunicationGapsinTobaccoControlamongFemaleYouth.

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Thailand

11)The proportions of fourth year female students who ever and currently

smokedintheprivateuniversitywashighestinproportion,thaninthepublic

universitywhichhadthelowest.

12)Publicuniversityhadthehighestscoreinknowledgeabouttobacco.

13)Factors significantly relating to current smoking behavior were daily

allowance,spending leisure timeswithfriends,havingfatherswhosmoked,

having closed friends who smoked, levels of knowledge about tobacco,

cumulativeGPA,andattitudestowardssmokingandfemalesmoking.

14)Factors associatedwith smoking include images of smoking as stylish and

macho,andapropensitytoexperiment.

15)Mostrespondentsfeltthatcurrentantismokingcampaignshadnoimpacton

the smoking behavior of young adults because the messages were

unconvincing,unappealing,andnotappropriatelytargetingtheaudience.

16)Most respondentsknew theharmfulhealtheffectsof smoking,but stressed

that effectivemessages should focus on the specific fears of young adults,

such as poor sexual performance for males and physical appearance for

females,andconcernaboutthewelfareoftheirlovedones.

17)Television is themost effectivemedia for expanding the coverage of anti

smokingcampaigns.


The tax on all tobacco products should be increased to make them

unaffordabletoyouth.

Allformsoftobaccopromotionshouldbebanned.Banningofthedepictionof

smokingandtobaccoproductsinthemediashouldalsobeconsidered.

Displayofcigarettepacksandads instoresrepresentsan importantformof

advertising,andshould,asinThailand,bebanned.

Alluniversitiesshouldpassandenforcestrictsmokefreepolicies.Allowing

students to smoke on campus sends a clear message that smoking isacceptable.

Warnings on cigarette packs should be clear, strong, specific, and use

pictures.

Antitobacco media campaigns should be expanded through all possible

means, such as mass media (TV, radio, newspapers) and interpersonal

communication.

Properhelpshouldbeprovidedtohelppeoplequitusingtobacco.

Smoke

Free

Home

campaigns

should

be

intensified.

Membersofthetargetaudience,includingfemaleyouth,shouldbeinvolved

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inthedevelopmentofantismokingcampaigns, including improvingrefusal

skills.

Research activities shouldbe extended in order to develop strategies and

actionsfortobaccocontrolamongwomenandgirls.

InCambodia, 47% ofmen and 6% ofwomen over age 15use tobacco.Rates are

higher inolderagegroups:72%ofmalesand10%of femalesagedover40years.

Tobaccouseamongwomen isashighas21%53% in thenortheastprovinces.The

smokingprevalencewithin theMalaysian female adultpopulation is significantly

lower(3.5%)thanthatofthemalepopulation(25%).

Smokingprevalence among the femalepopulation inThailand is less thanmales,

although smoking prevalence among female youth (1524 years) has increased in

recent years. Among Thai female university students, a fifth (19.8%) had ever

smoked,with the current smokingprevalence 3.1%.Among theMalaysianyoung

women, onefifth (21%) had tried smoking, and 4.3%were current smokers. The

prevalenceofeversmokingamongtheyoungerThaifemalestudents(grades712)

was13.4%,ofwhich5.1%werecurrentsmokers.

WhenCambodianwomenanalyzedcostsrelatedtotobaccouse,theyweresurprised

tolearnhowmuchmoneytheirfamilyloses.YoungThaistudentsmentionedharm

tothenationseconomyfromtobaccouse.InCambodia,amongbothusersandnon

users,nostrongnegativeattitudeswereexpressedtowardstobaccouseamongold

women.Buttobaccouse,particularlysmoking,wasseenasabsolutelyunacceptable

amongyoung

women

aged

15

25

years.

Almost

all

Cambodian

women

expressed

regretthattheyhadstartedsmoking.

Despite being well aware of the health hazards caused by tobacco use, Thai

university studentsdidnot strongly oppose female smoking.Most (71%) thought

thatsmokingwasanindividualsright,andathird(34%)werenotsureordisagreed

with the statement that female smokingwas not acceptable toThai society.Most

Malaysian studentsdisagreedwith the statements thatmale smokers lookedmore

attractive andmasculine, andmost agreed thatmenwho smoke smellbad. Both

nonsmokers and smokersprefermenwhodonot smoke,butmorenonsmokers

thansmokersexpressedstrongattitudesagainstsmoking.

MostoftheyoungThaistudents(grades712)agreedthatsmokingwasharmfulto

oneshealth.They alsobelieved that thehealth effects from smoking could affect

their academicperformance.However, even though theyknew that smokingwas

dangerous,thatknowledgehadlittleeffectinthefaceofpeerpressure.

MostCambodianwomen said theyhadnever tried toquit,and they thought that

quittingmightnotbepossible for them since, as longtimeusers, theywerevery

addictedtotobacco.HalfofThaiuniversitystudentsthoughtthatquittingsmoking

wasdifficult,thoughonly30%ofthosewhohadtriedtoquitsucceeded.Twothirds

oftheMalaysianstudentswhosmokedhadtriedtoquitsmoking.Almostall(95%)

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oftheThaismokersingrades712thoughttheycouldstopsmokingiftheywanted.

Theextentof tobaccoadvertisingvariedacross thecountries.Thailand,with strict

laws,hadvery little tobacco advertising,while advertisingwas abundant inboth

MalaysiaandCambodia.Pervasivetobaccoadvertisingevenwhereitisprohibited

bylawplaysasignificantroleinencouragingpeopleofallagesandbothsexestosmoke.Low taxesoncigarettescontribute to theiraffordability,andyouthand the

poor aremost affectedby price increases. The retention ofmessages from pack

warningsisfairlyhigh,especiallyinThailand,wherethemessagesarepictorialand

detailed. Finally, smokefree places contribute to a sense that smoking is

unacceptable.Strengthening tobaccocontrolpolicieswould thushaveasignificant

effectonreducingtobaccouseamongwomenandgirls.

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..

AboutSEATCA

TheSoutheastAsiaTobaccoControlAlliance(SEATCA)works

closelywithkeypartnersinASEANmembercountriesto

generatelocalevidencethroughresearchprograms,toenhance

localcapacitythroughadvocacyfellowshipprogram,andtobe

catalystinpolicydevelopmentthroughregionalforumsandincountry

networking.Byadoptingaregionalpolicyadvocacymission,ithassupported

membercountriestoratifyandimplementtheWHOFrameworkConvention

onTobaccoControl(FCTC)

Contactpersons:

Ms.BungonRitthiphakdee:SEATCADirectorEmail:[email protected]

Ms.MenchiG.Velasco:SEATCAResearchProgramManager

Email:[email protected]

SoutheastAsiaTobaccoControlAlliance(SEATCA)

Address: ThakolsukApartmentRoom2B,115ThoddamriRd.,Nakornchaisri

Dusit,Bangkok10300,THAILAND

Tel./Fax:+6622410082

Website:http://www.seatca.org

..

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About SEATCA

The Southeast Asia Tobacco Control Alliance (SEATCA) worksclosely with key partners in ASEAN member countries togenerate local evidence through research programs, to enhancelocal capacity through advocacy fellowship program, and to becatalyst in policy development through regional forums and in-countrynetworking. By adopting a regional policy advocacy mission, it has supportedmember countries to ratify and implement the WHO Framework Convention

on Tobacco Control (FCTC)

Contact persons:

Ms. Bungon Ritthiphakdee: SEATCA DirectorEmail: [email protected]. Menchi G. Velasco: SEATCA Research Program ManagerEmail: [email protected]; [email protected] Asia Tobacco Control Alliance (SEATCA)Address: Thakolsuk Apartment Room 2B, 115 Thoddamri Rd., Nakornchaisri

Dusit, Bangkok 10300, THAILANDTel./Fax: +662 241 0082

Website: http://www.seatca.org

Documents

27 Tobacco Use in Southeast Asia