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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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11
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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12
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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14
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.
Recommendationsfromtheresearchare:
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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15
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.
Recommendationsfromtheresearchare:
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.
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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
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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. >>
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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.
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8/12/2019 27 Tobacco Use in Southeast Asia
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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
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8/12/2019 27 Tobacco Use in Southeast Asia
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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.
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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.
>>
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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
>>
8/12/2019 27 Tobacco Use in Southeast Asia
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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.
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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.
Recommendationsfromtheresearch:
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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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.
Recommendationsfromtheresearch:
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