Acknowledgements
This case study would not have been possible without the kind support, time and commitment of the staff of the Viet Nam Committee on Smoking Health Standing Office and its Vice Director, Dr Phan Thi Hai, as well as the staff at Community Development Services, Family Health International, the Institute for Medical and Social Studies, HealthBridge - Viet Nam, The International Union Against Tuberculosis and Lung Disease, Johns Hopkins University School of Public Health, Thai Nguyen Provincial Health Information and Education Center, Viet Nam Ministry of Health/Department of Legislation, Viet Nam Public Health Association, World Health Organization - Viet Nam, World Lung Foundation and many others.
 
About the author
Burke Fishburn is a global public health consultant and strategist with over 21 years of experience in public health, public administration, and extensive international and cross-cultural work in the Asia-Pacific region. He has worked in Viet Nam with the government, international non-governmental organizations and donor agencies since 2001. He previously served as Regional Adviser for the Tobacco Free Initiative for WHO’s Western Pacific Regional Office, head of policy, planning and evaluation at the US Centers for Disease Control and Prevention’s Office on Smoking and Health and is currently the owner and principal consultant of Health Pragmatics, Ltd. based in Boulder, Colorado USA.
 
Disclaimer
The views and opinions expressed in this report are those of the author and are not necessarily shared by The Atlantic Philanthropies.
 

ACRONYMS AND ABBREVIATIONS
ACS:                           American Cancer Society
Bloomberg Initiative:          Bloomberg Philanthropies’ Initiative to Reduce Tobacco Use
CDC:                          United States Centers for Disease Control and Prevention
CDS:                           [Viet Nam] Community Development Services
COMBI                                   Communication for Behavioral Impact
FCTC:                         [WHO] Framework Convention on Tobacco Control
FHI:                            Family Health International – Viet Nam
HCMC:                                   Ho Chi Minh City
HIEC:                         Health Information and Education Center(s)
INGO:                         International Non-governmental Organization(s)         
ISMS:                                     [Viet Nam] Institute of Social and Medical Studies
JHSPH:                                   Johns Hopkins University School of Public Health
MOH:                                     Ministry of Health
NGO:                          Non-governmental Organization(s)
PPC:                            Provincial People’s Committee(s)
RSVP:                         Reduce Smoking in Vietnam Partnership
SEA:                           South East Asia
SHS:                           Secondhand smoke
Sida:                           Swedish International Development Agency
TFK:                           [Campaign for] Tobacco Free Kids          
TCWG:                                   [Viet Nam] Tobacco Control Working Group
The Union:                The International Union Against Tuberculosis and Lung Disease
VINACOSH:              Viet Nam Committee on Smoking and Health Standing Office
Vinatba:                     Viet Nam Tobacco Corporation
VPHA:                                    Viet Nam Public Health Association
WHO:                                     World Health Organization
WLF:                          World Lung Foundation
 

TABLE OF CONTENTS

1. Summary
2. Project description
3. Methodology
4. Background
   1. Tobacco use and secondhand smoke exposure in Viet Nam
   2. Socioeconomic costs of tobacco use in Viet Nam
   3. Viet Nam’s tobacco industry
   4. VINACOSH
   5. History of Viet Nam’s smokefree policies
   6. Viet Nam’s current smokefree policy
   7. Evolution of the Atlantic Philanthropies grant
   8. Building on other smokefree projects
5. Lessons learnt
   1. Summary
   2. Challenges
      1. Competing demands and jurisdictions
      2. Competition and lack of coordination
      3. Provincial leaders support
      4. Financial support
   3. Successes
      1. Potential to reduce secondhand smoke exposure and smoking
      2. Cooperation and synergies among multiple smokefree projects
      3. Formulation of smokefree policy guidance and legal framework
      4. Development and advocacy for the national tobacco control law
      5. Empowering leadership
      6. Capacity building
      7. Monitoring and evaluation
      8. Communications
      9. Sustainability
6. Conclusions
   1. Summary
   2. Project outcomes
   3. Key issues
   4. Recommendations
7. Resources

 SUMMARY This case study examines the 2009-2012 project conducted by the Viet Nam Committee on Smoking and Health Standing Office (VINACOSH) to pilot smokefree regulations in three project sites; Da Nang, Thai Nguyen and Tien Giang.[1]
 
Several analytical methods to review and evaluate this project, including in-depth interviews and a desk review of Viet Nam tobacco control activities and all available references and reports on the project.
 
Findings encompass background on tobacco use and secondhand smoke exposure in Viet Nam, socioeconomic costs of tobacco use, Viet Nam’s tobacco industry, a history of VINACOSH and tobacco control efforts in Viet Nam and a detailing of smokefree provisions of the new national tobacco control law. The evolution of the project in the context of other smokefree projects and VINACOSH’s involvement in those projects is discussed.  The lessons learnt section provides an analysis of the key successes and challenges of the project.
 
There were several important outcomes from the project. Among other things, virtually all hospital, school and workplace facilities developed smokefree regulations and established effective organizing bodies. It provides compelling evidence that implementation of smokefree policies at city and province levels is feasible and welcomed by leaders. The project also points to the future: it provides a clear detailed model for implementing smokefree policies at national and provincial levels.
 
Based on the findings, lessons learnt and conclusions, the author suggests a model process for development and implementation of the national tobacco control law’s smokefree policies is recommended, with core elements including the legal framework, a leadership and management structure, interventions steps, monitoring and evaluation, communication campaigns, capacity building and identification and allocation of financial and technical resources. 
 
PROJECT DESCRIPTION This case study examines the 2009-2012 project conducted by the Viet Nam Committee on Smoking and Health Standing Office (VINACOSH) to pilot smokefree regulations in three project sites; Da Nang, Thai Nguyen and Tien Giang.  Supported by Atlantic Philanthropies, VINACOSH implemented this project by developing comprehensive models of smokefree workplaces based on WHO’s guidelines and best practices from other countries, piloting the models in the three city/provinces, then further developing the models based on the pilot site experiences.  This case study reviews and evaluates the evolution of the project in the context of the history of tobacco control in Viet Nam, identifies successes, challenges, outcomes and key issues and makes recommendations for future implementation of smokefree models at the national and provincial level.
 
 
METHODOLOGY The case study uses several analytical methods to review and evaluate this project.
 
First, the author reviewed general information on tobacco control efforts in Viet Nam. Then, in consultation with VINACOSH, the author identified all experts and partners involved in the development and implementation of the smokefree models in three project sites in Da Nang, Thai Nguyen and Tien Giang as well as those who were involved in related, collaborative smokefree projects.
 
The author developed a set of standard interview questions with VINACOSH’s and other experts’ consultation. The author then arranged interviews, both in-person or via teleconference, with as many of the experts and partners who were available within the two-week case study project period.  These included representatives[2] from:
 

• VINACOSH Standing Office (all staff involved in the project)
• Viet Nam Community Development Services (CDS)
• Family Health International - Viet Nam (FHI)
• Institute of Social and Medical Studies (ISMS)
• The International Union Against Tuberculosis and Lung Disease (The Union)
• Johns Hopkins University School of Public Health (JHSPH)
• Ministry of Health/Department of Legislation
• Thai Nguyen Provincial Health Information and Education Center
• Viet Nam Public Health Association (VPHA)
• World Health Organization (WHO) - Viet Nam
• World Lung Foundation (WLF)

 
In addition, the author also developed a standard questionnaire for Da Nang and Tien Giang officials involved in the project, as they were not available for in-person interviews or calls. Although the author conducted an interview with the ISMS principal analyst conducting a formal evaluation of the outcomes of the grant project, the evaluation report was not yet available and results were not analyzed in this case study.
 
The author also conducted a desk review of all available references and reports on Atlantic Philanthropies grant, including the process for development of smokefree models and several reports on related collaborative smokefree projects conducted in Viet Nam by other organizations.
 
The author then synthesized and analyzed information from the interviews and desk reviews to develop findings, lessons learnt, conclusions and recommendations.
 
 

BACKGROUND Tobacco use and secondhand smoke exposure in Viet Nam
Approximately one-quarter of the adult Vietnamese population smokes, but that figure does not provide the complete picture: Viet Nam has one of the highest rates of adult male smoking and largest number of male smokers in the world.  According to Viet Nam’s 2010 Global Adult Tobacco Survey, about 15 million adult males smoke or 47% of the adult males population.
 
Smoking rates among adult females have been low, estimated between 2.0% and 1.4% since 2000. While historical, cultural norms prevent many women smoking, there is a concern that rapid economic development and signs of increased targeting by tobacco companies will increase their smoking rates.
 
Youth smoking rates are also relatively low. A 2007 Global Youth Tobacco Survey of youth aged 13-15, 3.8% currently used any form of tobacco and 3.3% students had currently smoke cigarettes.   In addition, 6.5% of male students and 1.5% of female students used any tobacco products, which include water pipe use. As with adult female smoking, there are concerns that youth smoking rates will increase with economic development and targeting by tobacco companies.
 
There are also distinct geographic and economic patterns. The rate of tobacco use in Viet Nam’s southern provinces has been found to be significantly higher than in northern provinces. Lower income populations also tend to have higher smoking rates than higher income populations. In addition, lower income populations have more difficulty quitting smoking: they have lower cessation rates than higher income populations.
 
Secondhand smoke (SHS) exposure in Viet Nam is very high among adults and youth.  About 49% of all adults are exposed to SHS in the workplace and 67% of adults are exposed at home. Among youth aged 13-15 almost 60% live in homes where others smoke, and more than 70% are exposed to smoke around others outside of the home.
 
Socioeconomic costs of tobacco use in Viet Nam
It is estimated that in Viet Nam more than 40,000 people die from tobacco-related diseases each year. As with other highly populated, developing countries the lost economic opportunities in Viet Nam are significant because half of all tobacco-related deaths occur during the prime productive years. In 2005 the cost to the government alone to treat just a subset of tobacco-related diseases (i.e., lung cancer, heart disease and chronic obstructive pulmonary disease) was estimated at USD $75 million, which was over 4% of Viet Nam’s yearly government budget for healthcare.
 
A 2007 study estimated that Vietnamese spent more than almost USD $1 billion annually on tobacco products. This figuring may not seem alarming until it is understood that among the poorest households in Viet Nam the household expenditure for tobacco products was 2.2 times higher than the expenditure for education and 1.6 times higher than for health care services.
 
Viet Nam’s tobacco industry
Tobacco control efforts have had a formidable foe in Viet Nam: a government-owned tobacco monopoly and foreign companies that have fought hard and often illicitly to gain market share and increase smoking rates. The Viet Nam National Tobacco Corporation (Vinataba), the government-owned tobacco company, holds about half of the cigarette market share, followed by British American Tobacco, Imperial Tobacco, Philip Morris International and Japan Tobacco.  The government has struggled with the logic of protecting an industry legitimized through nationalization in the face of staggering and increasing health and economic costs of the tobacco epidemic.
 
The tobacco industry has been represented by the Viet Nam Tobacco Association[3] at government meetings, and has continually raised objections to proposed effective tobacco control measures, such as large, graphic health warnings on tobacco products, increased tobacco taxes and smokefree laws, questioning thee viability of enforcing smokefree laws and insisting on designated smoking areas. 
 
VINACOSH
The VINACOSH Standing Office supports the operations of the inter-ministerial Viet Nam Committee on Smoking and Health.[4]  The VINACOSH Standing Office was set up by the Ministry of Health to develop tobacco control master plans, allocate all resources and coordinate tobacco control activities with relevant ministries, mass organizations and other partners. 
 
VINACOSH provides day-to-day staffing of activities, implements national tobacco control policy, oversees programmatic activities of provincial, district, and commune-level Committees on Smoking or Health and works with other NGOs and INGOs on tobacco control programs.
 
The Ministry of Health’s Director General of Medical Services Administration currently leads VINACOSH. The Vice Director of VINACOSH manages day-to-day operations. Several project managers and administrative officers currently staff VINACOSH.
 
History of Viet Nam’s smokefree policies
The first tobacco control efforts in Viet Nam began with the 1989 law that banned most forms of tobacco advertising and promotion—provisions that were relatively strictly enforced—and introduced smokefree policies—provisions that were largely unenforced.  By 1999 there were about 70 “sub-legal” documents guiding tobacco control and tobacco industry.
 
In the late 1990s the Ministry of Health, with the support of the Swedish International Development Agency (Sida) and World Health Organization (WHO)-Viet Nam, began tobacco control planning and some capacity building efforts.  These efforts led to the 2000 Prime Minister Resolution (No. 12/2000/NQ-CP) that established a national policy on “prevention and control of tobacco harms”, with general goals for the period 2000-2010 and also created VINACOSH under the Ministry of Health. 
 
In 2003 Viet Nam ratified the international tobacco control treaty, WHO Framework Convention on Tobacco Control (FCTC). Between 2003 and 2007 tobacco control activities undertaken by VINACOSH and other organizations were primarily focused on building organizations’ project and research and surveillance capacity and on a few small-scale smokefree projects, such as the JHSPH RSVP capacity building project funded by Atlantic Philanthropies.  During this time VINACOSH also began to develop plans for comprehensive national tobacco control legislation.
 
In 2007 tobacco control activities rapidly escalated, spurred by a new Prime Minister’s Directive, new status for VINACOSH and by a new international donor.
 
The 2007 Prime Minister Directive No. 12/2007/CT-TTg among other things expanded smokefree policies to public places and public transport, and set forth plans for increasing the size of health warnings on tobacco product packaging. The Directive did not have the force of national law, but was important in providing credibility to VINACOSH’s and impetus to coordinate among relevant ministries.
 
In 2007 MOH also officially designated VINACOSH as a separate office for tobacco control with fiscal autonomy and authority to convene its inter-ministerial partners and other organizations.
 
The new funding was made available through the Bloomberg Initiative, which provided small grants to multiple organizations and also provided technical assistance through the Initiative’s new partners, the Campaign for Tobacco Free Kids (TFK), The Union and the World Lung Foundation. Most Bloomberg Initiative-funded projects were focused on development of smokefree guidelines and pilot smokefree policies at local levels.
 
In this setting VINACOSH intensified efforts to develop the national tobacco control law. In collaboration with the MoH Department of Legislation, and assistance of international experts, they conducted research, developed position papers and impact assessments of various draft provisions and eventually produced the first draft of law.
 
VINACOSH also began to educate and work closely with other ministries, the Social Affairs Committee of the National Assembly, the Government Office of the Prime Minister, mass organizations and its tobacco control partners. This draft law featured important provisions that tobacco industry interests were intent on deleting or weakening, such as smokefree provisions, graphic health warnings and establishing a tobacco control fund financed by a tobacco industry surcharge.
 
In 2009 Prime Minister’s Directive 1315/QD-TTg instructed the government to implement national tobacco control in accordance with the WHO FCTC. Subsequently, MOH issued a directive requiring that all hospitals be smokefree and provided guidelines on implementation for this new policy. 
 
After an contentious four year-period involving dozens of revisions, the national tobacco control law was submitted to the National Assembly for consideration and discussion in November 2011 and passed June 2012. The law went into effect 1 May 2013. 
 
In addition to the smokefree provisions (detailed below), the law established the Fund for the Prevention and Control of Tobacco Harms that requires a compulsory contribution from the tobacco industry, calculated between 1% and 2% of cigarette factory prices. This compulsory contribution is additional to the existing excise tax and will begin to flow to the Fund starting May 2013. 
 
Viet nam’s Current smokefree policy
Under Article 11 of the new tobacco control law, smoking is completely prohibited both indoor and outdoor in a number of areas including schools, kindergartens, health facilities, and places at high risk of explosion and fire.
 
Public places are defined as, “places that serve commonly for the need of many people.” Workplaces are defined as “ the places that are used for the purpose of working.” Indoor areas are defined as “areas that have [a] roof, one or more walls or surrounding partitions.”
 
In Article 12 smoking is permitted in designated smoking areas in only few specifically enumerated public places including: boarding areas of airports, bars, karaoke, hotels and guesthouses, and discotheques. These places are required to have “separate rooms and ventilation systems [sic] from the no-smoking area.”
 
In addition, under Article 12, the government is required to “move the places” where designated smoking areas are allowed to “categories of complete indoor [smokefree] areas at a suitable time period.”
 
Under Article 13, smokers are prohibited from smoking “in the indoor areas (at homes) where there are children, pregnant women and the elderly.”
 
Article 14 authorizes “the head of facilities” to enforce the smokefree policies, including issuing fines (but this is subjected to detailed guidance from other relevant legal documents). In addition, Article 6 requires heads of agencies, organizations and localities to enforce the smokefree provisions, including restricting smoking at “weddings, funerals and festivals in the community” and to include these restrictions in “Village convention/regulations.”
 
Sub-national jurisdictions may have smokefree laws but these laws may not be more stringent than national law.
 
Evolution of the Atlantic Philanthropies grant
In Viet Nam, Atlantic Philanthropies and its grantees have focused on improving health outcomes for all, and to build and sustain local capacity for advocacy and policymaking on health issues. Consistent with this focus, Atlantic Philanthropies has made important investments in the tobacco control work of VINACOSH since 2000, directly and indirectly through other grantees, such as the Viet Nam Public Health Association (VPHA), HealthBridge - Viet Nam (née PATHCanada) and Johns Hopkins School of Public Health (JHSPH). 
 
For example, the Atlantic Philanthropies grant, “Reduce Smoking in Vietnam Partnership (RSVP)” (2005 – 2010) was funded by the Atlantic Philanthropies and executed by JHSPH in partnership with VINACOSH. The overall goal of the RSVP project was to change the social acceptability of tobacco use and to build capacity within Viet Nam to effectively conduct, monitor and advocate for tobacco control programs.
 
In 2008, Atlantic Philanthropies awarded a grant to the American Cancer Society (ACS), which teamed up with VINACOSH to develop a national tobacco control media advocacy strategy and build strategic partnerships with community-based groups, the business sector, and the donor community.
 
Following these efforts, Atlantic Philanthropies provided support to VINACOSH under Project 15332, the focus of this case study, with the overall goal of strengthening the implementation of smokefree environment policies in Viet Nam by developing comprehensive models of smokefree workplaces in three project sites based on WHO’s guidelines and best practices from other countries, and then to use the experience and results of the model to produce guidelines, lessons learnt for expansion to other provinces. There were three basic objectives of this project:
 

• To strengthen the infrastructure and coordination for the implementation of smokefree environment policies in three projected city/provinces;
• To develop comprehensive smokefree models in three key settings (government offices, hospitals and schools) at the three selected city/provinces;
• To increase awareness on tobacco harms and support for smokefree policies among policy makers and the public in the three city/provinces, and disseminate the best practices and lessons learned of the model to other provinces to follow.

 
Building on other smokefree projects
To understand and evaluate VINACOSH’s work with the Atlantic Philanthropies grant, it is important to first understand how the project was built upon numerous other smokefree projects in Viet Nam, conducted by VINACOSH or other organizations over the past 11 years.
 
In 2002 the Communication for Behavioral Impact (COMBI) for creating smokefree homes in Hai Phong district project, conducted by VINACOSH and funded by WHO, used school-based education interventions and mobilized mass organizations to encourage fathers to stop smoking inside or around homes.  The project demonstrated measurable behavior changes, established a credible working relationship between district leaders and the tobacco control community and led to further smokefree projects in Hai Phong.
 
In 2003 VINACOSH and WHO partnered create the first-ever smokefree policy for the South East Asian (SEA) Games with public education efforts aimed at spectators. This work provided a model for efforts that were replicated by the Philippines in 2005 and Lao PDR in 2009 when they hosted the SEA Games.
 
Starting in 2007 several smokefree projects were funded under the Bloomberg Initiative, such as the HealthBridge - Viet Nam’s project to establish comprehensive smokefree policies for Hanoi, working in partnership with the Hanoi People’s Committee.  However, this project was not successful, probably due to the lack of commitment at the political level, Hanoi’s focus on annexation of other jurisdictions. VPHA’s project to implement smokefree policies for transport, education, hospitals in 10 provinces, which has now been focused on Dong Tap, Hue and Nha Trang city/provinces in the project’s second phase. The 2010 HCMC HIEC project is seeking to implement smokefree policies in the public transport sector in HCMC.  CDS (Community Research and Development Service; a local NGO) Viet Nam is working to promote smokefree environments in Viet Nam’s major tourist destinations, Ha Long, Hai Phong and Hoi An. 
 
One of the more demonstrably effective initiatives, according to funders, has been conducted by CDS, with VINACOSH assistance, in Ha Long city (from 2009) and Hai Phong City starting in June 2011. During the first year and a half, CDS focused on establishing and support implementation of a smokefree policy in the cities, developing a model for replication and supporting advocacy for the national tobacco control law. This project has resulted in a PPC directive with an enforcement mechanism, empowered enforcement groups and a public education campaign.
 
These smokefree projects were also directly supported by WLF’s support to VINACOSH between 2008 and 2010 for communication campaigns that were initially aimed at supporting implementation of smokefree environments, then later shifted to support adoption of a strong tobacco control law. This work resulted in a national mass media campaign,  "Cigarettes are Eating You Alive," that informed millions of Vietnamese smokers about the serious health effects of tobacco and secondhand smoke on adults and children.  In addition, the project supported a website advocating for the tobacco control law, tobacco control news provided to mass media and journalists’ training courses.
 
 
LESSONS LEARNT Challenges
 
Competing demands and jurisdictions
Perhaps the most significant challenge for VINACOSH was managing this project during a critical time for the national tobacco control law. Early in the project, it seemed VINACOSH had to make difficult choices when responding to demands from the National Assembly, Prime Minister’s office, other donors and partners that impacted its ability to manage this project.  VINACOSH also indicated that working with the project sites’ PPCs and HIECs was very time intensive, compounded by the geographic distribution of the three sites.
 
Project sites also had to deal with competing demands. For example, Da Nang suffered a dengue fever outbreak in 2010.  The smokefree project was put aside as provincial leaders had to focus their public health efforts to address the outbreak.
 
In addition, the sites’ HIECs were empowered as the technical and communications focal points for the projects, but had difficulties establishing working relationships with non-health sectors under the PPC organizing structures.
 
Lastly, the project sites’ Steering Committees and focal point units (e.g., the HIECs in the case of Da Nang and Thai Nguyen) had to coordinate and manage activities across a huge number of partners and jurisdictions that comprised the health care sector, education sector, the People’s Committee at all levels, police departments, the Farmers Association, city inspectors, the Department of Culture, Sport and Tourism, the Department of Construction, the Department of Internal Affairs, the Department of Labor, Invalid and Social Affairs, the City Trade Union, the Department of Finance, the Department of Trade and Industry, the Department of External Affairs, the Department of Information and Communication, the Department of Resources and Environment, the city or provincial tax departments, the Department of Science and Technology and the Department of  Planning and Investment. Each of these partners had their own interests and often competing demands in developing and implementing the smokefree policies, which had to be facilitated by the Steering Committees and focal point units.
 
Competition and lack of coordination among multiple smokefree projects
When the Atlantic Philanthropies project was first started in 2009, other donors were also funding smokefree projects at local levels, such as the Bloomberg Initiative projects with HealthBridge - Vietnam, CDS and VPHA. 
 
According to views that were expressed by some donors and most grantees, one of the early challenges was the perceived competition and lack of coordination between VINACOSH and other organizations conducting smokefree projects. The organizations did not effectively or easily share information or experiences or make meaningful attempts to coordinate projects and resources. There was also perceived competition and lack of coordination between donors and confusion about grant processes that led to strained working relationships between grantees.
 
A review of the various smokefree project reports between 2009 and 2010 indicates a substantial overlap and sometimes duplication of efforts among organizations to produce smokefree guidance, model policies, training programs and communication materials. There was also evidence of competition to claim credit for developing smokefree models and guidelines that led to even less communication and coordination between in-country partners.
 
Some organizations also expressed concern that prior to 2009 VINACOSH had lacked the resources, technical and programmatic capacity and credibility to coordinate tobacco control efforts across the many ministries, organizations and donors involved with tobacco control, many with competing interests and demands.  This lack of confidence may have impacted the start of the Atlantic Philanthropies grant and VINACOSH’s early efforts to link the project to the formulation of guidance for other smokefree projects and for national smokefree policies. 
 
Provincial leaders support
One project site reported difficulty in gaining support for the smokefree policies among some provincial leaders who were smokers. A project site manager stated, “Some [leaders who were smokers] were sceptical and didn’t believe in the reason for the policies…they never really supported the project.“
 
The view that leaders who smoked were not supportive of tobacco control efforts was not shared across all project sites, but was continually identified by partners as a general barrier to national tobacco control efforts.
 
Financial support
Some project sites expressed a need for more financial support for implementation of the smokefree regulations. As one provincial leader stated, “the biggest challenge is the money for [the activities]; manpower is available, but money is too limited to fully socialize [the issue of smokefree policies] and to mobilize across sectors and for [enforcement].”
 
Some project sites also wanted to provide hospital-based cessation services, such as counseling and pharmacotherapies, and expressed frustration that the grant did not provide resources for this. 
 
Even though there was substantial print and electronic media made available for the project, some project sites wanted more financial support for communications to extend their communications reach. This remains a concern for the sites. They state that the general public’s knowledge of the social and health consequences of tobacco use, as well as requirements of the new national smokefree tobacco control law, still appears to be quite low.
 
Successes
 
Potential to reduce secondhand smoke exposure and smoking
Interim results of the project are impressive: virtually all hospital, school and workplace facilities developed smokefree regulations and established effective organizing bodies. Initial findings indicate a high level of compliance at the government offices and schools and that exposure of secondhand smoke has been significantly reduced. 
 
The project also promises to catalyze smoking cessation behaviors.  For example, Tien Giang reported observed increased cessation attempts among staff and teachers. A Da Nang secondary school reported that during the project 239 of 247 students and 5 of 6 teachers quit smoking. Thai Nguyen reported that several provincial leaders are now making attempts to quit smoking.
 
Cooperation and synergies among multiple smokefree projects
In the view of many of the partners, late 2009 marked a significant change for Viet Nam’s tobacco control community.  The Viet Nam Tobacco Control Working Group (TCWG), comprising participants from all national organizations working in tobacco control, had been in existence from early 2000s, but was not active between 2007-2009. 
 
With the leadership and increase technical and programmatic capacity of VINACOSH, the TCWG was revitalized in 2009 around advocacy for the tobacco control law, which also led to an increased exchange of information and technical expertise for organizations’ smokefree projects.
 
Formulation of smokefree policy guidance and a legal framework
Through this project VINACOSH developed comprehensive policy guidance for each of the three sectors; smokefree hospitals, smokefree schools and smokefree workplaces.  This guidance identified what smokefree policies and interventions should be implemented, the legal framework for the policies, the evidence base for the policies, how they should be implemented and where they should be implemented. As key requirement, VINACOSH stipulated that heads of government offices be charged with responsibility for implementing the policies, regulations and interventions in the facilities, a provision that was later included in the national tobacco control law.  The guidance also provided project implementation worksheets, templates, and scripts. For example, the smokefree hospitals guidance provided:
 

• Background on tobacco use in Viet Nam
• The harmful effects of smoking and passive smoking
• The need for smokefree hospitals
• National requirements for smokefree hospitals and suggested criteria for smokefree hospitals
• Steps for implementing smokefree hospitals
• Worksheet on establishing ​​smoking cessation counseling in hospitals for patients
• Handbook and script for smoking cessation counseling
• Sample survey questionnaire for smoking prevention among hospital staff
• Sample implementation plan for smokefree hospitals

 
VINACOSH provided similar guidance for schools and workplaces.
 
VINACOSH ensured wide acceptance and understanding of the guidance and legal framework by conducting extensive and consistently well-received training for the three project sites and further communicating it through official channels. The models and worksheets provided the project sites the ability to customize and adapt the interventions to their settings, an important factor in gaining leadership and public support. VINACOSH also made smart use of resources from other grant projects. For the smokefree hospitals component, VINACOSH used extant guidelines on establishing smokefree hospitals from the JHSPH project.
 
Development and advocacy for the national tobacco control law
VINACOSH was able to leverage the knowledge, expertise and experience of these three project sites and all other smokefree projects to provide important inputs to development of the national tobacco control law and advocate the law to the National Assembly and ministries.
 
It is important to understand how this was done. First, the project’s policy guidance, legal framework, training models, lessons learned in working with PPCs and the pros and cons of different approaches all led to VINACOSH’s better understanding of what was needed to implement smokefree policies at the local level.  The wealth of shared information and experiences of all the tobacco control partners’ projects also provided the evidence for the viability of smokefree policies and interventions at the province, district and city level.  Backed by this evidence VINACOSH, supported by its partners, gained the credibility needed to work with ministries and the national Assembly to develop the national smokefree policies and the national tobacco control law. This led directly to the development of effective, evidence-based measures in the law and provided an entry point for VINACOSH and all partners to advocate for the law.
 
Project sites were also mobilized to advocate for the law. With support from VINACOSH, Steering Committee members from Thai Nguyen and Tien Giang sent education materials to provincial National Assembly members, presented at National Assembly meetings, commented on the draft tobacco control law at the meetings of provincial National Assembly members and PPC representatives. In addition, as the draft law was submitted to the National Assembly, they contacted their provincial members to facilitate meetings with VINACOSH and encouraged them to approve the law.
 
Empowering leadership
VINACOSH identified a step-wise approach to empower the leadership of each project site.  First, they recognized that the People’s Committees would be the key decision-making and implementing body for the smokefree provisions and models, with the technical support of HIECS working as focal point units for the project.  For effective leadership and management of the project, the People’s Committee formed Steering Committees on Smoking and Health, essentially task forces comprising health, transport, culture and information and other sectors, with and significant role for mass organizations. The PPCs were also given responsibility for allocating the grant’s financial resources.  By training and empowering this structure, the PPC Vice Chairs became effective champions for smokefree regulations and tobacco control in general.
 
Second, HIECs were tasked with drafting initial action plans and submitting them to health departments for review and comment.  Plans were then submitted for review and approval by the Vice Chairs of PPCs, acting as Chairs of Steering Committees. The Steering Committees then mobilized the various sectors to implement the project through the PPC structures. This was generally the process utilized for all aspects of the project.
 
Third, leadership from the hospitals, schools and workplaces were fully engaged and empowered for this project, first through trainings provided by VINACOSH, then through the Steering Committee Structures.
 
Lastly, when the sites identified barriers that impeded leadership on the projects, VINACOSH was able to effectively intervene. For example, when one project site was experiencing early difficulties in coordinating across sectors, VINACOSH arranged for the Minister of Health to send a letter to the PPC and Department of Health to provide more support and guidance.
 
Capacity building
Through numerous strategically planned train-the-trainer workshops, education outreach and other training efforts the project increased the awareness and skill-levels across the three project sites. The broad reach of the project’s capacity building efforts is reflected in the numbers. For example, across the three project sites, capacity building was conducted for:
 

• 90 healthcare workers, teacher and government officials who became trainers for their project sites;
• 190 provincial staff in various sectors;
• Staff of 132 schools and universities;
• Staff of 102 healthcare facilities.

 
Project sites were unanimous on the efficacy and quality of the training provided under the project. All sites reported that VINACOSH worked closely with them to develop the projects, conducted training workshops on tobacco control and smokefree issues, train-the-trainers workshops and helped them develop communication materials.  They reported that the ongoing technical assistance was also invaluable.
 
Project sites reported significant skills transfer beyond smokefree and tobacco control issues.  They indicated that the project greatly enhanced their skills in project planning, surveillance, monitoring and evaluation, general communication strategies. Sites said these new skills were applied to the project and also will be helpful for other activities undertaken by the PPCs and HIECs.
 
VINACOSH also arranged for People’s Committees’ and HIECs’ leadership to attend study tours to Malaysia and Thailand to see how those countries implemented smokefree policies. The study tours not only increased leaders’ knowledge and enthusiasm for smokefree policies, but also raised the local political profile of the project.
 
Monitoring and evaluation
VINACOSH understood that monitoring and evaluation would be key to enforcement of the smokefree regulations, not just for the purposes of grant reporting. VINACOSH provided guidance on a monitoring and evaluation system that was active and systematic monitoring, not passive or piecemeal.
 
VINACOSH also backed up the monitoring and evaluation system with training. In addition, VINACOSH conducted a pre-intervention assessment to identify the appropriate interventions and activities for expected outcomes that also created a benchmark for the final evaluation of the overall project. 
 
Communications
VINACOSH knew there would be a low level of awareness of tobacco use issues and need for smokefree policies.  VINACOSH was able to provide previously available communication materials, including electronic media, from other campaigns and some support for adapting materials at the local level.  The three sites were creative in adapting these materials to reflect local situations, culture and other nuances.
 
Progress reports also clearly indicate VINACOSH built upon the extensive experience of previous communication campaigns and enlisted other resources to develop materials for this project. For example, VINACOSH recruited CDS to develop models on communications at the three project sites and WLF provided their media campaigns expertise as well as an evaluation of communication efforts.
 
Sustainability
Project sites’ expressed concerns about sustainability related to future effective implementation and enforcement of their smokefree regulations, especially as the national tobacco control law will require these project sites, and all other local jurisdictions to expand the smokefree regulations to other settings. 
 
They have begun to address this challenge. For example, Tien Giang People's Committee has developed a work plan for 2012-2013 to continue the implementation of smokefree environment in the province, with the Department of Health, in collaboration with the Department of Finance, tasked with providing a provincial budget allocation to implement the plan. In Da Nang, the HIEC has drafted the tobacco control work plan for 2012-2015 that provides for continuation and fuller implementation of the smokefree regulations. In Thai Nguyen, the HIEC also has drafted a long-term work plan to maintain the smokefree regulations.
 
This challenge will also be addressed by significant amount of government funds made available to tobacco control through the national tobacco control fund, which will start May 2013.

CONCLUSIONS Summary
VINACOSH, Da Nang, Thai Nguyen and Tien Giang had to aggressively address many challenges early on in the Atlantic Philanthropies project that could have undermined both the grant project as well as broader tobacco control efforts.  The extensive history and experiences of VINACOSH and its partners in conducting and fostering smokefree projects and policies, coupled with the lessons learned and successes of the Atlantic Philanthropies grant project have yielded smokefree best practices, a legal framework and a process for implementing smokefree policies at locals level and resulted in a strong new national tobacco control law. 
 
Project outcomes
The VINACOSH project on enforcement of smokefree regulations in Da Nang, Tien Giang and Thai Nguyen achieved several important outcomes:
 

1. It suggests that smokefree policies alone may result in long-term reductions in smoking and secondhand smoke exposure; 
2. Virtually all hospital, school and workplace facilities developed smokefree regulations and established effective organizing bodies;
3. It provides compelling evidence that implementation of smokefree policies at city and province levels is feasible and welcomed by leaders;
4. It suggests that project sites’ smokefree regulations can be sustained and expanded through PPCs and HIEC commitments, partnered with national technical and financial support;
5. It provides a clear detailed model for implementing smokefree policies at national and provincial levels;
6. It provided critical and timely provincial level and other political support for the passage of the national tobacco control law and retention of relatively strong and comprehensive smokefree provisions;
7. It provides further evidence that the way mobilize national support and advocacy for tobacco control is to empower local level leadership.

 
Key issues
The experience of VINACOSH and the many organizations that have been involved in this and other smokefree activities highlight some key issues for the future of smokefree policies in Viet Nam:
 

1. Champions. Political will, leadership and champions are essential to the success of implementing smokefree policies at the national and local levels. This includes commitment by PPCs and key ministries and sectors at all levels. This should be backed by the technical support of VINACOSH and the tobacco control community and educational and mobilizing power of mass organizations.
2. Local focus. Plans, approaches and materials should be adapted for local settings.  Consistent with this approach, significant efforts must be made to effectively engage and support provincial and city leaders to plan and implement smokefree policies.
3. Public education. National and local public awareness of smokefree policies appears to be low, making implementation and enforcement a key challenge. Accordingly, there is a need for national and local communication plans and well-resourced communication campaigns
4. Capacity building and technical support. Localities that have not yet established smokefree regulations lack technical and program capacity to implement smokefree regulations as required by the new tobacco control law. Therefore, substantial capacity building and technical support will be needed to fully implement smokefree policies.  This should include capacity building and technical support that addresses organizational structure and technical expertise, as it did with this project.
5. Future funding. The new Fund for the Prevention and Control of Tobacco Harms should provide more than adequate financial resources to fully implement smokefree regulations at all levels. The Fund provides national resources for tobacco control (with no termination date) to include proven, evidence-based efforts such as smokefree projects, health communication campaigns, cessation services and also research and capacity building on tobacco control.

 
As a rough estimation in the coming years, the Fund will potentially provide an average amount of USD $7 million per year specifically for tobacco control.  However, as of the date of this case study, the proper legal, strategic, organizational, administrative and financial structures for the Fund still need to be established. This is a critical issue for future smokefree policies and all tobacco control efforts.
 
 
Recommendations
Based on the findings and conclusion of this case study, the following future actions are recommended:
 

1. A model process for development and implementation of the national tobacco control law’s smokefree policies should be developed based on this project. This can be applied at national, provincial and municipal levels.  Core elements should include:
   1. Legal framework and policy guidance. The legal framework from the project is very robust but should be reviewed with the new national tobacco control and revised as necessary.
   2. Leadership and management structure. The project’s leadership and management structure can be adapted at many levels, e.g.:
      1. Task the Peoples’ Committees as the key decisionmaking and implementing body for the smokefree regulations;
      2. Under the People’s Committees, an inter-ministerial/department/sector steering committee also should be established and should be comprising communications, health, transport, other sectors and significant role for mass organizations;
      3. Empower HIECs or other partner to provide smokefree technical support to the steering committees;
      4. Task heads of facilities, as provided for under the national tobacco control law, for key responsibility for enforcing smokefree regulations.
   3. Interventions steps. The project’s step-wise guidance is clear and complete and can be easily adapted at all levels.
   4. Monitoring and evaluation. Monitoring and evaluation will be key to enforcement. It should be understood that enforcement will come from active and systematic monitoring. 
   5. Communication campaigns.  There is a low level of awareness of the tobacco control law and new smokefree policies. This should be addressed with well-focused communication campaigns at national and local levels to support smokefree regulations.  In fact, experience from many countries show a high compliance with smokefree regulations after with a period of public education campaigns.
   6. Capacity building.  There should be a substantial resource commitment to building a program of provincial and municipal capacity for smokefree regulations implementation.  The projects training toolkits should be the model for this program. Identify specific program and technical resources needed to implement smokefree regulations.
   7. Identification and allocation of financial and technical resources.  There should be a systematic accounting of the financial and technical resources needed to fully implement smokefree regulations, done with the full consultation of national, provincial and municipal leaders.  In addition, there is a critical and emergent need to establish the proper legal, strategic, organizational, administrative and financial structures for the Fund for the Prevention and Control of Tobacco Harms.

 
 
 

RESOURCES

1. American Cancer Society (2011). Clearing the Air: Communicating and Smoke-free Viet Nam
2. Centers for Disease Control and Prevention (CDC) (2007) Global Youth Tobacco Survey (GYTS) Viet Nam – National
3. CDC (2010) Global Adult Tobacco Survey (GATS) Vietnam Fact Sheet.
4. Euromonitor International (2008) Industry reports: Tobacco – Viet Nam.
5. Institute for Global Tobacco Control (IGTC), Johns Hopkins Bloomberg School of Public Health (JHSPH) (2011) Report on Reduce Smoking in Vietnam Partnership. Unpublished
6. Kinh, H. V., Ross, H., Levy, D., Minh, N. T. and Ngoc, T. C. (2006) The effect of imposing a higher, uniform tobacco tax in Vietnam. Health Research Policy and System.
7. Lam NT, Simon C, Taylor R (2006) The economic impact of tobacco expenditure on poor households in Vietnam. VINACOSH, Monograph of Research on Tobacco Control, period 1999-2005: Ministry of Health
8. Mackay J, Eriksen M, Shafey O (2006). The Tobacco Atlas. 2nd ed. Atlanta: American Cancer Society
9. Minh, H. V., Ng, N., Wall, S., Stenlund, H., Bonita, R., Weinehall, L. et al. (2006) Smoking epidemics and socio- economic predictors of regular use and cessation: findings from WHO STEPS risk factor surveys in Vietnam and Indonesia. The Internet Journal of Epidemiology, 3, DOI 10.5580/298c.
10. Mondaq/Russin & Vecchi  Report: Vietnam: The Tobacco Industry In Vietnam (2010) http://www.mondaq.com/x/107018/Government+Statutory+Law/The+Tobacco+Industry+In+Vietnam
11. Ross H, Trung DV, Phu VX (2007). The costs of smoking in Vietnam: the case of inpatient care. Tobacco Control 16:405-9.
12. Various print and electronic media and talk shows (2010-2012) Enforcement of smokefree regulations in three project sites in Viet Nam in Da Nang, Thai Nguyen and Tien Giang
13. Vietnam Decree No. 119/2007/NĐ-CP on Tobacco Manufacturing and Trading
14. Vietnam Decree No. 45/2005/NĐ-CP Dated May 6, 2005 on Sanctions Imposed on Administrative Violations of Public Health. May 21, 2005
15. Vietnam Decree No. 75/2010/ NĐ-CP on Sanctions Imposed on Administrative Violations in Cultural Sector
16. Vietnam Government Resolution No. 12/2000/NQ-CP on “National Tobacco Control Policy” 2000 – 2010
17. Viet Nam Grantee Reports on smokefree and tobacco control law projects, Bloomberg Initiative to Reduce Tobacco (2007-2013) (unpublished)
18. Vietnam Law No. 09/2012/QH13, Law on Prevention and Control of Tobacco Harms
19. Vietnam Law No. 36/2005/QH11 on Commercial Law and State President Order No. 10/2005/L-CTN of June 27, 2005 on the Promulgation of Law No. 36.
20. Vietnam Ministry of Health Decision No. 2019/2000/QD-BYT Provisional Regulations on the Hygiene of Cigarettes.
21. Vietnam Prime Minister Decision No. 1315/QD –TTg on Ratification of the Plan for the Implementation of the Framework Convention on Tobacco Control
22. Vietnam Prime Minister Directive No. 12/2007/CT-TTg on Strengthening Tobacco Control Activities
23. Vietnam Tobacco Control Master Plan 2000-2009. Unpublished.
24. Vietnam Steering Committee on Smoking and Health (VINACOSH) Project Progress Reports for Atlantic Philanthropies Project 15332, 2010 -2012. Unpublished.
25. VINACOSH (2012) Smokefree implementation and communication guidelines: a series of guidelines for four sectors
26. World Health Organization (WHO) (2007) WHO FCTC Guidelines on the protection from exposure to tobacco smoke (decision FCTC/COP2(7)
27. WHO (2008) Tobacco Control Economics Tobacco Free Initiative Vietnam Country Profile http://www.who.int/tobacco/economics/vietnam.pdf
28. WHO (2010) Global Adult Tobacco Survey (GATS): Vietnam.
29. WHO (2012). WHO Global Report Mortality Attributable to Tobacco. Geneva: WHO Press; 2012. Available from: http://whqlibdoc.who.int/publications/2012/9789241564434_eng.pdf 7