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
Budget Committee:  [Viet Nam] National Assembly Committee on Financial and Budget Affairs
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. Executive summary
2. Project description
3. Methodology
4. Findings
   1. Background
      1. Tobacco use in Viet Nam
      2. Socioeconomic costs of tobacco use in Viet Nam
      3. VINACOSH and key ministries’ role in tobacco control
      4. Viet Nam’s tobacco industry
      5. Tobacco control policies in Viet Nam
   2. The tobacco control law process
      1. Initiating the drafting process
      2. Delays and difficulties
      3. Turning point
      4. National Assembly considers the Tobacco Control Law
      5. National Assembly passes Tobacco Control Law
5. Lessons learnt
   1. Time and opportunity
   2. Evidence base and experts
   3. Capacity building
      1. VINACOSH capacity
      2. Capacity building efforts at decisive moments
   4. Partnerships
      1. Provinces
      2. National Assembly’s Social Affairs Committee
      3. Interministerial partnerships
      4. Tobacco Control Working Group
6. Conclusions
   1. Summary
   2. Key issues
      1. Funding
      2. VINACOSH strategic plan
      3. Capacity building
      4. Partnerships
      5. Surveillance, evaluation and program planning
   3. Recommendations
      1. Funding
      2. Strategic planning, reorganization and staffing
      3. Capacity building
      4. Partnerships Evidence
7. Resources

 
 

EXECUTIVE SUMMARY The 2009-2012 project conducted by the Viet Nam Committee on Smoking and Health Standing Office (VINACOSH), supported by Atlantic Philanthropies, piloted smokefree regulations in three project sites; Da Nang, Thai Nguyen and Tien Giang.[1]  This case study examines activities conducted during the last phase of the project when tasks were shifted to support the draft Law on Prevention and Control of Tobacco Harms (the Tobacco Control Law or the Law), specifically development of the Law and advocacy for the Law, which was eventually enacted by the National Assembly in 2012.
 
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 in Viet Nam, socioeconomic costs of tobacco use, VINACOSH’s and key ministries’ role in tobacco control, Viet Nam’s tobacco industry and Tobacco Control Law process efforts.  The lessons learnt section provides an analysis of four main themes that emerged from an analysis of events and activities.  Based on the findings, lessons learnt and key issues, the author suggests steps to support implementation and advocacy of the Law comprising
 
 
 

 
PROJECT DESCRIPTION The 2009-2012 project conducted by the Viet Nam Committee on Smoking and Health Standing Office (VINACOSH), supported by Atlantic Philanthropies, piloted smokefree regulations in three project sites; Da Nang, Thai Nguyen and Tien Giang.  
 
This case study examines activities conducted during the last phase of the project when tasks were shifted to support the draft Law on Prevention and Control of Tobacco Harms (the Tobacco Control Law or the Law), specifically development of the Law and advocacy for the Law, which was eventually enacted by the National Assembly in 2012.[2]
 
 
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 advocacy activities for the Tobacco Control Law.
 
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[3] 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.
 
The author also conducted a desk review of all available references and reports on Atlantic Philanthropies grant. The author then synthesized and analyzed information from the interviews and desk reviews to develop findings, lessons learnt and conclusions.

FINDINGS  
Background
 
Tobacco use 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 male 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.
 
VINACOSH and key ministries’ role in tobacco control
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 Directorof VINACOSH manages day-to-day operations. Several project managers and administrative officers currently staff VINACOSH.
 
Key ministries involved in national tobacco control include the Ministry of Health (MOH), which has the main responsibility for organizing, directing and coordinating interministerial tobacco control projects. The Ministry of Culture, Sport and Tourism is responsible for anti-smoking communication activities, health warnings on tobacco products and enforcing bans on tobacco advertising, promotion and sponsorship. The Ministry of Finance directs tobacco taxation and fees regulations.  The Ministry of Industry and Trade directs the agriculture, manufacture, export, trade and distribution, control of smuggling of tobacco products.
 
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, has 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[5]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. 
 
Tobacco control policies in Viet Nam
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).  In 2006 VINACOSH attempted to push through new regulations on warning labels on tobacco products that would comply with WHO FCTC requirements and meet its recommendations for a series of rotating, graphic (pictorial) warnings covering 50% of packaging. However, the Ministry of Trade and Industry and tobacco industry representatives successfully thwarted these efforts for strong.  The resulting Decree No. 119/2007/NĐ-CP on Tobacco Manufacturing and Trading (August 2007) only required one text warning, “Smoking Can Cause Lung Cancer” covering 30% of package surfaces.
 
 
The Tobacco Control Law Process
 
Initiating the drafting process
In 2006 VINACOSH began drafting the outlines for comprehensive national tobacco control legislation.  The first draft of the Law was produced by VINACOSH in late 2006 with support from a legal expert provided the Campaign for Tobacco Free Kids and review by several in-country experts and external partners. The draft was shared with experts, partners and donors, but was not formally considered by the government.
 
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 establishingfurtherimpetus for national tobacco control and VINACOSH’s authority to coordinate activities among relevant ministries.  MOH also gave VINACOSH additional authority and credibility by officially designating them as a separate office for tobacco control with fiscal autonomy and authority to convene its interministerial partners and other organizations.
 
In early 2009 MOH initiated the formal drafting of the Tobacco Control Law, with the MOH Department of Legislation leading the process.  Several drafts were produced and reviewed by interministerial working groups, with various outside experts providing informal inputs. 
 
In another step towards a comprehensive tobacco control law, the 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. 
 
Delays and difficulties
When the drafting process first started, VINACOSH estimated that the draft Law would be submitted to the Prime Minister’s Office and placed on the National Assembly’s agenda by early 2010.  But by late 2009, these expectations already began to shift. The National Assembly signaled that tobacco control would not be on the 2010 agenda, much to the initial disappointment of VINACOSH and the tobacco control community. 
 
There were numerous revisions and even concurrent versions that made it difficult for VINACOSAH to track.  VINACOSH would often report to partners that it was not sure of the status of certain provisions as they seemed to change from week to week.  At particular risk were provisions for smokefree policies, graphic warnings on tobacco products and the fund for tobacco control. 
 
One drafting workgroup participant stated that, “Each week it seemed the draft would change and get weaker. When we should have been [focused on strengthening language] we had to keep fighting just to keep provisions the same.” Another formal participant in the drafting process said that it seemed like the MOH Department of Legislation “was against us…They would keep coming back with revised language that was clearly written by or influenced by the tobacco industry…right out of their playbook.”
 
The drafting process now appeared to be heavily influenced by the tobacco industry and the Law was weakening with each revision. 
 
Turning point
External partners and donors also began to criticize the weaknesses of the draft provisions, especially the smokefree requirements and the language establishing a tobacco control fund.  In an early 2010 meeting, when the draft Law was arguably at its weakest, a major donor questioned VINACOSH’s efforts and expressed doubts about their further support for the Law drafting process and related activities.  Members of the Tobacco Control Working Group (TCWG), comprising in-country organizations supporting tobacco control, reported afterwards that they were angry and embarrassed by the external criticism and worried that without significant support the Law would be further weakened.
 
Faced with managing several grant projects, and without a strategic plan to guide its own work,VINACOSH decided to turn its full attention to the Law.  Its first task was to convene the TCWG to plot a strategy to advocate for the Law. 
 
First, each TCWG organization agreed to take on specific tasks to advocate for the Law using the same materials that were provided by VINACOSH, providing for consistency of the messages as well as budget savings to all organizations. VINACOSH then sent a letter to the drafting committee, documenting evidence for stronger smokefree provisions and citing the support and implementation experience of provinces.  They also enlisted technical advice from the Viet Nam Lawyers Association.
 
Through their different projects, each TCWG conducted media campaigns at different levels, which were amplified by the VINACOSH national media campaign supported by the World Lung Foundation. 
 
VINACOSH also began to react more quickly to advocate and defend the Law at critical moments. For example, at one point the Government Office, a ministry-level agency which had a coordinating role in the Prime Minister’s review of the draft Law, gave VINACOSH only two days notice of the final review meeting where the tobacco association was expected to strongly condemn the law. VINACOSH mobilized its partners to attend the meeting who gave a point-by-point defense of provisions, basically overwhelming tobacco association representatives with the evidence base.
 
VINACOSH began to work more closely and cooperatively with the MOH Department of Legislation, with a deeper appreciation of the Department’s mediating role in managing the drafting process.  While many tobacco control partners expressed concerns about the Department of Legislation’s lack of explicit support for stronger provisions, the Department proved to be adept in mitigating tobacco industry influence and interference. 
 
VINACOSH, with support and participation of the TCWG, also began to conduct more intensive workshops with National Assembly/Social Affairs Committee members, as well as meetings with key Ministries. After each National Assembly/Social Affairs Committee workshop, VINACOSH would conduct a workshop evaluation survey to gauge members’ support and concerns about the Law and then immediately addressed their concerns and questions, if possible.
 
VINACOSH followed up the workshops by mobilizing provincial leaders—who had conducted tobacco control activities, especially smokefree projects—and the TCWG to contact the National Assembly members.  These efforts helped secure the National Assembly’s Social Affairs Committee support for the Law. As a result, the draft Law was approved by the Prime Minister and was placed on the formal agenda of the National Assembly In October 2011.
 
National Assembly considers the Tobacco Control Law
With the submission of the draft Law with key provisions on smokefree policies, graphic health warnings intact, the fight shifted to defending provisions for the tobacco control fund.  At the critical first National Assembly Standing Committee hearing on the draft Law in early 2012, the Chairman wanted the provisions for the tobacco control fund dropped, stating that Viet Nam’s experience with similar national funds was not positive, a position that was also held by the head of the Committee on Financial and Budget Affairs [Budget Committee].
 
VINACOSH again mobilized support from the other offices, ministries, the TCWG and provincial leaders.  Members were contacted, technical information was provided and a letter writing campaign was conducted. VINACOSH also supported several meetings with key officials from the Government Office, the National Assembly and the National Assembly Budget Committee to provide evidence for the tobacco control fund.  The Ministry of Finance also made a significant defense of the tobacco control fund, which apparently convinced many members.
 
At the second National Assembly Standing Committee hearing, the Law received about 25 comments in support of the Law and only about five still opposed the Law specifically stating concerns about the tobacco control fund.
 
National Assembly passes Tobacco Control Law
After contentious few months again involving multiple revisions, the National Assembly passed the Law in June 2012. The law went into effect 1 May 2013. 
 
Key provisions of the new Law include requirements for: smokefree work places, restaurants and public places; graphic health warning labels covering 50% of the cigarette pack; a strengthened prohibition on advertising and promotion of tobacco products and restrictions on sponsorship;
restrictions on sales to minors and on tobacco sales within 100 meters of child care facilities, schools and hospitals; and a ban on “kiddie packs” (packs that contain fewer than 20 cigarettes), easily accessible to youth.
 
In addition, 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 taxand will begin to flow to the Fund starting May 2013. 
 
 
LESSONS LEARNT What was essential to the development and advocacy efforts leading to the successful passage of the Viet Nam Law on Prevention and Control of Tobacco Harms? There are four main themes that emerge from an analysis of events and activities: 

• Time and opportunity
• Evidence base and experts
• Capacity building
• Partnerships

 
Time and opportunity
As many observers agreed, there is no “regular” process for developing and passing a national law in Viet Nam. The process for the Tobacco Control Law was even more circuitous and confusing than predicted and largely beyond the control of any particular organization, including VINACOSH.  There were also definite expectations about when the draft Law would be placed on the agenda of the National Assembly and fear about the prospects for a strong national law when delays were added to delays.
 
However, the delays in the drafting process turned out to be an enormous opportunity for tobacco control advocates and ultimately resulted in a strengthened Law, although at the time many tobacco control partners and donors were disheartened by the delays and even critical of VINACOSH’s participation in the drafting process.  
 
With no concrete strategic plan to guide its work, VINACOSH used the additional time allowed to rally the TCWG to build broader support for the Law and key provisions, and counter tobacco industry interference and misinformation, especially for the smokefree policies, graphic health warnings and the tobacco control fund.   The additional time also allowed them to build credibility with provincial leaders, the National Assembly Social Affairs Committee and key ministries.  If the law had been pushed through in 2010/2011, it is likely they key provisions would have been weaker, or in the case of the tobacco control fund, even dropped.
 
Lastly, the delays allowed the MOH Department of Legislation to patiently deal with opposition to key provisions. Despite observers’ criticisms that the Department of Legislation was being a barrier to strengthening the Law’s language, there is evidence that they actually acted a buffer, absorbing attacks and slowly and gently pushing back attempts to weaken the draft Law. Sometimes they would have to revise language to temporarily appease critics, but they were able to keep the Law on track and ultimately improve provisions.
 
Evidence base and experts
There is overwhelming global scientific evidence that comprehensive national tobacco control programs that are sustained and evaluated have been shown to reduce smoking rates, tobacco- related deaths, and diseases caused by smoking.  This evidence is the basis for the WHO FCTC and WHO’s recommendations for country-level implementation of effective interventions to reduce the demand for tobacco, known as the WHO MPOWER measures.
 
This evidence is reinforced by the research and experiences of Viet Nam’s neighbors in the Asia-Pacific region, both countries that have made rapid progress and provide incontrovertible models in tobacco control, such as Thailand, Singapore, Malaysia and Australia and others that face enormous challenges, such as China.  In addition, there is a substantial body of research on tobacco use in Viet Nam comprising surveillance, policy and program evaluation and behavioral, prevention and economic studies. 
 
VINACOSH and the TCWG were to draw on all this evidence to develop workshops, educational and communication materials, and most importantly, the language of the draft Law.  They were able to leverage the combined knowledge, expertise and experience of all tobacco control projects in Viet Nam provide important inputs to development of the Law and advocate for the Law to the National Assembly and ministries.  They used this evidence to effectively counter the tobacco industry’s baseless arguments, even showing how the industry used the same tactics in other countries.
 
The wealth of shared information and experiencesof all the tobacco control partners’ projectsalso provided the evidence for the viability of policies and interventions at the province, district and city level, especially the smokefree policies.  Backed by this evidence VINACOSH and its partners gained the credibility needed to work with ministries and the National Assembly.
 
In addition, VINACOSH was able to organize authoritative external experts to present the evidence before interministerial working groups and the National Assembly.  Of particular note were Dr Nguyen Tuan Lam representing WHO - Viet Nam, and Dr. Prakit Vathesatogkit and Mrs. Bungon Ritthipakdee, who both worked for the Thailand Health Promotion Foundation.  Over the course of five years each of these experts developed a close working relationship with both interministerial working groups and the National Assembly.  While other international experts’ interventionswere very valuable, these three seemed to establish a special level of credibility and trust through recurring and timely participation in key meetings, and presentation of scientifically valid and compelling evidence. 
 
Capacity building
Capacity building—activities that helpedstrengthen people’s skills and abilities as well as organizational infrastructure that enabled effective performance—was clearly essential to the Tobacco Control Law development and advocacy efforts. There were two main areas of capacity building: the strengthening of VINACOSH’s own capacity and the increased and coordinated capacity building efforts of VINACOSH and its tobacco control partners conducted for the National Assembly, ministries and provinces.
 
VINACOSH capacity
It is a widely expressed and documented view that in the early- to mid-2000s, VINACOSH lacked the resources, the capacity, the understanding and credibility to coordinate tobacco control efforts across many of ministries, organizations, donors, many with competing interests and demands.  Early on in the Tobacco Control Law drafting process many partners expressed frustration that VINACOSH seemed to want “to control everything” yet did not have sufficient technical or programmatic expertise. They were also perceived as being unwilling to empower other organizations.
 
This is no longer the case.  Despite still being staffed primarily by junior project managers—none of whom have more than seven years of tobacco control experience—VINACOSH rapidly increased its technical and programmatic capacity between 2010 and 2013.  Notably, project staff became conversant on smokefree policies, tobacco-tax based health promotion foundations and the evidence for graphic health warnings.  Donors and partners support for VINACOSH staff training were certainly a factor contributing to their increased capacity.  However, the more significant cause seems to be simply “battleground experience.”  The interviews, the grants history and record of managing the Tobacco Control Law show that the evolution of VINACOSH was the result of experience and many struggles, increased capacity from both training and that experience, and perhaps most importantly, committed and effective leadership within the Ministry of Health.
 
Another important factor was VINACOSH’s change from an office working under MOH to an office that was given inter-Ministerial coordination authority. 
 
Partners’ views of VINACOSH have changed radically, as shown in various internal and published reports.
 
“VINACOSH has grown tremendously in the past 5 years in terms of capacity, and established credibility with the Ministries and partners.”
 
“VINACOSH is now was very well-connected and able to tap into [and use] all available resources.“

“Their coordination of the Tobacco Control Working Group was a huge factor [in getting the Tobacco Control Law passed].”
 
“VINACOSH is now very savvy: they have more inside knowledge of Ministries’ and the National Assembly’s needs and views and are able to respond immediately to requests.”
 
 
Capacity building efforts at decisive moments
VINACOSH’s increased capacity enable it to effectively conduct capacity building activities and also gave it the confidence to empower its in-country partners.  Between 2011 and 2012 there was a critical mass of capacity building activities that energized a broader group of leaders at the national and provincial level.There are numerous examples of these activities, especially during decisive moments for the Tobacco Control Law:
 

• In May 2011 the Ministry of Health, with VINACOSH organization, conducted a National Tobacco Control Conferencefor about 200national and provincial and city leaders, mass organizations and NGOs.

 
While the focus of the conference was the 10-year evaluation of the National Tobacco Control Policy (Resolution No. 12/2000/NQ-CP), it provided VINACOSH a real opportunity to increase awareness and need for the Tobacco Control Law and also advocate for stronger provisions.  The Deputy Prime Minister, Nguyen Thien Nhan, led the proceedings and called for the ministries, People's Committees to intensify their tobacco control effort and to review the contents of the draft Tobacco Control Law to make it stronger. 
 
A few months after that National Conference, VINACOSH held a draft Law “appraisal meeting” with the ministry representatives to revise the draft before submitting it to Government Office. Again, VINACOSH too advantage of the meeting to conduct training on tobacco control issues.
 

• In late 2011 at two key meetings of the Committee on Social Affairs to review the draft Law, VINACOSH provided the members withevidence and arguments for key provisions, solicited their understanding and concerns of the provisions,thenimmediately followed up on their specific questions. They also enlisted members of the TCWG to follow-up with certain members with whom the organizations had a close relationship.

 

• Working with the Committee of Social Affairs, VINACOSH also developed a National Assembly newsletter, disseminated in late 2011, that explained important contents of the draft Law, such as graphic health warnings warning, bans on“kiddie packs” and the tobacco control fund.

 

• In April 2012VINACOSH conducted a training workshop in HCMC for National Assembly members from Southern provinces, followed by a workshop Hai Phong for members from Northern provinces.  Experts such as Dr. Nguyen Van Tien, Vice Chairman of Committee for Social Affairs and Mrs Bungon Ritthpakdee presented on the evidence for tobacco controland the experiences of other countries. After these two workshops, the drafting workgroup revised and finalized the draft Law before submitting it to the National Assembly.

 

• VINACOSH also arranged for National Assembly members, ministries and provincial leaders leadership to attend study tours to other countries to see how those countries implemented tobacco control, sometimes with a focus on smokefree policies as well as health promotion foundations that were models for the tobacco control fund. The study tours not only increased leaders’ capacity and support for tobacco control, but also raised their credibility to speak on tobacco control issues.

 
It should also be noted that scores of trainings were conducted through the various projects conducted for and by VINACOSH and NGOS that created support for the Law. In addition, 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.
 
Partnerships
Tobacco control partnerships and coalitions that supported development and advocacy for the Law did not happen overnight.  These were relationships that were nurtured over a decade, sometimes because they were required by law, sometimes because of the suggestions of a donor, sometimes out of necessity and not always by design.  In any case, these partnerships were significant strengthened between 2009 and 2012.
 
Provinces
The role of the provinces in supporting the Tobacco Control Law cannot be understated.  Over the last decade there have been many provincial and city tobacco control projects conducted by VINACOSH and other organizations, mostly focused on smokefree policies.  Provinces’ exposure, increased capacity and positive experiences on tobacco control issues were a very important input to the National Assembly’s consideration of the draft Law. VINACOSH and others were able to mobilize the leaders to form a provincial coalition to advocate for the law, which was perhaps a decisive factor in getting the law passed.
 
For example, 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.
 
National Assembly’s Social Affairs Committee
Another key to the success in passing the Tobacco Control Law was the treatment of the National Assembly’s Social Affairs Committee as a tobacco control partner, involving and empowering them to lead tobacco control discussions at high-level meetings.  Through capacity building workshops, members of the Social AffairsCommittee became de facto tobacco control experts, equipped to both organize and participate workshops for provincial leaders.  Most notably, Dr. Nguyen Van Tien, Vice Chairman of Committee for Social Affairs became an expert and helped guide discussionsin provincial workshops and National Assembly meetings.
 
Interministerial partnerships
Over the last decade the Ministry of Health and VINACOSH had fostered a close working relationship on tobacco control issues with the Ministry of Education and Training and the Ministry of Culture, Sports and Tourism of Vietnam, as well as mass organizations such as the Women’s Union, Youth Union.  They relied on these partnerships for support on the draft Law, especially for graphic health warnings, strengthened bans on tobacco advertising, promotion and sponsorship and smokefree policies
 
During the last few years VINACOSH also developed a close working relationship with the Ministry of Finance, through a small cooperative research project that builttowardsthe proposal for the establishment of tobacco control Fund. This may be one of the most important partnerships to come out of the Tobacco Control Law process as 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. In just 10 years, the Fund will provide over USD $77 million specifically for tobacco control.  In just one year this level of funding far exceeds total funding for all tobacco control projects across all organizations in Viet Nam in the past five years. 
 
VINACOSH also established a cooperative partnership with the MOH’s Department of Legislation, even though it appeared the Department was not fully supportive of some of the draft provisions. However, VINACOSH recognized that it needed to work collaboratively with the Department of Legislation as they had extensive experience in developing public health legislation and navigating the complex path to National Assembly approval.  For their part, the Department began to have more confidence in VINACOSH’s technical expertise and ability to mobilize high-level support.
 
Tobacco Control Working Group
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’ projects.
 
The TCWG was also strengthened when the Ministry of Health expanded the VINACOSH Steering Committee’s “Secretary Group” to include international organizations (such as WHO - Viet Nam), INGOs and NGOs.  Before this expansion only directors of departments from ministries and mass organizations were members.
 
At various points in drafting and advocacy for the Law, different TCWG organizationsacted as primary points of contact for National Assembly members and alsotook the lead on divisive issues to absorb attacks from tobacco industry interests and address negative criticisms. This was a successful tactic that allowed VINACOSH to continue to work effectively with the National Assembly and other ministries.
 
 
CONCLUSIONS Summary
In a little over a decade, Viet Nam went from a few disconnected tobacco control projects and lawsthat only existed on paper to a national comprehensive tobacco control law that will save lives and protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke.
 
The Law also meets the requirements and recommendations of the WHO FCTC, with national funding for implementation.  This was all in spite of a hostile government tobacco monopoly, obstructive ministries and lack of high-level political support and public awareness
 
Much of this success was made possible through the financial and technical support from multilateral and bilateral organizations that went through a few discouraging cycles.  However, one element was consistent though the ebbs and flows of funding and various battles with tobacco industry interests: MOH and VINACOSH leadership’s long-term commitment to a national comprehensive tobacco control law.
 
Only because of this leadership were VINACOSH and its partners able to take on the development and advocacy activities necessary for the successful passage of the Law.  And only because of this leadership were they able to turn the unpredicted delays to opportunities, effectively use the substantial evidence base and experts, build the capacity of key players, and foster strongpartnerships and coalitions.
 
Key issues
Viet Nam must now turn its attention to rapid and earnest implementation of the Law on Prevention and Control of Tobacco Harms. VINACOSH and its tobacco control partners need to capitalize on the momentum that led to passage of the Law and build on its new partnerships.  To do this, they should pay careful attention to several key issues:
 

1. Funding: The new Fund for the Prevention and Control of Tobacco Harms will securenational funding and ensuring the self-sufficient future of tobacco control. It 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 for all tobacco control efforts.
 

2. VINACOSH strategic plan:  Although there have been national policies and related instructionsto guidethem, VINACOSH has lacked a specific strategic plan and thus a strategic vision for its own work. 

 
TheTobacco Control Law development and advocacy activities conducted by VINACOSH were primarily reactive and opportunistic rather than strategically planned. VINACOSH has organized its work to respond to discrete project requirements rather than laying out a strategic plan that both incorporates and directs projects.  They have been the sum of their projects, many overlapping, some duplicative and some even inconsistent with each other.  VINACOSH had difficulty establishing a strong strategic thread through the projects, which was especially difficult when donorsoften had different expectations and insisted on different approaches and sometimes different outcomes. It was not until the Law and funding support was threatened that VINACOSH developed a more coherent development and advocacy short-term strategy in collaboration with its partners.
 
VINACOSH has now developed a strategy for implementation of the Law with inputs from the Government Office, Ministry of Finance, Ministry of Culture, Sport and Tourism, other ministries and mass organizations. This strategy will provide guidance for the development of regulations, implementation circulars, communication, capacity building, etc.  However, this is a government-wide plan and not specific to VINACOSH.
 

3. Capacity building:  Most of the implementation enforcement of the Tobacco Control Law will take place at local levels, particularly bans on smoking in workplaces and public places. It is clear that most local governmentslack technical and program capacity to effectively implement the Law, especially the smokefree policies.

 

4. Partnerships: Continued and new partnerships are essential to the successful implementation of the Tobacco Control Law.  The experience with the development and advocacy for the Law points to an entirely new model for partnerships between the government at all levels and the People’s Committee, mass organizations, NGOs, INGOs, multilateral organizations and donors.

 

5. Surveillance, evaluation and program planning:  VINACOSH should continue to build the evidence base for tobacco control.  This means maintaining existing tobacco use surveillance systems, establishing rigorous monitoring and surveillance systems for the Law’s implementation, project and program evaluation and documentation of progress and outcomes.  The data should be analyzed, communicated and used for future planning. This will require up-front investments and political commitment, especially when prioritizing activities for the new Fund for the Prevention and Control of Tobacco Harms.

 
 
Recommendations
Based on the findings and key issues, it is recommended that aprocess for supporting implementation and advocacy for the Tobacco Control Law should be developed and applied at national, provincial and municipal levels.  Core elements should include:
 
 

 
 

1. Funding
   1. The government must put top priority on establishing the infrastructure for new Fund for the Prevention and Control of Tobacco Harms. Work on the regulations, strategies, and organizational, administrative and financial arrangements must begin immediately, or the financial resources to control the tobacco epidemic in Viet Nam will go unused and could be vulnerable to misuse and abuse. If the Viet Nam Tobacco Control Fund is not set up now and correctly with a strong foundation, all future tobacco control efforts will be in jeopardy, including any hope for effective, sustainable funding.
   2. Infrastructure for the Fund should be based on the strategy for implementation of the Law.

 

2. Strategic planning, reorganization and staffing
   1. In addition to the strategy for implementation of the Law—a process that is already underway—VINACOSH should develop a long-term strategic plan for its own work that includes the Law’s implementation, current and potential donor projects, reorganization and other tasks.
   2. VINACOSH should reorganize around this strategic plan so that staffing is no longer based on donors’ project requirements.  VINACOSH should review models from other national tobacco control organizations, but it is suggested that staff be organized in the following four technical areas, along with the needed administrative staff:
      1. Policy, planning and evaluation;
      2. Research and surveillance;
      3. Communications;
      4. Community-based support, including capacity building for localities.
   3. VINACOSH should build competencies in the above areas through trainingand recruitment of new staff.
   4. The strategic planning, reorganization and investments in staffing can be mirrored at the provincial and municipal levels:
      1. PPCs and HIECS should have tobacco control strategic plans, and be organized and staffed to support implementation of the Law;
      2. VINACOSH can prioritize key provinces and cities for these activities that can catalyze efforts in other provinces and cities.

 

3. Capacity building:
   1. In addition to strengthening its own internal capacity, VINACOSH should make substantial investment in developing tobacco control capacity within all PPCs and HIECs, with the participation and support of the TCWG and international partners.
   2. PPCs and HIECs should be required and supported through funding and technical assistance to transfer these skills and knowledge to district, city and commune level leaders.
   3. Capacity building should be sustained, regular and evaluated.

 

4. Partnerships
   1. VINACOSH should formalize and strengthen its partnerships and establish partnership network infrastructure through the following activities:
      1. Provide financial and technical support to NGOs and mass organizations through the tobacco control fund to include:
         1. Projects;
         2. Trainings;
         3. Meetings.
      2. Conduct regular international partnership/donor meetings to communicate Viet Nam’s priorities and needs:
         1. Pro-actively develop project proposals with the following features:
            1. Developed in partnership with TCWG partners and/or key ministries;
            2. Developed as long-term cooperative agreements with donors, rather than discrete grants.
      3. Conduct regular outreach and progress updates with key Ministries and the National Assembly through both working groups and high-level national meetings.
      4. Engage these partnership networks in:
         1. Planning for the tobacco control fund;
         2. Developing regulations required by the Law;
         3. Develop a system and carrying out monitoring and evaluation of the Law’s implementation.
      5. All the above activities should include current partnerships as well as new organizations identified through the strategic planning process

 

5. Evidence
   1. VINACOSH should conduct surveillance and research that should be directly connected to monitoring and evaluating the Law’s progress.  Elements of the surveillance and research program can include:
      1. Regular updates to national tobacco use surveys, i.e., the Global Adult Tobacco Survey and Global Youth Tobacco Survey;
      2. Smokefree policies enforcement and scientific measures of levels of secondhandsmoke exposure;
      3. Cessation modalities that can be sustained with Viet Nam’s healthcare system;
      1. Systematic efforts to communicate the evidence to policymakers, the public and partners;
      2. Analysis of data to inform improvements to the Law’s required interventions and programs.

 
 

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