Mortality attributable to smoking in Vietnamese men in 2008
Introduction
Smoking prevalence among Vietnamese men is one of the highest in the world with smoking an integral part of male social behavior (Morrow and Barraclough, 2003, The Tobacco Atlas Online, ND). Reliable smoking prevalence data are not available prior to 1990. A regional study in the 90s reported smoking prevalence of 70% (Jenkins et al., 1997) with the first national estimate of prevalence in excess of 60% for Vietnamese males (General Statistics Office, 1994). Given the very low smoking prevalence among women, per capita annual cigarette consumption implies an annual consumption of about 2600 cigarettes per adult male in the mid-90s (Guindon and Boisclair, 2003). Taken together these data suggest that past consumption has been substantial for men.
Over the last decade, Vietnam has implemented the National Tobacco Control Policy 2000–2010 (Government of Vietnam, 2000) aimed at reducing tobacco-related morbidity and mortality through a number of public interventions including excise tax and advertising bans, but the nation is in a relatively early stage in its tobacco control efforts (Levy et al., 2006). The paradox surrounding the tobacco control policy in Vietnam arises from the contradictory position of a government that benefits from manufacturing of tobacco products, and is also responsible for controlling tobacco consumption. Even with some evidence of success, limited resources and competing interests have impeded the effective implementation of the policy to its full potential. This is reflected in current smoking prevalence which has remained high among adult males at almost 50% (GATS Vietnam Working Group, 2010, General Statistics Office, 2007). Exposure to passive smoking also remains exceedingly high (67.6%) among non-smokers (GATS Vietnam Working Group, 2010). Despite some delays, recent passing of the Tobacco Harm Prevention Law is expected to strengthen implementation of the policy (Ministry of Health (Vietnam), 2012).
Such a policy framework can benefit from a better understanding of the current and future health effects of tobacco. This study applies the method of Peto and Lopez (Peto et al., 1992) to the first ever national estimates of causes of death for Vietnam (Ngo et al., 2010, Nguyen et al., 2011) in order to quantify mortality attributable to smoking in 2008. Given the low smoking prevalence among females the focus is on male smoking attributable mortality. Since smoking risks have not previously been published for Vietnam, the study provides analysis of uncertainty and sensitivity analyses. These estimates are provided to emphasize the urgency of strengthening tobacco control initiatives in Vietnam.
Section snippets
Methods
We used cause-specific mortality estimates from the first burden of disease and injury study for Vietnam in 2008 (Nguyen et al., 2011) based on a nationally representative cause of death survey using verbal autopsy methods (Ngo et al., 2010).
Relative risk estimates for cause-specific mortality related to tobacco use were derived from a re-analysis of the American Cancer Society Cancer Prevention Study, Phase II (CPS-II) which included adjustment for important covariates (Table 1) (Ezzati et
Results
The SIR method using lung cancer to measure cumulative smoking exposure estimated 70,236 attributable deaths (95% uncertainty interval 60,900–77,800) accounting for 24% (95% uncertainty interval 21–27%) of all male deaths and 28% (95% uncertainty interval 24–31%) of all adult male deaths 35 years and older in Vietnam in 2008 (Table 3). Lower estimates of smoking attributable mortality were obtained in the prevalence-based sensitivity analysis where tobacco-attributable mortality accounted for
Discussion
Despite inevitable uncertainty with regard to the precise level of mortality attributable to smoking in Vietnam, we estimate that tobacco is an important cause of preventable premature death among males. In Vietnam, as in developed countries, about half (52%) of those killed by tobacco were in middle age (35–69 years) (Peto et al., 1992) and a third were 35–60 years of age.
The prevalence-based method yielded lower smoking attributable deaths compared with baseline results estimated using the
Conclusion
Despite the different methodological options applied, we have obtained a remarkably consistent range of tobacco-attributable mortality in Vietnam, around a quarter of all adult male deaths. This suggests that tobacco is already a major risk factor for adult male survival in Vietnam. The high current smoking prevalence among Vietnam males has important implications not only for preventing the uptake of tobacco but also for developing and implementing effective smoking cessation policies. While
Author contributions
Rosana Norman conceived, designed, and coordinated the study, analyzed the data and wrote the manuscript. Hideki Higashi, Emily Carnahan and Jan Barendregt contributed to data analysis and manuscript review. Bui Ngoc Linh and Nguyen Thanh Huong contributed to data interpretation and manuscript review. Theo Vos and Alan Lopez contributed to conception and design, data interpretation and revised the manuscript critically for important intellectual content. All authors approved the final version
Conflict of interest statement
JJB owns Epigear International, which sells the Ersatz software used in the analysis. Other authors declare no conflicts of interest.
Acknowledgments
This study was carried out as part of the Evidence for Health Policy in Vietnam (VINE) project which is funded through the Atlantic Philanthropies. We also gratefully acknowledge the help of Heather Adair-Rohani who provided guidance in the interpretation of data from the WHO Household Energy database. Jill Boreham is thanked for providing expert advice and access to smoker and non-smoker cancer mortality data for China.
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