Health Promotion International, Vol. 18, No. 4, 373-380, December 2003
© Oxford University Press 2003 All rights reserved
PERSPECTIVES |
Tobacco control and gender in south-east Asia. Part II: Singapore and Vietnam
1Australian International Health Institute, School of Population Health, The University of Melbourne, Victoria 3010 and 2School of Public Health, La Trobe University, Bundoora, Victoria, Australia
Address for correspondence: Martha Morrow, Australian International Health Institute, School of Population Health, University of Melbourne, Victoria 3010, Australia E-mail: martham{at}unimelb.edu.au
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SUMMARY |
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In the World Health Organization's Western Pacific Region, being born male is the single greatest risk marker for tobacco use. While the literature demonstrates that risks associated with tobacco use may vary according to sex, gender refers to the socially determined roles and responsibilities of men and women, who initiate, continue and quit using tobacco for complex and often different reasons. Cigarette advertising frequently appeals to gender roles. Yet tobacco control policy tends to be gender-blind. Using a broad, gender-sensitivity framework, this contradiction is explored in four Western Pacific countries. Part I of the study presented the rationale, methodology and design of the study, discussed issues surrounding gender and tobacco, and analysed developments in Malaysia and the Philippines (see the previous issue of this journal). Part II deals with Singapore and Vietnam. In all four countries gender was salient for the initiation and maintenance of smoking. Yet, with a few exceptions, gender was largely unrecognized in control policy. Suggestions for overcoming this weakness in order to enhance tobacco control are made.
Key words: gender; policy; Singapore; tobacco control; Vietnam
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SINGAPORE |
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TOPSUMMARYSINGAPOREVIETNAMDISCUSSIONNOTE ADDED IN PROOFREFERENCES |
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Although Singapore derives substantial income from the international trade in tobacco, its government has shown strong political will to control the domestic use of tobacco by its citizens and has succeeded in reducing overall rates of smoking, particularly among males. Between 1984 and 1998 the prevalence of smoking for Singapore fell by some 27%, notwithstanding some minor fluctuations. In contrast, the rate for women returned to a similar rate after some major fluctuations (see Table 1).
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Of especial interest is the apparent increase in smoking prevalence amongst younger Singaporean women between 1992 and 1998 (see Table 2). This contrasts with a decrease in the rates for males in the same age groups. In the case of 20- to 24-year olds, the prevalence of female smoking had increased by just over two and a half times compared with a slight decrease for males in the same age bracket. The Ministry of Health has conceded that this is cause for concern, while noting that an increase in the prevalence of female smoking has also been observed in other developed countries (Ministry of Health Singapore, 1999a
). A 1999 survey of 13 111 pupils in forms 1–4 presented further evidence of changing gender dynamics among young Singaporeans, since the prevalence rate for female current smokers (8.8%) was not far behind that for males (11.3%) (http://www.cdc.gov/tobacco/global/gyts/factsheets/pdf_files/singapore.pdf).
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Tobacco control in Singapore
For the most part, Singapore has adopted generic measures to control tobacco. There has been a strong emphasis upon youth, and religion has been used to persuade Muslims to quit smoking. The smoking rise among younger women and overall plateau observed over time have not yet prompted the government to develop any special campaign for women.
Singapore's national policy on tobacco control, introduced in 1986, identified public education, legislation, taxation, intersectoral collaboration and community participation as key elements for implementation. These elements have found form in a number of measures. The advertising of tobacco products, including tobacco brand names, is prohibited in Singapore, as are cigarette vending machines, smokeless tobacco, and paraphernalia bearing cigarette brand names. Sponsorship of sports by tobacco companies is prohibited, although such support for the arts is permitted with ministerial approval. Cigarette packets must display health warnings, although none of these are gender-sensitive.
Since 1970, legislation controlling smoking in public and in workplaces has been gradually extended. By international standards, Singapore's controls are strict. Since 1993 those aged <18 years have been prohibited from even possessing tobacco in a public place (Tan et al., 2000). Inbound passengers receive no duty-free tobacco allowance. Tobacco control leadership in Singapore lies with the Ministry of Health. Both sexes are represented in the formulation of governmental tobacco control activities and women comprise the majority of Ministry staff engaged in tobacco control.
An examination of television advertisements screened as part of the National Smoking Control Programme from 1986 to 2000 revealed an increasing recognition of the female smoker. In 1986 advertisements for the programme, all the smokers portrayed were male, but a year later women were also shown, as well as disapproving of male smoking. By 1996 a female role model (‘Zoe Tay doesn't smoke’) had appeared alongside males in advertisements. In 1997 a television commercial screened as part of the National Smoking Campaign featured a young man determined to help a young woman to quit. In 1999, the Ministry of Health sponsored television advertisements based upon a previous Australian campaign emphasizing the damage to the body caused by smoking. These were gender-neutral and were targeted at both male and female smokers of all ages [Ministry of Health Singapore, Smoking Television Commercials 1986–2000 (videos, Resource Centre, National Health Education Department)].
The Ministry of Health publishes a range of pamphlets and booklets in English, Chinese and Malay, dealing with smoking and health. An examination of these publications, mostly aimed at youth, reveals that most included female images, while some showed only males. The issue of smoking and pregnancy was raised a number of times, and by 1997 there were references to glamour and models. One pamphlet (‘Say No to Smoking, Yes To Life’) counselled:
Models and stars spend a lot of time and are paid a lot of money to look glamorous. Cigarettes have nothing to do with it. In fact, many of them don't smoke in real life because they know that smoking will damage their good looks.
A bilingual publication published jointly with the Singapore Islamic Council, aimed at Malays (all of whom are Muslims), appealed to them to quit smoking permanently as a gesture for the holy month of Ramadan, during which Muslims may not smoke during daylight hours. Quoting the Prophet Muhammad, who warned that ‘Whatever harms the body or other people is sinful’, the pamphlet described the effects of passive smoking upon wives of smokers and unborn children (Majlis Ugama Islam Singapura and Ministry of Health, 1997). It is significant that the pamphlet referred to the ‘wives of smokers’, when evidence from prevalence studies suggests that some 12.8% of Malay women aged 18–24 years are smokers themselves (Ministry of Health Singapore, 1999b).
Women's magazines are included in the Ministry's programmes. A modest amount is spent on anti-smoking advertisements in such magazines, and the Ministry also ensures that information on smoking and health is provided to their editors.
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VIETNAM |
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TOPSUMMARYSINGAPOREVIETNAMDISCUSSIONNOTE ADDED IN PROOFREFERENCES |
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In 1986, in efforts to stimulate economic growth, the government introduced a modified free-market system and opened the country's doors to the outside, bringing rapid social change and economic growth, especially in urban centres. The manufacturing and sale of tobacco is lucrative in Vietnam and accounted for 3.2% of the national budget in 1994. To protect the local industry and stem foreign currency outflows, Vietnam banned cigarette imports in 1990, but enforcement costs, efforts by smugglers and corruption impeded implementation of the decree; illegal imports met 10% of domestic demand in the mid-1990s (Kinh et al., 1995
). In 1994 the government authorized local production of foreign brands through joint-ventures between its state-managed tobacco enterprise (Vietnam National Tobacco Corporation) and Rothman's of Pall Mall, Philip Morris and British American Tobacco. However, sales have not taken off as predicted, possibly due to a popular preference for foreign-produced (smuggled) brands. Smuggling continues to neutralize efforts designed to protect the local manufacturers, ensure revenue levels and implement effective tobacco control.
Vietnam has very high male smoking rates. Smoking has been an integral part of male social behaviour for many decades, and offering cigarettes a matter of common courtesy. Photographs of national hero Ho Chi Minh with a cigarette remain ubiquitous. In their 1995 survey, Jenkins and colleagues found that men were more likely than women to feel cigarettes should be offered at social gatherings (Jenkins et al., 1997). As elsewhere in Asia, smoking by young women has been frowned upon, although older, less educated rural women have traditionally used hand-rolled or chewed tobacco (often with areca) (S. Bales and H. V. Kinh, manuscript in preparation; Jenkins et al., 1997; Trong et al., 1999).
In the absence of nationwide prevalence data collected over time, we must focus on the past decade (see Table 3). In their comparison of the 1992–1993 and 1997–1998 Vietnam Living Standards Surveys, Bales and Kinh (S. Bales and H. V. Kinh, manuscript in preparation) found that consumption fell among both sexes, even without rigorous tobacco-control activities. A 1997 nationwide survey found that 50% of males and 3.4% of females aged >15 years used tobacco, with the highest rates among those with only primary school education (Trong et al., 1999).
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Few of our respondents expressed concern about potential uptake of tobacco use among women, nor did they indicate awareness of gender norms as an influence for either sex. Little is documented about gender and smoking in Vietnam, although ‘women shouldn't smoke’ was a main reason women gave for shunning it in the 1997 national survey. Women's potential role in tobacco control was evident in the fact that 15.3% of men who had quit smoking attributed this to advice from their wives (Trong et al., 1999
). Two qualitative explorations found that normative expectations influenced young men to initiate and continue smoking, but discouraged it in young women (Ngoc, 1995; PATH Canada/RTCCD International Tobacco Initiative, 1998). Among a randomly selected sample of 2020 female workers and students aged 15–24 years in Ho Chi Minh City in 2000, 20% had tried at least one puff and 6.3% reported regular smoking (Morrow et al., 2002); this is substantially higher than the rate of <1% found among women aged 18–25 years in Ho Chi Minh City in 1995, and higher than the 1997 national rate. Worryingly, the recent survey found that only 4.5% of respondents mentioned heart disease, and 16% lung cancer, as risks of tobacco use (Morrow et al., 2002). Traditional gender norms were routinely cited by young women to explain female non-smoking, but some ambivalence was voiced about their own intentions. Nearly half of the 24% who said they might initiate smoking one day linked their decision to potential future ‘unhappiness’ (Morrow et al., 2002).
Tobacco control in Vietnam
Vietnam has moved towards stronger tobacco control over the past 16 years. In 1986, cigarette sales were banned to those aged <15 years. Vietnam has observed World No Tobacco Day since 1988, and in 1989 the Ministry of Health established an advisory body on tobacco control, now known as the Vietnam Committee on Smoking and Health (VINACOSH). The Vice-Chair of this body is a woman. In 1989 smoking was prohibited in some public places, e.g. cinemas, with further venues added in 1991. A decree in 1992 exhorted government sectors to collaborate in smoking prevention, and prohibited public servants from using cigarettes as ‘gifts’. It also banned tobacco advertisements in the mass media. The lax implementation of these measures has been apparent in their reiteration, if in slightly altered form, in subsequent decrees.
More serious efforts began around the mid-1990s. The government banned advertising in electronic and print media in 1994, and in 1995 raised taxes on cigarettes (ranging from 32% to 70% of retail price) and promulgated more stringent guidelines about the media ban. Smoking was banned in the army in 1996, and tobacco sponsorship of sport and culture was prohibited a year later.
One non-governmental organization (NGO), PATH Canada, has been active in tobacco control research and advocacy. Based in Hanoi, it has sponsored several in-depth social research studies in which gender norms are highlighted (PATH Canada/RTCCD International Tobacco Initiative, 1998), and has examined the impact of tobacco promotion in Vietnam (PATH Canada/RTCCD International Tobacco Initiative, 1998). It has supplied no-smoking stickers to hospitals, and circulated its reports in Ministry of Health meetings. In 1997, together with the Vietnam Women's Union, PATH sponsored a smoking seminar attended by representatives of various sectors and NGOs, where the issue of female smoking was discussed.
Growing national commitment has culminated in a Prime Ministerial Resolution to enact a highly ambitious National Tobacco Control Policy (NTCP), which was signed in August 2000. The working group that drafted it comprised 
20 members from 12 ministries and mass organizations, about one-quarter of whom were women. The NTCP will be implemented by a committee headed by the Minister of Health, drawn from most ministries (including Trade and Finance) and mass organizations. The NTCP sets targets for the next decade of reducing smoking rates dramatically among men (from 50% to 20%) and youth aged 15–24 years (from 26% to 7%), and to reduce female rates to <2% (Vietnam, 2000). However, it makes no explicit mention of gender in its current form. Looking beyond the NTCP, we found no mention of gender elsewhere in health education materials, apart from the PATH Canada publications, which are not widely disseminated.
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DISCUSSION |
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Gender: an abiding, but overlooked social influence on tobacco use in south-east Asia
Our review of available statistical data in the four south-east Asian countries in this study confirms the salience of gender for the initiation and maintenance of smoking. In Singapore, the male smoking prevalence in 1998 (26.9%) was nearly nine times higher than the female rate (3.1%). This gap was even greater in Malaysia (49.2% compared with 3.5%, respectively) and Vietnam (50% compared with 3.4%, respectively). The Philippines recorded the highest rates for both sexes (54% for males, 12.6% for females), with male rates ~4.3 times those of female rates. Even here, the disparity was much larger than that found in most western countries (World Bank, 1999
). In drawing further cross-national comparisons, however, we must be mindful of deficiencies in the secondary data used in our analysis. The popularity of chewing tobacco among rural, often older women is not reflected in current survey findings, which focus mainly on smoking. A further limitation is the lack of comparable data over time. Other than for Singapore, available statistics from different surveys have used inconsistent sampling methods, asked different questions, and have not always disaggregated by sex, age, location or ethnicity. There is no real question that differences along sex lines are large and abiding in every country, but our observations in some instances must be made with caution.
Bearing in mind this caveat, we offer a number of reflections. The countries of our focus ranged from high- to low-income. Literacy rates are high in every state. The sex-linked differentials in tobacco consumption were almost identical in Malaysia and Vietnam, despite Malaysia's greater affluence and urbanization. No clear cross-national differences in prevalence could be readily attributed to religion or ethnicity, although ethnic differences in tobacco use emerged within countries.
Closer scrutiny of Singapore's trends suggests that it may be inappropriate to link its current profile to the strong tobacco control policies initiated in 1987. Singapore actually introduced its legislation against a (male) prevalence base that was far lower than that found at present in the other countries of our sample (just 37% in 1984); hence, other factors (e.g. small size and area, and disapproval by the country's leaders) may have already effected a cultural change in the acceptability of male smoking. This interpretation gains credence in view of the smaller reductions (proportionately) in male prevalence by comparison with western countries, and the plateau in female rates (virtually unchanged in 1998); moreover, higher and rising rates are found among certain subgroups (younger and Malay women), suggesting that new social dynamics may imperil Singapore's future successes.
Our investigation found little evidence that the significance of gender is recognized. Where one sex is singled out (which is rare), it is almost invariably in relation to women (as new smokers or as ‘wives of smokers’), while the normative values that appear to precipitate male tobacco use go largely uncommented upon. This is paradoxical considering the actual prevalence rates. It seems that for the most part, sex differences in smoking spark little interest, an omission found in many other international pronouncements [the WHO Kobe Declaration (WHO, 1999) is an exception]. This omission is greatly regrettable, given current patterns of use and the successful exploitation of gender by the tobacco industry, to say nothing of industry expectations for expanding female markets. The potential for further tobacco promotion through the internet and liberalized trade make even more urgent the need to develop effective control strategies that incorporate an awareness of the social context of use (and non-use). Finally, it should be noted that although the WHO has called for each country to establish a distinct tobacco control programme for women, this has not been done in any of the four countries in our study.
Singapore: more innovation may be needed to maintain the momentum
In looking specifically at the range of policies being planned or implemented, Singapore stands out as having introduced most of the inter-sectoral strategies recommended by international experts. It also has a commitment to frequent monitoring, and to undertaking social research to illuminate changing patterns. The focus on women, on ‘wives’ and on Muslims in the Ministry of Health campaigns reflect the changing trends revealed through its systematic data collection. Nonetheless there is no room for complacency, as the plateau among both sexes, and rises in young women, may herald a transition to the more gender-equal profiles found in parts of Europe and North America. Singapore's current policy approach could be described as gender-neutral (incorporates sex-disaggregated data, using resources to target the ‘different concerns’ of men and women). However, little mention is made of male smokers, who appear to be considered as the generic smoker. Singapore should expand its focus to social influences on male tobacco use.
Malaysia: some gender sensitivity set against industry promotion
Malaysia's tobacco control policies are seriously compromised by permitting the industry to advertise through ‘brand-stretching’, a mechanism that also exploits gender. The Health Ministry's 1996/1997 National Health and Morbidity Survey singled out normative gender roles as risk factors for males at the present time and, potentially, for females, calling for gender-sensitive approaches. The extent to which such approaches can be built into control programmes remains to be seen, but it should be noted that some of the government's public statements demonstrated more gender awareness than we found in similar pronouncements from the other three countries.
Time to make a start in the Philippines
The Philippines remains the poor cousin in terms of tobacco control, which is reflected in its prevalence rates for both sexes. The focus of broad-based social research in Manila has included gender influences on both males and females, and it is encouraging that the consortium responsible for investigating social and economic aspects of tobacco use in the Philippines works closely with the Department of Health and advises the Congress. It is to be hoped that the important findings about gender are eventually incorporated into Department of Health strategies, as well as into proposed legislation; however, the current stand-off in Congress makes it unlikely that the country will see any sort of tobacco control legislation soon, let alone gender-sensitive policies and programmes.
Vietnam: a new policy with ambitious targets
Vietnam's new NTCP has not been fully implemented, and, therefore, it is not possible to assess the implications of resource allocation, pricing decisions, and content of health education programmes in terms of gender sensitivity. The policy itself specifies targets for reduction in tobacco use for both sexes, even though current female consumption is relatively very low. Some might argue that these targets are unreasonably optimistic.
Vietnam's previous policies and programmes, and the new NTCP (aside from the targets by sex) are gender-blind; no mention is made of normative influences on tobacco use, and existing and proposed activities are generic. Vietnam is at a critical juncture as it translates the NTCP into concrete legislation and interventions; this provides a golden opportunity to enhance its effectiveness by taking into account not only cultural norms, but also differential impacts of price rises on men and women, as well as people of different social classes.
Asian values and the ‘protective paradox’
The low prevalence of female tobacco use in Malaysia, Singapore and Vietnam should not be viewed with inordinate relief, although, obviously, low prevalence is the goal of tobacco control. There are three main reasons for continued concern. First, the large population base of these countries means that in absolute numbers, millions of women are endangering their health and that of family members. Secondly, the tobacco industry acknowledges an interest in expanding the market to female consumers, and has shown a capacity to capitalize on the social aspirations, dreams and anxieties that are associated with tobacco use.
The third reason for concern is that gender norms are not immutable. They are constantly changing, particularly with globalization, cross-national communications, employment opportunities and demographic shifts. There are lessons to be learned from the uptake of smoking in western countries as women achieved more social and economic equality. There are also lessons from other Asian societies, with smoking prevalence among Japanese women aged 20–29 years rising from 12% to 22% over the last three decades (Tominaga, 1999), and with the decision in 1998 to launch two women's cigarette brands for China's 30 million female smokers (Kaufman and Nichter, 2001). ‘Asian values’ cannot be depended upon to prevent tobacco use among women indefinitely. Moreover, the normative traditions that protect women from the dangers of tobacco are part and parcel of structures that relegate women to subservient positions within the family and wider community (Waldron et al., 1988). A commitment to gender equity demands that this ‘protective paradox’ must be seen for what it is.
Tobacco control needs gender and social awareness
Effective tobacco control policy demands a better understanding of the social influences on health behaviours, of which gender is just one. As Christofides has noted, there is a need for reliable data on trends in tobacco use, disaggregated by sex, age, social class, ethnicity and other social factors (Christofides, 2001). Tobacco use also must be widely defined to include smokeless forms popular in south-east Asia. Given the links between tobacco and mental disorders, the expected increase in these conditions, and the sex-linked differentials in depression, it is particularly important to monitor co-morbidities. However, surveys alone are not enough. It is time to learn from public responses to the HIV/AIDS pandemic that have built upon in-depth knowledge of attitudes, practices, beliefs, and the wider environment of risk and opportunity. Social research is necessary to explore how and why various factors are implicated in tobacco use, leading to the development of multilevel, multidisciplinary, culturally sensitive approaches to tobacco use prevention and cessation, which include public health, educational and clinical models [(Hunter, 2001), p. 126].
It is obvious that the four south-east Asian countries surveyed should focus more on cessation for men, and on prevention for women and youth, but incorporating gender sensitivity into tobacco control would enhance health education messages and offer greater promise of success for broader programmes including bans, taxation, price rises and challenges to media images. It is imperative to recognize that sex-linked patterns of tobacco use are not ‘givens’, but are the product of social forces. The negative impact of gender norms on male health behaviours should be acknowledged by men themselves, and by feminist groups (Courtenay, 2000). Gender awareness should be reclaimed to take into account the risks and sequelae embedded in norms for both sexes.
The results of this study have relevance for international efforts at tobacco control
Given the massive sex-linked disparities in tobacco use in this region, strategies should incorporate a gender awareness and not rely only on generic approaches. By giving gender explicit focus, we will be more likely to prevent a new epidemic among women in countries where female rates are low, and more likely to identify why there continues to be so much appeal among young people of both sexes, in much of the world, for a product that carries disease and death to so many of its users.
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NOTE ADDED IN PROOF |
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TOPSUMMARYSINGAPOREVIETNAMDISCUSSIONNOTE ADDED IN PROOFREFERENCES |
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Since this article was written, the Malaysian government has announced that indirect advertising by tobacco companies will be phased out under proposed legislation dealing with tobacco control.
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ACKNOWLEDGEMENTS |
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The authors wish to thank the many informants in the four countries studied for generously giving their time to provide information and opinions. They also wish to thank the Australian Research Council for the small grant that helped to finance parts of this research. Unless otherwise indicated, the views expressed are solely those of the authors.
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