This survey of patients from 46 health facilities in 4 provinces of Vietnam shows a high prevalence of smoking among male patients seeking healthcare. Current smokers who were asked about smoking by a healthcare provider were more likely to make quit attempts than those not asked. Smoking cessation aids and assistance were generally not used by smokers who attempted to quit. Current smokers visiting central/provincial hospitals were more inclined to quit, yet almost four in ten current smokers seeking healthcare were not interested in quitting smoking.
This study is the first to measure the prevalence of smoking among patients presenting to all four levels of Vietnam’s government healthcare system. Our finding on substantial sex difference is consistent with previously reported data in many low- and middle-income countries (LMICs) [15] and those collected among patients with HIV in Vietnam [16]. The higher prevalence among male patients aged 25 to 64 years is also in keeping with population-wide data [11]. Even though the high ratio of males to females among smokers in South East Asia and Western Pacific regions has been well documented, a recent scoping review found few research articles on the association between masculinity and smoking behaviour [17]. This association and effective interventions specifically for male smokers remain to be studied, especially in countries where male-to-female ratio of smoking prevalence is high.
Identifying patients who smoke by healthcare providers may increase the likelihood of quitting. A meta-analysis found that a system to screen tobacco use in healthcare settings significantly increases the chance of clinical intervention [18]. In our analysis, the majority of current smokers who had been asked about smoking behaviour also received advice to quit from healthcare providers. We also observed a higher proportion of attempting to quit among current smokers who had been asked about smoking by medical professionals than those who had not been asked. Nevertheless, only about one third of the current smokers in our study had been asked about their smoking behaviour in the past 12 months and a high proportion of current smokers did not want to quit. The findings warrant the implementation of screening for tobacco use and quit advice in healthcare facilities in Vietnam, particularly commune health centres where prevalence of current smoking is the highest.
After identifying smokers in healthcare settings, the establishment of other system-based approaches might increase the chance of quitting. This may include capacity building activities for healthcare workers, a reminder system to prompt cessation discussion with the patients [19], and incorporating cessation as a routine part of care management for patients admitted to hospitals [20, 21]. Optimal management for following up patients after discharge should be considered as well. The lower prevalence of current smoking in healthcare settings than in the general population, coupled with the finding that a third of current smokers lived with another smoker, suggests the importance of smoking cessation activities beyond the healthcare system. According to the GATS 2015, more than half of current smokers were considering quitting but less than one third of them ever visited to a healthcare provider during the previous 12 months [11]. An analysis from the same survey showed high secondhand smoke exposure in public places [22]. We agree with the recommendation from the GATS 2015 that the national cessation programme should be strengthened in order to better reach those smokers who do not access healthcare. A recent study showed a positive result about the toll-free quit line run by Bach Mai Hospital [23]. Currently, this quit line provides around 10 follow-up counselling calls over 12 months. Provision and promotion of similar quit line services to the entire country will benefit those who are not reached by healthcare-based interventions. Similarly, mobile phone-based tobacco cessation interventions (mCessation) may achieve effective and cost-effective results in Vietnam and other LMICs [24, 25]. A cluster randomised controlled trial evaluating the effectiveness of a smoking cessation intervention that incorporates mCessation is currently underway (registration number: ACTRN12620000649910). Other measures, such as community-based cessation interventions and implementation of smoke-free environment, may also increase smokers’ motivation to stop smoking. Another ongoing cluster randomised controlled trial attempted to assess the effectiveness of involving community health workers in smoking abstinence [26]. Further studies to evaluate the effectiveness and cost-effectiveness of different interventions, both healthcare-based and non-healthcare-based, are desirable.
We demonstrated a very low rate of utilisation of smoking cessation services among patients who made quit attempts in the past 12 months. This finding was similar to a cross-sectional survey among 321 men calling the quit line service run by Bach Mai Hospital [27]. Only less than 5% of these male smokers used direct counselling, nicotine replacement therapy, or medicines (bupropion/varenicline) before calling the quit line. An important barrier to accessing this service includes the lack of awareness of the phone number by smokers, which could be addressed by increasing funding for health promotion in Vietnam, and including the Quitline number on the packages of tobacco products [28].
Our analysis also showed differences in willingness to quit among patients at different levels of health facility. This finding, along with the differences in prevalence of smoking across sex, age groups, and levels of facility, indicates the need to tailor evidence-based smoking cessation interventions to the local context. An example to achieve this is the “Ottawa Model for Smoking Cessation”, a systematic approach to tobacco dependence management delivered for patients attending healthcare settings [21].
The strength of this study is inclusion of participants from all levels of the health system in four geographically distinct provinces of Vietnam, increasing its generalisability. We also used standardised questionnaires to assess current smoking behaviours, and contact with tobacco control services. However, our study sample may slightly under-represent the proportion of patients attending commune level facilities – in comparison to higher level facilities [29].
This study has a number of important policy implications. First, the low proportion of current smokers been asked about smoking habits highlights the need for a screening system to identify patients who smoke that can be integrated into routine practice. Second, the intervention to support quit smoking in the healthcare facilities should be tailored to patients’ characteristics and capacity of the facility. Third, even though cessation medications are effective in assisting smokers quit, these medications are expensive and not readily available in Vietnam. Policies to provide cessation medications covered by public health insurance that are cost-effective will be necessary to further reduce smoking prevalence.
Further research is required to address several questions. How smokers acquire information about cessation services and access assistance in Vietnam is still not clear. For example, the quit line operated by Bach Mai Hospital is the first national quit line service that has been available since 2015. It is desirable to know that smokers did not use this service because they were not aware of the service or they did not consider it helpful. A recent systematic review of randomised controlled trials showed that nicotine replacement therapy, behavioural counselling and brief advice are effective interventions in LMICs [30]. Nevertheless, implementing these interventions in healthcare settings remains a big challenge in many LMICs [31]. A flexible model to include evidence-based smoking cessation services into clinical practice in different levels of health facilities should also be established. Finally, it is needed to study the role of health authorities in supervising the implementation, which is critical to maintain the sustainability of the model.
