Tobacco and the Malays: ethnicity, health and the political economy of tobacco in Malaysia.

OBJECTIVES: To identify the historical nexus between Malaysia's largest and politically dominant ethnic group and the political economy of tobacco, and to consider the implications of this connection for tobacco control. DESIGN: Primary and secondary documentary sources in both English and Malay were analysed to illuminate key events and decisions, and the discourse of industry and government. Sources included: speeches by Malaysian political and industry actors; tobacco industry reports, press releases and websites; government documents; World Health Organization (WHO) tobacco control literature; and press reports. RESULTS: Malays have the highest smoking prevalence among Malaysia's major ethnic groups. The tobacco industry has consistently been promoted as furthering Malay economic development. Malays play the major role in growing and curing. Government-owned Malay development trusts have been prominent investors in tobacco corporations, which have cultivated linkages with the Malay elite. The religious element of Malay ethnicity has also been significant. All Malays are Muslim, and the National Fatwa Council has declared smoking to be haram (forbidden); however, the Government has declined to implement this ruling. CONCLUSION: Exaggerated claims for the socio-economic benefits of tobacco production, government investment and close links between tobacco corporations and sections of the Malay elite have created a conflict of interest in public policy, limited the focus on tobacco as a health policy issue among Malays and retarded tobacco control policy. More recently, ratification of the WHO Framework Convention on Tobacco Control, regional free trade policies reducing the numbers of growers, concerns about smoking from an Islamic viewpoint, and anxieties about the effects of smoking upon youth have increasingly challenged the dominant discourse that tobacco furthers Malay interests. Nevertheless, the industry remains a formidable political and economic presence in Malaysia that is likely to continue to proclaim that its activities coincide with Malay socio-economic interests.

Documenting a long-term development model in the slums of Delhi.

BACKGROUND: Achieving development outcomes requires the inclusion of marginalised populations that have the least opportunity to participate in and benefit from development. Slum dwellers often see little of the 'urban advantage', suffering more from infectious diseases, increasing food costs, poor access to education and health care, inadequate water and sanitation, and informal employment. A recent Cochrane Review of the impact of slum upgrading strategies found a dearth of unbiased studies, making it difficult to draw firm conclusions. The Review calls for greater use of process data, and qualitative alongside quantitative methods of evaluation. India is a lower middle income nation with large gender disparities and around 65 million slum inhabitants. The Asha Community Health and Development Society, a non-governmental organisation based in Delhi, has delivered a multi-sectoral program across 71 slums since 1988. This article reports on a mixed-method study to document measureable health and social impacts, along with Asha's ethos and processes. METHODS: Several observational visits were made to 12 Asha slums where informal discussions were had with staff and residents (n = 50). Asha data records were analysed for change over time (and differences with greater Delhi) in selected indicators (maternal-child health, education, child sex ratio) using descriptive statistics. 34 semi-structured individual/small group interviews and 14 focus group discussions were held with staff, residents, volunteers, elected officials, civil servants, bankers, diplomats, school principals, slumlords and loan recipients (n = 147). RESULTS: Key indicators of health and social equity improved over time and compared favourably with those for greater Delhi. The Asha model emphasises rights, responsibilities, equity and non-violence. It employs strategies characterised by long-term involvement, systematic protocols and monitoring, development of civil society (especially women's and children's groups) to advocate for rights under the law, and links with foreign volunteers and fund-raisers. Stakeholders agreed that changes in community norms and living conditions were at least partly attributable to the Asha model. CONCLUSIONS: While lacking a control group or complete baseline data, evidence suggested substantial improvements in slum conditions and social equity. The Asha model offers some lessons for slum (and broader) development.

Social context, diversity and risk among women who inject drugs in Vietnam: descriptive findings from a cross-sectional survey.

BACKGROUND: Women who inject drugs (WWID) are neglected globally in research and programming yet may be likelier than males to practise sexual and injecting risks and be infected with HIV and more stigmatised but seek fewer services. Little is known about characteristics, practices and nexus between drugs and sex work of WWID in Vietnam, where unsafe injecting has driven HIV transmission, and commercial sex and inconsistent condom use are prevalent. This was the first quantitative investigation of Vietnamese WWID recruited as injecting drug users. This article summarises descriptive findings. FINDINGS: A cross-sectional survey was conducted among WWID in Hanoi (n = 203) and Ho Chi Minh City (HCMC) (n = 200) recruited using respondent-driven sampling. Characteristics varied within and between sites. Twenty-two percent in Hanoi and 47.5 % in HCMC had never sold sex. Almost all commenced with smoking heroin, some as children. Most injected frequently, usually alone, although 8 % (Hanoi) and 18 % (HCMC) shared equipment in the previous month. Some had sex--and sold it--as children; most had multiple partners. Condom use was high with clients but very low with intimate partners, often injecting drug users. HIV knowledge was uneven, and large minorities were not tested recently (or ever) for HIV. Nearly all perceived intense gender-related stigma, especially for drug use. CONCLUSION: This ground-breaking study challenges assumptions about characteristics and risks based on anecdotal evidence and studies among men. Most WWID were vulnerable to sexual HIV transmission from intimate partners. Interventions should incorporate broader sociocultural context to protect this highly stigmatised population.

The impact of human immunodeficiency virus (HIV) service scale-up on mechanisms of accountability in Zambian primary health centres: a case-based health systems analysis.

BACKGROUND: Questions about the impact of large donor-funded HIV interventions on low- and middle-income countries' health systems have been the subject of a number of expert commentaries, but comparatively few empirical research studies. Aimed at addressing a particular evidence gap vis-à-vis the influence of HIV service scale-up on micro-level health systems, this article examines the impact of HIV scale-up on mechanisms of accountability in Zambian primary health facilities. METHODS: Guided by the Mechanisms of Effect framework and Brinkerhoff's work on accountability, we conducted an in-depth multi-case study to examine how HIV services influenced mechanisms of administrative and social accountability in four Zambian primary health centres. Sites were selected for established (over 3 yrs) antiretroviral therapy (ART) services and urban, peri-urban and rural characteristics. Case data included provider interviews (60); patient interviews (180); direct observation of facility operations (2 wks/centre) and key informant interviews (14). RESULTS: Resource-intensive investment in HIV services contributed to some early gains in administrative answerability within the four ART departments, helping to establish the material capabilities necessary to deliver and monitor service delivery. Simultaneous investment in external supervision and professional development helped to promote transparency around individual and team performance and also strengthened positive work norms in the ART departments. In the wider health centres, however, mechanisms of administrative accountability remained weak, hindered by poor data collection and under capacitated leadership. Substantive gains in social accountability were also elusive as HIV scale-up did little to address deeply rooted information and power asymmetries in the wider facilities. CONCLUSIONS: Short terms gains in primary-level service accountability may arise from investment in health system hardware. However, sustained improvements in service quality and responsiveness arising from genuine improvements in social and administrative accountability require greater understanding of, and investment in changing, the power relations, work norms, leadership and disciplinary mechanisms that shape these micro-level health systems.

Harm reduction and law enforcement in Vietnam: influences on street policing.

BACKGROUND AND RATIONALE: The HIV epidemic in Vietnam has from its start been concentrated among injecting drug users. Vietnam instituted the 2006 HIV/AIDS Law which includes comprehensive harm reduction measures, but these are unevenly accepted and inadequately implemented. Ward police are a major determinant of risk for IDUs, required to participate in drug control practices (especially meeting quotas for detention centres) which impede support for harm reduction. We studied influences on ward level police regarding harm reduction in Hanoi to learn how to better target education and structural change. METHODS: After document review, we interviewed informants from government, NGOs, INGOs, multilateral agencies, and police, using semi-structured guides. Topics covered included perceptions of harm reduction and the police role in drug law enforcement, and harm reduction training and advocacy among police. RESULTS: Police perceive conflicting responsibilities, but overwhelmingly see their responsibility as enforcing drug laws, identifying and knowing drug users, and selecting those for compulsory detention. Harm reduction training was very patchy, ward police not being seen as important to it; and understanding of harm reduction was limited, tending to reflect drug control priorities. Justification for methadone was as much crime prevention as HIV prevention.Competing pressures on ward police create much anxiety, with performance measures based around drug control; recourse to detention resolves competing pressures more safely. There is much recognition of the importance of discretion, and much use of it to maintain good social order. Policy dissemination approaches within the law enforcement sector were inconsistent, with little communication about harm reduction programs or approaches, and an unfounded assumption that training at senior levels would naturally reach to the street. DISCUSSION: Ward police have not been systematically included in harm reduction advocacy or training strategies to support or operationalise legalised harm reduction interventions. The practices of street police challenge harm reduction policies, entirely understandably given the competing pressures on them. For harm reduction to be effective in Vietnam, it is essential that the ambiguities and contradictions between laws to control HIV and to control drugs be resolved for the street-level police.

Smoking among Lao medical doctors: challenges and opportunities for tobacco control.

BACKGROUND: Smoking is an increasing threat to health in low-income and middle-income countries and doctors are recognised as important role models in anti-smoking campaigns. OBJECTIVES: The study aimed to identify the smoking prevalence of medical doctors in Laos, their tobacco-related knowledge and attitudes, and their involvement in and capacity for tobacco prevention and control efforts. METHODS: This was a cross-sectional national survey by a researcher-administered, face-to-face questionnaire implemented at provincial health facilities throughout the central (including national capital), northern and southern regions of Laos in 2007. Both descriptive and inferential statistics were used. RESULTS: Of the 855 participants surveyed, 9.2% were current smokers and 18.4% were ex-smokers; smoking was least common in the central region (p<0.05) and far more prevalent in males (17.3% vs 0.4%; p<0.001). Smoking was concentrated among older doctors (p <0.001). Over 84% of current smokers wanted to quit, and 74.7% had made a recent serious attempt to do so. Doctors had excellent knowledge and positive attitudes to tobacco control, although smokers were relatively less knowledgeable and positive on some items. While 78% of doctors were engaged in cessation support, just 24% had been trained to do so, and a mere 8.8% considered themselves 'well prepared'. CONCLUSION: The willingness of doctors to take up their tobacco control role and the lower smoking rates among younger respondents offers an important window of opportunity to consolidate their knowledge, attitudes, skills and enthusiasm as cessation advocates and supports.

Medical students' perspectives on gender and smoking: a mixed methodology investigation in Karachi, Pakistan.

OBJECTIVE: To explore the gender dimensions on influences of tobacco uptake on medical students using both qualitative and quantitative methods. METHODS: A phased mixed-method study design was used with in-depth interviews followed by a survey questionnaire in a 'smoke-free' medical college campus in a private university of Karachi. Eight in-depth interviews were conducted to under-pin themes that were further used for developing the questionnaire. Tabulation and analysis of the quantitative data was done using SPSS software version 12. All the ethical issues for the research were taken into consideration. RESULTS: One hundred and sixty-five (72 male, 93 female) students participated in the study. Mean age was 21.57 +/- 1.66 years. The survey results reported perceived reasons for male smoking as stress relief (74%), image (62%), companionship (54%), leisurely independence (46%) and male power and masculinity (44%). Among reasons for women for not smoking by the majority was that it was frowned upon (87%) while the reasons for smoking clustered around concepts of images (65%), western culture (66%), stress relief (51%) and advertising (36%). A large proportion (55%) of students felt bad and bothered by male and female smoking. CONCLUSION: Despite being medical students, the anti-tobacco future role models, traditional concepts of gender were frequently involved that explains smoking and non-smoking gendered behaviours.

Rural-to-urban male migrant workers' vulnerability to HIV infection in Chengdu, China: qualitative findings from a mixed-method study.

OBJECTIVE: This paper aimed to assess rural-to-urban male migrant workers' HIV vulnerability and prevention needs in a Chinese context, specifically in the city of Chengdu, capital of the south-western province of Sichuan. PARTICIPANTS: The primary sample group were 23 male migrant workers recruited from textile factories and construction sites. In addition, a total of 16 key informants (e.g., factory managers, healthcare providers and policy makers) and seven community members participated in the qualitative phase. METHODS: Qualitative methods included semi-structured interviews with male migrant workers and key informants, focus group discussions with migrant workers and local community members, observation, and review of key policy and programmatic documents related to HIV prevention and/or migrant workers. RESULTS: Findings highlight migrant workers' vulnerability to HIV for a variety of reasons. Their migrant status rendered them economically marginalised and socially isolated. HIV knowledge was poor and discriminatory attitudes towards infected people commonplace. Perceptions of personal HIV risk were low, even though study participants reportedly engaged in sexual behaviours that placed them at risk of infection. CONCLUSIONS: A number of interrelated factors contributed to male rural-to-urban migrant workers' vulnerability to HIV infection. Targeted HIV prevention programs for male migrant workers in Chengdu are urgently needed.

Gender equity and tobacco control: bringing masculinity into focus.

Gender is a key but often overlooked--determinant of tobacco use, especially in Asia, where sex-linked differences in prevalence rates are very large. In this article we draw upon existing data to consider the implications of these patterns for gender equity and propose approaches to redress inequity through gender-sensitive tobacco control activities. International evidence demonstrates that, in many societies, risk behaviours (including tobacco use) are practised substantially more by men and boys, and are also viewed as expressions of masculine identity. While gender equity focuses almost exclusively on the relative disadvantage of girls and women that exists in most societies, disproportionate male use of tobacco has profound negative consequences for men (as users) and for women (nonusers). Surprisingly, health promotion and tobacco control literature rarely focus on the role of gender in health risks among boys and men. However, tobacco industry marketing has masterfully incorporated gender norms, and also other important cultural values, to ensure its symbols are context-specific. By addressing gender-specific risks within the local cultural context--as countries are enjoined to do within the Framework Convention's Guiding Principles--it may be possible to accelerate the impact of mechanisms such as tobacco pricing, restrictions on marketing, smoking bans and provision of accurate information. It is essential that we construct a new research-to-policy framework for gender-sensitive tobacco control. Successful control of tobacco can only be strengthened by bringing males, and the concept of gender as social construction, back into our research and discussion on health and gender equity.

The political economy of tobacco and poverty alleviation in Southeast Asia: contradictions in the role of the state.

Of the members of the Association of Southeast Asian Nations (ASEAN), all but Indonesia have embraced the Framework Convention on Tobacco Control and all endorse some form of tobacco control policy. Nevertheless, except for Brunei, all these states are, to varying degrees, complicit in investing in or promoting the tobacco industry, often using the justification of poverty alleviation. Tobacco use is the major preventable cause of illness and death among the populations of these countries. Claims that tobacco alleviates poverty in developing countries have increasingly been discredited: thus continuing state support for the industry represents a fundamental paradox. Using primary documents from governments and the tobacco industry, and published studies investigating tobacco and poverty, this article explores the contradictions inherent in the state seeking to prevent tobacco use in the interests of health, while actively promoting tobacco for the economic benefit of its citizens. These contradictions result in both symbolic and substantial harm to tobacco control efforts: tobacco production is legitimized, rational policy principles are violated, direct cooperation between the state and multinational tobacco corporations is made possible with associated opportunities for mollifying control policies, and different state agencies work at cross purposes. Although tobacco exports within the Association of Southeast Asian Nations (ASEAN) also threaten the group's health solidarity, it is argued that divestiture of state ownership of capital in tobacco corporations and a commitment by states not to promote tobacco are urgently required if the Convention is to have full effect both in the countries of the region and in other states that have ratified it.

Pathways to malaria persistence in remote central Vietnam: a mixed-method study of health care and the community.

BACKGROUND: There is increasing interest in underlying socio-cultural, economic, environmental and health-system influences on the persistence of malaria. Vietnam is a Mekong regional 'success story' after dramatic declines in malaria incidence following introduction of a national control program providing free bed-nets, diagnosis and treatment. Malaria has largely retreated to pockets near international borders in central Vietnam, where it remains a burden particularly among impoverished ethnic minorities. In these areas commune and village health workers are lynchpins of the program. This study in the central province of Quang Tri aimed to contribute to more effective malaria control in Vietnam by documenting the non-biological pathways to malaria persistence in two districts. METHODS: Multiple and mixed (qualitative and quantitative) methods were used. The formative stage comprised community meetings, observation of bed-net use, and focus group discussions and semi-structured interviews with health managers, providers and community. Formative results were used to guide development of tools for the assessment stage, which included a provider quiz, structured surveys with 160 community members and 16 village health workers, and quality check of microscopy facilities and health records at district and commune levels. Descriptive statistics and chi-square analysis were used for quantitative data. RESULTS: The study's key findings were the inadequacy of bed-nets (only 45% of households were fully covered) and sub-optimal diagnosis and treatment at local levels. Bed-net insufficiencies were exacerbated by customary sleeping patterns and population mobility. While care at district level seemed good, about a third of patients reportedly self-discharged early and many were lost to follow-up. Commune and village data suggested that approximately half of febrile patients were treated presumptively, and 10 village health workers did not carry artesunate to treat the potentially deadly and common P. falciparum malaria. Some staff lacked diagnostic skills, time for duties, and quality microscopy equipment. A few gaps were found in community knowledge and reported behaviours. CONCLUSION: Malaria control cannot be achieved through community education alone in this region. Whilst appropriate awareness-raising is needed, it is most urgent to address weaknesses at systems level, including bed-net distribution, health provider staffing and skills, as well as equipment and supplies.

Smoking among future doctors in a "no-smoking" university campus in Karachi, Pakistan: issues of tobacco control.

OBJECTIVE: To determine the level of tobacco-related attitudes and practices among medical students who study in a designated 'No-Smoking University' in Pakistan's largest city, Karachi. It further highlighted some challenges for tobacco control at the university. METHODS: The study design adopted mixed methods. It commenced with an initial qualitative phase using in-depth interviews with medical students and university staff to refine and expand areas of enquiry for the development of a structured cross-sectional survey among second and fifth (final) year students. Thematic analysis was used to analyse qualitative data, while descriptive statistics and various statistical tests were applied to investigate differences along a number of parameters in the survey data. RESULTS: Overall smoking prevalence across both years was 14.5%; however, there was a sharp disparity along sex lines, with 32% of males and just 1% of females self-identifying as current or occasional smokers. Importantly, the majority of smokers initiated smoking after starting their medical education. Despite students' expressed expectations that they can and should be future non-smoking role models and advocates, their actual knowledge and practices - for males at least - were disappointing. Significantly fewer second year than final year students knew that Hamdard had been designated a 'No-Smoking University', and about half of the participants believed the university had 'effectively' controlled tobacco use on campus. A large majority supported stronger tobacco control measures at the university and in the wider society. CONCLUSION: This study highlights weaknesses in the measures taken for tobacco control on the university campus through the picture it provides of the presence of tobacco use, the on-campus initiation of smoking and the increase in smoking rates among final year students by comparison to those in the initial years of medical studies.

Long term efficacy of DOTS regimens for tuberculosis: systematic review.

OBJECTIVE: To identify published studies assessing tuberculosis recurrence after successful treatment with standard short course regimens for six months to determine the strength and sufficiency of evidence to support current guidelines. DESIGN: Systematic review. DATA SOURCES: Medline, Embase, Cochrane clinical trials register, specialist tuberculosis journals, and reference lists. Only English language publications were eligible. REVIEW METHODS: Studies were included irrespective of methodology or quality. Abstracted information included inclusion and exclusion criteria for participants, duration of follow-up, and definitions of treatment success and disease recurrence. The primary outcome was the proportion of successfully treated patients recorded with recurrent tuberculosis during the follow-up period. RESULTS: 17 study arms from 16 studies met the inclusion criteria; 10 were controlled clinical trials and six were either studies done under programmatic conditions or observational studies from functioning tuberculosis programmes. Although several clinical trials supported the use of daily treatment regimens, studies reporting tuberculosis recurrence after intermittent regimens were limited. Few studies carried out under routine programmatic conditions reported disease recurrence. Overall there was wide variation in recurrence after successful treatment, ranging from 0% to 14%. Considerable heterogeneity across studies precluded the systematic assessment of factors contributing to tuberculosis recurrence. CONCLUSIONS: Despite DOTS (directly observed treatment, short course) being implemented for more than 10 years and millions of patients treated for tuberculosis, few studies have assessed the ability of standard DOTS regimens to result in lasting cure for patients treated under routine programmatic conditions.

A grim contradiction: the practice and consequences of corporate social responsibility by British American Tobacco in Malaysia.

In the wake of the World Health Organization Framework Convention on Tobacco Control, corporate social responsibility (CSR) is among the few remaining mechanisms for tobacco corporations publicly to promote their interests. Health advocates may be unaware of the scale, nature and implications of tobacco industry CSR. This investigation aimed to construct a typology of tobacco industry CSR through a case study of the evolution and impact of CSR activities of a particular tobacco corporation in one country - British American Tobacco, Malaysia (BATM), the Malaysian market leader. Methods included searching, compiling and critically appraising publicly available materials from British American Tobacco, BATM, published literature and other sources. The study examined BATM's CSR strategy, the issues which it raises, consequences for tobacco control and potential responses by health advocates. The investigation found that BATM's CSR activities included assistance to tobacco growers, charitable donations, scholarships, involvement in anti-smuggling measures, 'youth smoking prevention' programs and annual Social Reports. BATM has stated that its model is predominantly motivated by social and stakeholder obligations. Its CSR activities have, however, had the additional benefits of contributing to a favourable image, deflecting criticism and establishing a modus vivendi with regulators that assists BATM's continued operations and profitability. It is imperative that health advocates highlight the potential conflicts inherent in such arrangements and develop strategies to address the concerns raised.

Fostering disability-inclusive HIV/AIDS programs in northeast India: a participatory study.

BACKGROUND: Manipur and Nagaland in northeast India are among the Indian states with the highest prevalence of HIV. Most prevention and care programs focus on identified "high risk" groups, but recent data suggest the epidemic is increasing among the general population, primarily through heterosexual sex. People with disability (PWD) in India are more likely than the general population to be illiterate, unemployed and impoverished, but little is known of their HIV risk. METHODS: This project aimed to enable HIV programs in Manipur and Nagaland to be more disability-inclusive. The objectives were to: explore HIV risk and risk perception in relation to PWD among HIV and disability programmers, and PWD themselves; identify HIV-related education and service needs and preferences of PWD; and utilise findings and stakeholder consultation to draft practical guidelines for inclusion of disability into HIV programming. Data were collected through a survey and several qualitative tools. RESULTS: The findings revealed that participants believe PWD in these states are potentially vulnerable to HIV transmission due to social exclusion and poverty, lack of knowledge, gender norms and obstacles to accessing HIV programs. Neither HIV nor disability organisations currently address the risks, needs and preferences of PWD. CONCLUSION: The Guidelines produced in the project and disseminated to stakeholders emphasise opportunities for taking action with minimal cost and resources, such as using the networks and expertise of both HIV and disability sectors, producing HIV material in a variety of formats, and promoting accessibility to mainstream HIV education and services. The human rights obligations and public health benefits of modifying national and state policies and programs to assist this highly disadvantaged population are also highlighted.

KAP surveys and malaria control in Vietnam: findings and cautions about community research.

The malaria disease burden is increasing in many countries despite the existence of effective preventative strategies and antimalarial drugs. An understanding of community perspectives and practices is one of the essential components of a successful malaria control program. This paper reports on a KAP (Knowledge, Attitudes and Practices) survey among the Raglai ethnic minority population in Ninh Thuan Province, Vietnam, which in 2003 had one of the country's highest confirmed rates of malaria. We found high levels of correct knowledge about malaria's transmission and symptoms, and self-reports of adequate bed net usage and appropriate health-seeking behavior. While the survey generated useful findings, an initial, qualitative investigation (eg, observation and focus group discussions) to explore the large numbers of potential influences on behavior and exposure risk would have provided a more robust underpinning for the design of survey questions. This would have strengthened its validity and generated additional information. The adoption of rigorous, multi-disciplinary research methods offers the best chance of contributing to the development of successful malaria control programs and effective policies.

Tobacco control and gender in south-east Asia. Part II: Singapore and Vietnam.

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.

Tobacco control and gender in Southeast Asia. Part I: Malaysia and the Philippines.

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 discusses issues surrounding gender and tobacco, and analyses developments in Malaysia and the Philippines. Part II deals with Singapore and Vietnam. In all four countries, gender was salient for the initiation and maintenance of smoking, and in Malaysia and the Philippines was highly significant in cigarette promotion. 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 in Part II.

Smoking and young women in Vietnam: the influence of normative gender roles.

Smoking in Vietnam, as elsewhere in Asia, is strongly sex-linked. A 1997 national prevalence survey found about half of males but just 3.4% of females used tobacco regularly. Little is known about smoking-related health awareness or attitudes in Vietnam. There is concern that women may take up smoking if rapid social change brings alteration in traditional gender norms that discourage this behaviour. Effective tobacco control depends upon accurate understanding of prevailing knowledge and views. This paper reports on a 1999-2000 collaborative study into smoking attitudes, practices and health awareness, with particular reference to gender norms. A survey, based partly on findings from initial focus groups, was administered to young female students (n = 1018) and factory workers (n = 1002) in Ho Chi Minh City, Vietnam's largest metropolis. Participants were recruited through random cluster sampling. Results indicated that smoking continues to be shunned by the vast majority of young urban students and factory workers, although prevalence was slightly higher than found in national surveys, and there was a moderate degree of experimentation. Perhaps of greater concern was the degree of ambivalence voiced about taking up smoking in the future. Moreover, while nearly all expressed awareness of negative health effects of tobacco, these were vaguely worded and excluded key mortality risks. Gender norms appeared to be strongly enduring, with female non-smoking attributed overwhelmingly to its 'inappropriateness'. Male smoking was seen as normative. Overall, workers (representing a low-income, less-educated population) had higher rates of tobacco use and less health knowledge than students. The paper concludes with a discussion about ramifications for public health interventions.