INTRODUCTION
Tobacco use is the leading preventable cause of death globally, responsible for over 8 million deaths annually1,2. More than 80% of smokers live in low- and middle-income countries (LMICs), where cessation services remain underdeveloped3. In Vietnam, 35.3% of adult men were current smokers in 2024 according to the Provincial Global Adult Tobacco Survey (PGATS), among the highest in South-East Asia4. The WHO Framework Convention on Tobacco Control (FCTC) Article 14 requires that cessation advice be systematically integrated into health systems1. Brief advice from health workers is highly cost-effective, raising quit success rates by 40%5 while other cessation supports such as pharmacotherapy and e-cigarettes are also effective6. Yet, coverage remains poor in LMICs: in China, only 29% of smokers reported advice7; in India and Indonesia, fewer than one-third received cessation support8,9. This reflects what has been described as the ‘prevention paradox’2, where systems respond reactively to older adults with comorbidities but miss younger smokers2, despite their greater long-term risk. Vietnam has strengthened tobacco control through taxation, smoke-free policies, and adoption of the WHO PEN package10. However, little is known about whether smokers receive cessation advice in practice, or whether advice is equitably distributed across groups, despite recent evidence on quit intentions and cessation behaviors in Vietnam11-14. Studies from Bangladesh15, China7, India8, and Indonesia9 suggest inequities by age, comorbidity, and socioeconomic status. This study, therefore, examined who receives quit advice in Vietnam, and whether advice is integrated with other forms of behavioral counseling.
METHODS
Study design and data source
This study is a secondary analysis of the 2021 Vietnam WHO STEPwise Approach to Surveillance (STEPS) survey, a nationally representative cross-sectional survey designed to assess noncommunicable disease (NCD) risk factors among adults aged 18–69 years. The STEPS survey follows a standardized WHO methodology consisting of three components: Step 1 (behavioral risk factor questionnaire), Step 2 (physical measurements), and Step 3 (biochemical assessments). Detailed STEPS protocols have been described elsewhere and were adhered to throughout data collection16.
Sampling and participants
A multistage, geographically clustered probability sampling design was used. In the first stage, clusters were selected proportional to population size. Households were sampled in the second stage, and one eligible adult was selected per household using the Kish method. A total of 4436 individuals completed Step 1. Data collection was carried out by trained field teams using standardized WHO instruments. Interviewers were trained centrally, and supervisors conducted routine quality checks. Measurement devices were calibrated daily WHO data-cleaning guidelines were followed prior to analysis.
For this analysis, we included respondents who were current smokers, defined as reporting daily or occasional smoking at the time of the survey (n=1086). All analyses used sampling weights provided by WHO to account for differential selection probabilities, nonresponse, and population structure.
Ethical approval
The Vietnam STEPS survey received ethical approval from the Ministry of Health Ethics Committee. All participants provided informed consent. This study involved analysis of publicly available, de-identified data and therefore did not require additional institutional review.
Measures
Primary outcomes included the receipt of cessation advice, defined as self-report of receiving advice from a healthcare provider to quit smoking within the past 12 months (yes, no) and the receipt of any behavioral counseling defined as reporting at least one type of lifestyle counseling in the past year, including advice on diet, salt reduction, physical activity, weight management, or sugary drink reduction.
Sociodemographic variables that were included were age (18–29, 30–49, and ≥50 years), sex (male, female), education level (none, primary, secondary, tertiary), and socioeconomic status (SES), defined as the WHO-derived asset-based wealth quintiles17, and residence (urban, rural).
Clinical and behavioral risk factors
All clinical measurements were collected following WHO STEPS protocols [ref missing] and included hypertension (systolic BP ≥140 mmHg, diastolic BP ≥90 mmHg, or current antihypertensive use), diabetes (fasting plasma glucose ≥126 mg/dL or self-reported diagnosis), high cholesterol (total cholesterol ≥200 mg/dL), alcohol use (any alcohol consumption in the past 30 days), as per the WHO and STEPS criteria18.
Statistical analysis
We calculated weighted prevalence estimates for cessation advice and behavioral counseling. Multivariable logistic regression was used to examine associations between sociodemographic/clinical factors and each outcome. Results are reported as adjusted odds ratios (AORs) with 95% confidence intervals (CIs). Models were adjusted for sex, age, SES, comorbidities, and alcohol use. Sampling weights and analyses accounted for the complex survey design and were performed using IBM SPSS version 29. A p<0.05 was considered statistically significant.
RESULTS
The analytic sample comprised 1086 smokers, predominantly men (98.7%). Nearly half were aged 30–49 years, 28% were 18–29 years, and 27% were ≥50 years. Nineteen percent reported hypertension, 11% diabetes, and 24% high cholesterol. Nearly 60% reported alcohol use (Table 1). Characteristics of current smokers in Vietnam 2021 STEPS (n=1086, weighted) shows that only 25.6% of smokers reported receiving quit advice. Prevalence was lowest among smokers aged 18–29 years (4%) and highest among those ≥50 years (43.9%). Advice was more common among those with hypertension or cholesterol, but less common among those with diabetes (Table 2). Prevalence of quit advice among smokers, by subgroup (n=1086, weighted) as shown in regression models, suggests that younger smokers had substantially lower odds of quit advice (AOR=0.04 for 18–29 vs ≥50 years). Hypertension (AOR=1.37; 95% CI: 1.36–1.38) and cholesterol (AOR=1.44; 95% CI: 1.43–1.45) increased odds, while diabetes was negatively associated (AOR=0.53; 95% CI: 0.53–0.54). Alcohol users were less likely to receive advice (AOR=0.83; 95% CI: 0.82–0.84). Primary education level was associated with higher odds than university level (AOR=3.27). SES quintiles showed no gradient (Table 3). When considering any behavioral advice, 40% of smokers reported some form, while 60% received none. Only 15% reported multiple types (Table 4). In regression models, men (AOR=2.15; 95% CI: 2.15–2.16), young smokers (AOR=2.17; 95% CI: 2.15–2.18), and smokers with comorbidities were more likely to receive any advice, with cholesterol the strongest predictor (AOR=3.96; 95% CI: 3.93–3.99). Alcohol users were slightly more likely to receive any advice (AOR=1.14; 95% CI: 1.13–1.14). Socioeconomic status (SES) quintiles showed no gradient (Table 4).
Table 1
Characteristics of current smokers in Vietnam, WHO STEPwise (STEPS) Survey 2021 (N=1086; weighted)
Table 2
Prevalence of tobacco-cessation advice received from healthcare providers among current smokers in Vietnam, WHO STEPwise (STEPS) Survey 2021 (N=1086; weighted)
Table 3
Adjusted logistic-regression predictors of receiving quit-smoking advice among current smokers in Vietnam, WHO STEPwise (STEPS) Survey 2021 (N=1086; weighted)
Table 4
Predictors of receiving any behavioral counseling among current smokers in Vietnam, WHO STEPwise (STEPS) Survey 2021 (N=1086; weighted)
DISCUSSION
This is one of the first national analyses of cessation advice in Vietnam, and the findings reveal a variably implemented system. Only one in four smokers reported receiving quit advice, a coverage level similar to that reported in China7, India8, and Indonesia9. A particularly concerning finding is the neglect of younger smokers. Those aged 18–29 years were 96% less likely to receive quit advice, despite being the group with the most to gain from early cessation. Qualitative research also indicates that Vietnamese men face structural and cultural barriers in accessing cessation support16, underscoring that weak system responsiveness17 compounds individual-level challenges. Similar neglect of youth has been observed in China7, India8, and Bangladesh15, reflecting a broader LMIC pattern of reactive rather than preventive counseling2. Comorbidity-driven counseling was inconsistent. Hypertension and cholesterol increased the odds of advice, but diabetes reduced the odds. This mirrors evidence from Bangladesh15 and stands in contrast to strong evidence that smoking worsens diabetes outcomes18. This gap suggests insufficient emphasis on tobacco in diabetes management protocols17,18. Alcohol–tobacco dual users were less likely to receive quit advice, despite clear evidence of synergistic risks19 and the high prevalence of dual use in South-East Asia20. Missing this group represents a blind spot for Vietnam’s NCD strategy. This blind spot is particularly concerning given that simulation models suggest comprehensive tobacco control in Vietnam21 could avert hundreds of thousands of deaths15. Finally, general behavioral advice (diet, exercise, weight) was more common than tobacco advice, particularly for younger smokers. This reflects a siloed approach inconsistent with WHO PEN5,10, which calls for integration of tobacco counseling into every NCD contact10,22. Unlike findings from the Global Adult Tobacco Survey that show wealthier smokers are more likely to receive advice in some LMICs22, we observed no SES gradient in Vietnam. This suggests a universal failure: cessation advice is inconsistently delivered across all groups, rich and poor alike. Policy implications could be that Vietnam must strengthen the implementation of FCTC Article 141,23. Quit advice should be universalized at every patient encounter. Younger smokers should be prioritized to prevent decades of harm5,24. Tobacco counseling should be integrated into all NCD counseling sessions, especially those addressing diet and exercise. Health workers require systematic training in brief advice22,25. Finally, dual users of alcohol and tobacco should be recognized as a high-priority group. Embedding brief cessation advice into all primarycare contacts is essential to align Vietnam’s health system with WHO FCTC Article 14.
Limitations
This analysis relied on self-reported data, which may introduce recall and social desirability bias. Residual confounding is possible, and the cross-sectional design limits causal inference. Nevertheless, findings are nationally representative and provide a benchmark for improving system responsiveness.
CONCLUSIONS
Vietnam’s health system delivers fragments of behavioral counseling, but too often omits the most important message: quit smoking. With only one in four smokers receiving cessation advice, and young adults and alcohol– tobacco dual users systematically neglected, the system is failing to meet its prevention mandate. To fulfil WHO FCTC Article 14 obligations and reduce the long-term tobacco burden, cessation advice must become a standard component of every primary care encounter. This requires not only integrating brief advice into all NCD services, but also training health workers and establishing accountability mechanisms to ensure delivery. Without decisive action, Vietnam risks perpetuating a fragmented response that leaves millions of smokers unsupported and undermines progress toward national and global tobacco control goals.
