Alcohol and Drinking Cultures in Vietnam: A Review

Abstract

Background

Epidemiological data suggest that national levels of alcohol consumption have increased rapidly in contemporary Vietnam; concomitantly, social and public health harms associated with alcohol use are on the rise.

Methods

Over the last decade, a research literature on alcohol use in Vietnam has begun to develop.

Results

A consideration of this literature indicates lines of analysis to be extended and gaps to be filled.

Conclusion

This synopsis provides an overview of the major trends that studies have addressed, evaluates the state of research to date, and suggests avenues for further research on alcohol use in this newly middle-income nation.

1. INTRODUCTION

Macroeconomic growth is typically framed as an important input to the improvement of living standards in low- and middle-income countries, but economic development is not necessarily an unqualified good from a public health standpoint. Research on alcohol use in low- and middle-income countries suggests that economic development tend to be associated with increased alcohol consumption, entailing a range of negative consequences for public health (Schmidt and Room, 2012). Vietnam furnishes an important case to study patterns of shifting alcohol use trends in a lower-middle-income country of the Global South. Vietnam’s experience with changing patterns of alcohol consumption have implications for settings with similar demographic, social, and economic characteristics; of course, the nation’s successes and failures will also be consequential for its substantial and increasing population, currently some 92.5 million citizens. Subpopulations that differ along axes of socioeconomic status, ethnic identity, gender, and rural or urban location are also important as cases for comparative analysis and in their own right.

Over the last thirty years, Vietnam has experienced rapid and comprehensive sociocultural change impelled by the transformation of a command economy to “a market economy with socialist orientation” that began in 1986. Previously dependent on subsidies and trade with member countries of the socialist bloc, Vietnam has become increasingly integrated into regional and global economies. Market liberalization, free trade, private ownership, the normalization of political relations with the United States, and the conversion of collectively held institutions to opportunities for private profit have contributed to rapid economic growth.

Economic reform has also brought a sea change in established frameworks for identity, behavior, and cultural practices. During the socialist period (1945–1986), access to money, private property, and basic consumer goods in Vietnam was limited by the high prevalence of poverty and the protocols of a state subsidy economy, not to mention decades of almost continuous armed conflict against foreign powers. In the early 1980s, Vietnam initiated a series of reforms aimed at reviving the declining economy; these measures have been widely apprised as a success. In Vietnam’s post-reform period, increased access to money, mobility, and commodities has radically changed consumption behavior. While the nation’s population remains concentrated in rural areas, rural-to-urban migration has become an increasingly significant trend, and Vietnam’s experience of urbanization has been among the most intense in Southeast Asia. An urban middle class has come into existence (c.f. King et al., 2008), and increasing socioeconomic inequity is replacing the former emphasis on egalitarianism.

Vietnam’s economic transition is understood to influence an array of behaviors and contexts that contribute to public health outcomes, including alcohol consumption. Within the last fifteen years, researchers have noted an alarming appreciation in rates of alcohol consumption in Vietnam, and have tended to interpret this trend as an epiphenomenon of increasing wealth and economic as well as social openness. Alcohol use is understood to contribute to Vietnam’s increasing national burden of chronic diseases (Hoy et al., 2013), as well as to other negative public health outcomes – driving after drinking, traffic crashes, injuries, intimate partner violence, and sexual risk-taking.

However, the research base on alcohol use in this national setting remains less than robust. The literature currently lacks topical breadth and has yet to deliver a comprehensive analysis or hypothesized causal model of Vietnam’s changing patterns of alcohol use. Limitations on knowledge limit opportunities for context-responsive policy setting and the development of effective public health interventions.

2. METHODS

Sources are drawn from two major disciplinary categories, social sciences and public health. Strategies for generating references differed by discipline, and methods used in retrieving sources from these two literatures reflect these distinctions.

2.1 Review of social science literature

To date, no book-length ethnography has addressed alcohol use in contemporary Vietnam, but references to the social and ritual use of alcohol commonly occur in anthropological and sociological accounts, as well as in a select number of historical sources. I reviewed approximately twenty-five recently published ethnographic monographs and other social scientific texts on diverse topics in contemporary Vietnam (2000-present), using search terms including “alcohol,” “drinking,” “beer,” “wine,” and “spirits”; this breadth reflected an attempt to capture episodic mentions of alcohol-related issues, given the unsystematic attention to these themes in the social science literature. I conducted a similar search in area-specific disciplinary journals.

2.2 Review of public health research literature

Within the last fifteen years, public health research on alcohol use and associated health risks in Vietnam has grown significantly and now comprises a thematically and methodologically broad literature that can be retrieved through more traditional keyword-based search methods. To identify these reports, I conducted a search of relevant research databases (PubMed, Google Scholar, AnthroSource, JSTOR, and ProQuest) for research articles, review articles, theses, and dissertations published in English during the period 2000–2015 that contain the search terms “Viet*” and “alcohol” in any field.

Publications were reviewed for content, methods, and implications. In the case of particularly comprehensive and highly rated research resources, I reviewed bibliographic references to identify additional relevant publications. Major findings and recommendations were abstracted and compiled for analysis. Review of the publication content supported the development of a literature review that summarizes major findings as well as an assessment of current state of research on alcohol use in a country where alcohol-related public health risks are believed to be rapidly increasing.

3. RESULTS

The major themes that emerged from the review of research include alcohol use, drinking culture, at-risk populations, drinking contexts, and alcohol-associated harms. In the following review, I summarize substantive findings in each of these areas, characterize the state of alcohol research to date, and conclude by suggesting potential directions for future investigation.

3.1 Alcohol use

Sources provided descriptive statistics on average per capita consumption, quantity/frequency of alcohol use, and rates of problematic consumption of alcohol among adults. The WHO’s 2014 Global Status Report on Alcohol suggested that average per capita consumption for adults who drank had almost doubled from 2003–2005 to 2008–2010, increasing from 3.8 to 6.6 liters of pure alcohol (inclusive of both recorded and unrecorded products; WHO, 2014). This rate is slightly above the global rate of per capita alcohol consumption per annum, which is estimated at 6.2 liters (WHO, 2014). Though WHO data indicate a dip in alcohol use rates in Vietnam during the postwar 1980s, a net increase of 28% was found between the early 1970s and 1996 (Kaljee et al., 2005). Studies using other measures found that median consumption among male rural alcohol users in one province of North Vietnam was 8.9 standard drinks per week; this study also found a 35% prevalence of problematic drinking among males surveyed (Giang et al., 2013). Per 2004 AUDIT data, the prevalence of problematic consumption nationally was 25.5% in men and 0.7% in women (Giang et al., 2005) – a gap between sexes that is considerably larger than those reported in other national settings (Giang et al., 2008).

However, national alcohol consumption may be substantially underestimated owing to the high prevalence of home-brewed alcohol (Healthcare Strategy and Policy Institute, 2006). Home brewing has long been practiced in Vietnamese communities. During the colonial era, the French administration’s imposition of a monopoly on alcohol production generated intense resentment and resistance in the form of legal appeals, clandestine alcohol manufacture, and violence (Peters, 2012; Sasges, 2012). Home alcohol production was evidently an important enough institution that in this way, it “withstood at least two attempts in the twentieth century by outside cultures to dismantle it” (Luu et al., 2014).

In 2007, sources estimated that private homes produced some 250 million liters of alcohol annually (Lâm, 2008). High rates of home alcohol production suggesting that drinking at home or in neighborhood/community settings may also represent a space where problematic use of alcohol should be studied, and that qualitative and quantitative research on the home production of alcohol might also be informative. Incidents of poisoning and fatalities associated with improperly prepared or adulterated alcohol have been reported in the last decade: From 2000–2008, 159 cases of poisoning by contaminated alcohol were reported nationally, with a case fatality rate of 21.4% (Lâm, 2008). A study by Lachenmeier et al. (2009) suggested that contaminants did not represent a significant threat to public health, but on the basis of their small sample, the authors called for further analyses of the quality of artisanal and commercial alcohol products. Given that injuries and even deaths associated with alcohol adulteration are frequently reported in Vietnamese media, such study might generate a better understanding of risks associated with home alcohol production.

3.2 Drinking culture(s)

To date, no published ethnographic monograph has focused exclusively on alcohol or drinking in Vietnam, or “drinking culture” associated with alcohol consumption patterns in different social locations of Vietnam (though see Phong, 2013). This lack is in part owing to the limitations on social science research in Vietnam --which has, for the most part, only been possible since the 1990s. However, discourse about alcohol’s connection to “culture” in Vietnam is fairly commonly recycled in the form of stereotypes, however: a perception that alcohol risk is almost exclusively limited to poor rural communities and ethnic minority groups (who are, virtually by definition, rural and poor) remains commonly held in Vietnam. This characterization tends to attribute alcoholism to poverty and vice versa – a version of the notorious “culture of poverty” formulation coined by anthropologist Oscar Lewis (1966).

However, the consumption of alcohol and its cultural associations are mentioned en passant with some regularity in the anthropological literature on ethnic majority and minority groups. For example, the early work of anthropologist Gerald Hickey (1964) contains numerous mentions of the uses of alcohol, wine, beer, and drinking, even though these terms do not appear in the index. This suggests that alcohol has slipped below the analytic radar of social scientists more preoccupied with the problematics of society, politics, and culture than the physical substances that help materially produce these abstractions (i.e., “culture”). In the post-reform period, alcohol has perhaps become so ubiquitous in everyday sociality that it may be said to be “hiding in plain sight” in the anthropological literature. It is frequently captured in ethnographic or quasi-ethnographic writing, though often with limited commentary or elaboration. For example, in his relatively early contribution to the ethnographic literature in postwar North Vietnam, David Craig (2002) writes of ritual drinking with the village authorities during fieldwork in the Red River Delta; though his ostensible subject matter was folk understandings of illness and medicine, he nonetheless describes features of local norms surrounding the use of alcohol to demonstrate both hospitality and masculinity. Therefore, the following discussion of drinking culture in Vietnam is meant as a synopsis of the somewhat impressionistic literature on alcohol, rather than a definitive claim regarding what “drinking culture” in Vietnam can be said to entail.

In Vietnam, like in many other societies, alcohol consumption is frequently represented in ambivalent terms, which simultaneously index the pleasures of sociable drinking alongside the regrettably human weaknesses associated with intoxication. Alcoholic beverages – beer, rice wine, liquor, and other intoxicants – are consumed during the observation of traditional national holidays such as the Lunar New Year; they also mark rites of passage such as weddings, housewarmings, funerals, and death anniversaries (ngày giỗ); increasingly, alcohol facilitates business transactions and everyday sociality. Despite the rising rates of alcohol consumption and associated public health problems in recent decades, the perception of drinking as a valued part of Vietnamese identity has yet to be denormalized. As many of the quantitative studies under review suggest, alcohol use and intoxication in Vietnamese society are expected, normalized, and sanctioned behaviors among male youth and adults. In the context of driving after drinking, for example, perceptions of potential harms associated with drinking are generally low; expectation of impunity is generally high (Nguyen, 2010a, 2010b). Sociocultural bias towards alcohol normalization may contribute to a generally limited awareness of alcohol’s potential effects on public health, with impacts including the underreporting of problematic alcohol use, under-diagnosis of problematic alcohol use in the health sector, and a failure by policymakers to attribute public health concerns such as intimate partner violence or accidents to alcohol use.

Domestic alcohol production in Vietnam has increased by 15 percent annually from 2006 to 2010 (Ngoc et al., 2012). Though imported beer and spirits are increasing their market share, also national and regional alcoholic beverages remain important. In cities and towns, domestic brands of beer, wine, and spirits are readily available, and include proprietary products like Saigon Beer, Can Tho Beer, 333 Beer, and Hanoi Vodka. Wine is also produced domestically, though to a rather limited extent. Small-scale production of rice-based alcohol is common in Vietnam, and takes place both in private households and in a more institutionalized fashion via communal production in specialized villages in rural areas (Lachenmeier et al., 2009). Informally manufactured product is frequently untaxed and therefore invisible in estimates of national consumption averages. While the most common preparation is alcohol made from fermented sticky rice (rượu nếp, rượư gạo), private families also produce “moonshine” from glutinous or regular rice (rượu đế¹). Somewhere between anonymously produced home brew and official brands are the numerous regionally famous brands of distilled liquor (ruou trắng), some of which are associated with a particular individual and may be produced from rice, corn, cassava, local water, and medicinal or other herbs. In the Central Highlands, an herb-infused rice wine called rưụu cấn is consumed with straws from ceramic cylinders at festive occasions. Commercial or home-produced medicinal spirits (rượu thuốc) are also a popular form of tonic beverage; one author suggests that according to traditional Chinese and Vietnamese medical principles, alcohol acts as a vehicle to convey medicinal substances into the bloodstream rapidly. As elsewhere in East Asia, preparations of alcohol containing snakes, scorpions, geckoes, and other fauna are consumed for their tonic properties.

Drinking is chiefly the province of men in Vietnam. In the humoral system that structures Vietnamese lay understandings of physical constitution and dietary practices, alcohol is considered to be a “hot” substance (Rydstrøm, 2004); and is understood to contribute to physical and emotional states (thin build, predisposition to thirstiness, skin eruptions; anger, impulsiveness, assertiveness) that are also considered “hot.” As a result, alcohol is understood to be tonic for male bodies, which are essentially “hot” and less salutary for the female constitution, which is essentially “cold” (Craig, 2002). The social expectation that men drink alcohol is also underscored by the saying “A man without spirits is like a flag without wind” (nam vô tửu như kỳ vô phong). Composed in Sino-Vietnamese instead of everyday language, this locution nods to a sensibility that dignifies and celebrates the association of masculinity with drinking.

As Craig (2002) suggests, a number of standard features structure collective consumption of alcohol by Vietnamese men: the requirement for drinkers to down shots of liquor in tandem (a practice called trăm phấn trăm, or “a hundred percent”), and the tone of peer pressure that often inflects the sharing of alcohol with male foreign visitors. Craig also reflects the common understanding that intoxicated celebrants tend to bọc phét, or speak in a self-aggrandizing, teasing, or ridiculous fashion. Drinkers themselves understand this as part of alcohol’s social significance in Vietnam, insofar as it permits a “time out” period (MacAndrew and Edgerton, 1969) where social hierarchies can be temporarily leveled. The common saying “With liquor in, talk comes out” (rượu vào, lời ra) suggests both the social quality of drinking and the tendency of alcohol to generate grandstanding and braggadocio; the significance of this saying is the opposite of “in vino veritas.” In my own experience, people sharing drinks are more likely to repeat the couplet “Not drunk, not going home” (không say, không về), as when pressing their fellow drinkers to keep it up or, more subtly, acknowledging the customary pressure to drink to intoxication. Australian anthropologist Philip Taylor (2001) has also commented on the use of alcohol to shore up social relations and smooth over potential interpersonal and intergroup difficulties.

The doctoral dissertation of sociologist Vu Hong Phong (2013) elaborates on this insight regarding the prosocial use of alcohol under conditions of social change, demonstrating how drinking cultures in Vietnam’s Northwest indicates the utility of drinking to build social capital in a newly multi-ethnic community. Phong argues that “heavy drinking reflects local tactics to maintain harmonious relationships as well as sources of support” (2013) between male members of the more recently settled Kinh majority group and the Muong “minority” group (who are in fact a numeric majority in Muong Khen, Phong’s field site). Demonstrating the pragmatic use of alcohol in the formation and stabilization of social relations, Phong debunks the highly prevalent construction of problematic use of alcohol as an “ethnic minority problem,” and reveals how drinking is part of a strategy for adapting to a community that is in the process of becoming more ethnically diverse:

Ha was optimistic about Kinh and Muong relationships, despite the fact that many Muong still considered the Kinh ‘cunning’ and many Kinh still considered the Muong ‘backward.’ He asserted that Kinh and Muong shared the same ancestors and that Kinh and Muong cultures were similar. (…) Especially, he believed that interethnic drinking could help Kinh and Muong express ‘true feelings’ for each other and overcome stereotypes and misunderstandings:

“Through drinking, we share our true feelings about each other. Therefore, we understand each other better. Without alcohol, some people may be shy and quiet. With alcohol, they can talk without hesitancies.” (Muong man, 62 years old) [Phong, 2013]

The use of alcohol to shore up social relations between men is also noted by Nguyễn-võ Thu-hương (2008) and Kimberly Kay Hoang (2014), whose research on the rise of commercial sex in the post-reform period argues that a significant share of the nation’s new wealth has depended on deals brokered over drinks by private-sector businessmen and Communist Party cadres. Business drinking is, in the account of these ethnographers, facilitated by the sexualized labor of bar hostesses, who serve alcohol to groups of male drinkers in an ambiance of cosmopolitan elegance and conspicuous consumption.

Normative alcohol use expectancies and related behaviors among Vietnamese men – such as heavy drinking, peer approval of intoxication, drinking as part of professional networking and career advancement, and a perception of alcohol as an essential prerogative of masculinity – might be assumed to entail high rates of gender-based violence, including intimate partner violence and sexual assault targeting women. This issue has received relatively little attention in the literature on alcohol (though see Tran et al., 2012 and Fisher et al., 2012). However, the association between masculinity, alcohol, and violence against women is hinted at in anthropological analyses of gender in Vietnam, as in the following passage in Tine Gammeltoft’s ethnographic study of reproductive decision-making in North Vietnam:

Nhị is one of the unlucky women who have married men who are lazy workers and drink or gamble the family’s money away: “Whenever there are conflicts in the family, the husband has the power, no matter what the wife says, he still only scolds her, beats her. (…) You don’t want to work anymore, so the family’s finances deteriorate. The more the family finances deteriorate, the worse relations between husband and wife will be, and this often leads to beatings and fights.” [Gammeltoft, 1999]

More subtle than physical violence are the political and economic privileges that are widely acknowledged as the right of male members of a neo-Confucian household; men understand special rights as permission to drink and entertain themselves as they see fit:

Stephen O’Harrow (1995) writes that in Vietnam the height of machismo seems to be ‘a gentlemanly idleness’ at women’s expense. An old folksong goes like this: ‘Drinking and gambling till you’re on over your head/But even if you are out of money, your kid’s mother is still out there selling her wares.’ [Gammeltoft, 1999]

Clearly, to attribute these forms of gendered violence to “drinking culture” would be as problematic as an attribution to alcohol qua alcohol. The concept of “drinking culture” in Vietnamese settings, while potentially valuable, needs to be interrogated and clarified. Both quantitative and qualitative accounts of alcohol and drinking behavior have tended to treat “culture” as an independent variable having nebulous explanatory power of alcohol consumption trends. The concept of culture, and its articulation with macro-structural inputs such as economic factors, policy and enforcement, and alcohol availability, require more rigorous theorization. Culturalist accounts of marginalized ethnic and socioeconomic groups as susceptible to risky alcohol use, for example, demonstrate how two-dimensional constructions of “culture” lead to flat and static models of alcohol’s role in society, and underwrite prejudicial accounts of disempowered populations. Theories of culture’s role in shaping alcohol use should historicize culture critically and account for it as a dynamic process – not as a prescribed set of perceptions or behaviors that hold constant over time.

3.3 At-risk populations

As the previous section on drinking culture indicates, high prevalence of problematic drinking among Vietnamese men is a universal finding of the studies cited. A study using the AUDIT² in a rural district of North Vietnam found that 26.1 percent of the male population were at-risk, harmful, or dependent alcohol users (Giang et al., 2005); male medical students in Hanoi reported higher frequency of drinking, higher rates of binge drinking, and higher rates of alcohol-associated harms than their female counterparts (Pham et al., 2013). A study in Can Tho, a medium-size commercial city in the Mekong Delta, South Vietnam, found that 38.6 percent of men surveyed consumed five or more drinks on at least one day in the past week (Pham et al., 2009). A study of male traffic crash victims admitted to a hospital in central Vietnam found that 60.4 percent had blood alcohol levels in excess of legal limits (Nguyen et al., 2012).

As these findings indicate, problematic levels of male drinking are widespread in urban and rural areas as well as in both the North and South of Vietnam. However, these studies also suggest that the standardization of instruments and definitions of problematic alcohol use would increase researchers’ ability to analyze and compare trends among different populations, social groups, and regions. Research on alcohol consumption, based primarily in the United States, Canada, Australia, and Western Europe, has developed numerous approaches to quantifying alcohol consumption and qualifying alcohol use patterns, but whether these tools and methods are appropriate or meaningful in other national contexts is frequently unknown. Currently, the lack of nationally institutionalized definitions and standards for measurement in alcohol research in Vietnam challenges attempts at comparison between populations or time periods. Though Kim Bao Giang et al. (2008) provide a useful pilot study regarding the differential burden of problematic alcohol use across demographic groups in one rural district, the available literature does not clearly indicate trends of alcohol use or alcohol-related health risks at the scale of the nation. It is unclear whether particular socioeconomic groups, age groups, regional groups, or urban/rural populations are exposed to qualitatively and quantitatively different alcohol-related risks. Awareness of alcohol as a social and public health problem is generally believed to be low in Vietnam; while middle-class and urban individuals may also be at risk for alcohol-related problems, alcohol abuse and dependency is typically conceived of as a problem mostly affecting rural or ethnic minority populations. This perception surfaces in the ethnographic literature where Philip Taylor evokes the common cosmopolitan perception of the Mekong Delta. Dismayed that their Australian friend was planning a trip to what they considered a backwater, his colleagues at a university in Ho Chi Minh City warned him of the lack of cultural advancement in the Delta, where

…[B]inge drinking, low schooling, and prevalence of superstition (mê tín) were equally prevalent and linked with each other. Lack of schooling led to credulous minds, few work opportunities and, with opportunities foreclosed, a resort to alcoholism. [Taylor, 2001]

As Taylor alludes, this folk model of “drinking culture” in a rural area imputes a circular causation between poverty and alcohol use, and presumes high prevalence of alcohol abuse and dependency. However, despite the highly commonly held perspective that rural populations are more likely to be abusive or dependent drinkers, no published study indicates whether urban and rural populations in Vietnam have different risk profiles for problematic alcohol use.

Studies address alcohol use among Vietnamese adolescents and young adults (c.f. Pham et al., 2010; Nguyen et al., 2012; Pham et al., 2013), as investigators have attempted to discover whether young drinkers are at risk for associated harmful behaviors such as smoking and unsafe sex (Nguyen et al., 2012; Tho et al., 2007, Kaljee et al., 2005). This is a particularly significant research area given the relative youth of the national population. A relatively high rate of alcohol use is reported in youth below age 18: Phuong et al. (2013) found a prevalence of 15% of past-month alcohol use among surveyed students in grades 6, 7, 8 in Hanoi, a higher rate than previous studies identified. However, the literature on alcohol in Vietnam contains little analysis of the factors that influence alcohol initiation and the development of alcohol use patterns over the life course. Jordan et al. (2013) attempt to address the first gap in the literature with a study of alcohol use initiation among children aged 9, 10, and 11 in North Vietnam, concluding that “peer use is the most powerful explanatory measure of early adolescent drinking”; Nguyen et al. (2012) reach similar conclusions regarding cigarette smoking and drinking among adolescent rural-to-urban migrants. Kaljee et al. (2005) concur that “peer pressure and imitating peers” are important factors for adolescent boys initiating alcohol use. These studies indicate the potential of interventions targeting peer groups at an early age.

3.4 Drinking contexts

No studies in the articles sampled explicitly focus on the significance of drinking contexts, and as a result there is a lack of specific knowledge regarding where and in what social settings individuals are more likely to be at risk for problematic alcohol consumption. Some studies note that alcohol permeates public culture; with minimum drinking and purchase ages rarely enforced, alcohol is “widely available … and easily accessible” (Giang et al., 2013). No study has compared the risks associated with alcohol consumption in different social contexts or physical places. However, one study notes the proliferation of drinking venues in recent years, naming “the bia hoi (beer hall), café, or karaoke bar” (Nguyen et al., 2012) as spaces where young men have become increasingly likely to consume alcohol socially; Giang et al. (2008) note that alcohol “can be bought in any food or coffee shop”.

The ethnographic research of Nguyễn-võ Thu-hương (2008) has also suggested that since liberalization, after-hours drinking in bars and restaurants is a virtual job requirement for cadres in the public sector as well as private-sector professionals. This development in drinking patterns has a gendered aspect: as one of Nguyễn-võ’s respondents alludes, the venue of choice for this style of drinking is frequently a type of bar called bia ôm (literally, “hugging beer”), where hostesses also provide clientele with sexual services (Uhrig and Kauffman, 1996):

While showing me the nightlife at Restaurant XYZ, Tình attributed his expertise in these matters to the fact that every single one of his contracts had been signed in one of these ‘eat and play’ places. XYZ was a popular pickup point for businessmen and high-class taxi dancers out from the dance halls after twelve at night. Minh and Hằng, who had worked as bia ôm hostesses, said most of their customers were there for business, such as to sign contracts or pick up áp phe – money-making deals of all kinds, usually involving a commission.” [Nguyễn-võ, 2008]

Kimberly Hoang’s publications document the highly particularized, stratified landscape of nightlife venues in Ho Chi Minh City, demonstrating how bars and their patrons are segregated by socioeconomic status, race/ethnicity, and gender. Though alcohol consumption and drinking contexts are not an explicit focus of her work, Hoang’s ethnography reveals that it is inadequate to speculate about “Vietnamese drinking culture” or “Vietnamese bars,” given the diversity of the venues to which her fieldwork attested.

Hoang’s work also shows that the distinction between drinking venues and commercial sex venues may be porous, and not only because drinking among Vietnamese men has also been identified as an important predictor for visiting commercial sex workers (Thuy et al., 1999). Though not all women who work in bars and other nightlife establishments are commercial sex workers, Hoang notes (2011) that “mid-tier” sex workers in Ho Chi Minh City frequently work “in local bars disguised as bartenders,” whereas women able to command more cultural capital typically “hung out in high-end bars and lounges as bar-goers rather than as bar employees”. Emphasizing the status consciousness of the newly wealthy and the entanglement of this awareness with alcohol, one of the male Vietnamese clients that Hoang interviewed also suggested how conspicuous consumption of alcohol helps domestic elites display economic power:

In Paris, you know I could walk into a bar and drop over a thousand dollars and no one would notice. … Here in Saigon, it’s different. When I walk into a bar, the ten men at the door to greet me will walk me to my table. When I spend five hundred dollars on a good bottle of Remy, people notice it. The same happens with girls. … [W]hen other people see her with an expensive phone or handbag, it makes me look good. [Hoang, 2011]

3.5 Alcohol-associated harms

Though Vietnam’s national drinking patterns are not judged to be among the “most risky” by international comparison, they are among the most fatal: the 2014 WHO report gave Vietnam the highest possible score for alcohol-attributable years of life lost, a summary metric which encompasses liver cirrhosis, road traffic crashes, and the prevalence of alcohol use disorders and alcohol dependence (WHO, 2014). Patchiness in the data certainly obscures or conceals some of the public health burden associated with alcohol, but researchers’ efforts to read between the lines of official statistics discern that alcohol is a leading contributor to death and disability nationwide.

Drinking after driving is widely represented as an extremely common phenomenon in Vietnam, with contributing factors including the increasing motorization of society, lack of adequate public transportation in some areas, and a widespread failure to translate risk perceptions into safe practices (Tran et al., 2012). Road traffic injury is a leading cause of death and disability in Vietnam (Passmore and Nguyen, 2012). In 2011, over 17,000 road traffic injury deaths were reported, equivalent to a “mortality rate of 20.2 per 100,000 population” (Passmore and Nguyen, 2013). Official statistics attribute only 6.8% of traffic crashes to intoxicated driving (Giang et al., 2013), but other sources suggest that the prevalence of driving after drinking is much higher. Key findings include high rates of elevated BAC in motorists and the influence of structural factors that neither discourage driving after drinking nor facilitate safe and situationally viable transportation alternatives. One study suggested that “only 29 percent of study participants reported that they do not drink and drive” (Tran et al., 2012). A study of 26,518 road traffic injured patients at three hospitals revealed that 29.1% of drivers were above the permitted threshold for BAC³ (Passmore and Nguyen, 2012), but other studies have found even higher percentages of road traffic injured patients with BAC exceeding the legal limit (Passmore and Nguyen, 2013). T.M. Nguyen et al. found that 65% of their sample of hospitalized patients “tested positive for alcohol and 276 (57.5%) had a BAC over Vietnam’s legal limit of 80 mg/100mL; 219 (45.6%) of the injured patients had a BAC of 150 mg/100 mL or higher.” (Nguyen et al., 2010). In a case-crossover analysis including a sample of uninjured drivers, T.M. Nguyen (2010) found that 76.6% of male restaurant patrons had a BAC above the legal limit; both injured and uninjured respondents had erroneous perceptions of the amount of time required for BAC to return to safe levels, and most never planned to avoid driving after drinking.

Alcohol’s contribution to chronic disease (Minh et al. 2008, Hoy et al. 2013) is somewhat better documented than alcohol’s association with mental health concerns, which latter topic remains poorly studied across the board in Vietnam. The doctoral dissertation of Kim Bao Giang (2006) addresses both alcohol prevalence and mental distress in rural Vietnam, but does not draw conclusions regarding any association between these two types of risk. However, the finding of Thiem (2004) that the prevalence of alcohol-related psychoses increased substantially from the mid-1980s to the mid-1990s remains suggestive and in need of further investigation.

4. SUMMARY

As this review suggests, research on alcohol use in Vietnam in the past fifteen years reveals appreciating rates of per capita and national alcohol consumption, and indicates reason for concern regarding the current and future burden of alcohol-related harms, especially among men. It seems apparent that inputs to these phenomena are to be found at diverse social scales, from the global and regional to the levels of the locality, the household, and the individual. Economic, regulatory, social, and commercial factors are importantly influential in the reshaping of national drinking habits; sociocultural factors also shape alcohol consumption behaviors. However, there is still a lack of baseline data and in-depth analysis regarding numerous aspects of alcohol consumption in Vietnamese society. Trends in alcohol use, drinking contexts, at-risk populations, and alcohol-associated harms should motivate next steps in alcohol research and policy-setting in Vietnam. Ideally, future research will both seek to complete the knowledge base and put forward robust interdisciplinary analysis of the disparate issues that influence alcohol use trends. In the following sections, I make specific suggestions regarding potential directions for research on alcohol use in Vietnam.

4.1 Research Directions

As the above commentary suggests, it is imperative for quantitative researchers to continue documenting shifts in alcohol use trends in Vietnam going forward; quantitative research should also address the respective significance of diverse inputs to increasing alcohol consumption, identify groups that may be at disproportionate risk of alcohol-related harms, and ultimately offer findings that support evidence-based prevention strategies. There is also a need for well-designed qualitative and mixed methods studies to amplify understandings of alcohol’s uses in diverse Vietnamese communities. Community-based research on alcohol use could deliver deeper knowledge of the spaces, occasions, beverage types, and other factors that contribute to alcohol-associated harm; this knowledge could potentially inform preventive public health measures, interventions, and alcohol policy. Ideally, some qualitative or mixed-methods research will be scoped to include an analysis of the economic, policy, and other macro-structural inputs to drinking “culture.” Analysis of the role of alcohol tax revenues in the Vietnamese economy, the status of alcohol in recently promulgated policies of the Ministry of Health, and trends in alcoholic beverage imports and advertising would contribute to a clearer assessment of the place of alcohol in Vietnamese society in the post-transition period. As the next sections suggest, some topics that would benefit from continued investigation include gender, globalization (or “Westernization”), and institutional capacity for alcohol research.

4.1.1 Gender

To amplify and nuance understandings of the disparity between male and female drinking patterns and its effects in contemporary Vietnam, there is a need for studies focusing on the use of alcohol use to construct masculinity. All studies reviewed emphasize that drinking is a pressing public health concern among men of diverse ages and backgrounds in Vietnam, with very low rates of consumption reported among women. At this writing, then, the study of drinking in Vietnam implies the study of male sociality, spaces, and health, and research with an explicit focus on gender dynamics and ideologies could advance understandings of male drinking.

However, one study (Giang et al., 2013) found that “the prevalence of alcohol use among women was slightly higher than reported in earlier studies from Vietnam.” Both the changing patterns of alcohol use by women and the variation of consumption patterns by different groups of women might represent worthwhile themes for future research. At present, given the extremely low levels of alcohol consumption recorded among women to date, men are therefore are more likely to be exposed to the immediate physical consequences of drinking, and women or other non-drinkers such as dependent children may be at risk for secondary alcohol-associated harms. However, as norms and expectancies regarding gender roles and gendered behavior in the post-transition period shift, drinking patterns between men and women may converge, and women may also be at increasing risk for problematic alcohol use and alcohol-related harms. Future research may bear out this hypothesis.

4.1.2 Globalization/”Westernization“

The literature on alcohol use in Vietnam would benefit from a more systematic effort to contextualize national trends in a broader global and/or regional context. While situating Vietnam with respect to other East Asian or Southeast Asian countries would likely reveal interesting continuities and contrasts, a comparative analysis need not be bound strictly by geography. For example, increasing rates of problematic use of alcohol and alcohol-related harms in other post-socialist settings, particularly the countries of the former Soviet Union, has been associated with macroeconomic decline and the destabilization of political economic and cultural institutions (c.f. Treml, 1997). The extent to which macroeconomic shifts have affected alcohol use patterns in Vietnam (or China, which has followed a similar path of economic liberalization) remains unstudied.

Speculative and anecdotal associations between Vietnam’s new openness to international influence and alcohol use trends occurs in some of the literature. While this may indicate real trends that can be substantiated with evidence, these claims have yet to be demonstrated rigorously. For example, Nguyen et al., 2012 attribute increased alcohol use nationally to the “Westernization” of drinking patterns in the Vietnamese population:

With increasing exposure to international influences through a globalized media, greater international travel and communication, patterns and locations for drinking are evolving and, particularly among young Vietnamese, have become more Westernized. [Nguyen et al., 2012]

The influence of globalization on alcohol use trends is an intriguing issue, but one whose terms require clarification. Potentially, we might hypothesize that this trend references increasing youth consumption of alcohol, relaxation of traditional mores about alcohol and intoxication, and increasing alcohol use by women. It may potentially also reference increasing public awareness and policy consciousness of the harms associated with alcohol consumption. This issue and other trends that are time-dependent would be better understood via longitudinal analysis. While references to the appreciating use of alcohol in Vietnam are ubiquitous, the larger-scale factors that have structured change in the national epidemiology of alcohol use remains unresolved. The literature reviewed in this article is heavily reliant on cross-sectional data, which problematizes attempts to generalize, predict, or compare alcohol use trends over time. A large, nationally representative, and well-designed longitudinal study of drinking patterns over the coming decades – and/or over the life course of a study cohort – would represent a valuable contribution to the knowledge base regarding patterns of alcohol use in Vietnam.

4.1.3 Institutional capacity

A theme that emerges indirectly from this review is the capacity of existing public health and other institutions to study and generate interventions into the phenomena of alcohol consumption, problematic alcohol use, and alcohol-related harms. In Vietnam, the professionalization of fields such as clinical psychology and social work is still relatively nascent. Resources regarding the prevention, diagnosis, and treatment of substance use and dependency are not widely available. Though the Ministry of Health is drafting a National Policy on Alcohol-Related Harm Prevention and Control (Nguyen et al., 2012), state capacity for alcohol research and intervention development is limited; the government’s political will to address alcohol-related problems may also be compromised by conflict of interests. In other sectors, lack of institutional capacity may also mask the true extent of alcohol’s influence on public health. For example, Ngoc et al. (2012) suggest that given the limitations of protocol adherence and equipment, police data may underreport the problem of driving after drinking; additionally, they cite a 2008 study by Hanoi School of Public Health that found that hospitals reported 20 times more casualties from road crashes than the police over a given period.

More broadly, Nguyen et al. (2012) have suggested that progress towards effective alcohol policy in Vietnam is challenged by “vested interest in the government in alcohol manufacturing, a lack of appreciation of the evidence base, challenges imposed by free trade agreements and involvement of the alcohol industry in policy processes.” This suggests that multi-sectoral political and economic obstacles at the national level complicate the conversation on reforming alcohol policy and its enforcement. Further research on institutional capacity from local to national policy-setting circles could contribute to the development of methods and strategies appropriate to the national context. Further, as this review has emphasized, alcohol has been compartmentalized in explanatory frameworks that overemphasize merely its cultural or public health interest. Research addressing the institutional, policy, and economic aspects of alcohol in Vietnamese society will compel a more serious accounting of its significance.

Highlights for Review.

• I review recent research literature on alcohol use and drinking culture in Vietnam.

• Alcohol is a source of current and future health risk in transitional and developing countries.

• The sociocultural dynamics of alcohol use in Vietnam remain poorly understood

• Opportunities in alcohol research in Vietnamese communities are suggested.