Abstract

The article presents a review of Brazilian tobacco control policies from 1986 to 2016, based on contributions from political economics and analyses of public policies. The institutionalization of tobacco control in the country was marked by more general changes in health policies and by specific events related to the theme. Brazil’s international leadership role, a robust National Tobacco Control Policy, the role of civil society and the media all contributed to the success of tobacco control in this country. However, challenges remain regarding crop diversification in tobacco farms, illegal trade in cigarettes, pressure from the tobacco industry and the sustainability of the Policy. This study reinforces the importance of bearing in mind the relationship between the domestic and international context, and the articulation between different governmental and non-governmental sectors and players when analyzing complex health policies. Continuity and consolidation of the tobacco control policies depend on the persistence of a broad institutional framework to guide the State’s actions in social protection, in accordance with Unified Healthcare System guidelines.

National Tobacco Control Program; Tobacco; Public health policy

Introduction

There are 1.1 billion smokers worldwide¹1. U.S. National Cancer Institute, World Health Organization (WHO). The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph 21. NIH Publication No. 16-CA-8029A. Washington: U.S. National Cancer Institute, WHO; 2016., and about one third of all adults and half of all youth are regularly exposed to tobacco smoke¹1. U.S. National Cancer Institute, World Health Organization (WHO). The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph 21. NIH Publication No. 16-CA-8029A. Washington: U.S. National Cancer Institute, WHO; 2016.,²2. Oberg M, Woodwardb A, Jaakkolac MS, Perugad A, Prüss-Ustün A. Global estimate of the burden of disease from second-hand smoke. Geneva: WHO; 2010.. Estimates indicate that tobacco use is related to some 50 diseases³3. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General [Internet]. Atlanta: Centers for Disease Control and Prevention (US); 2014. (Reports of the Surgeon General). [acessado 2014 Dez 19]. Disponível em: http://www.ncbi.nlm.nih.gov/books/NBK179276/
http://www.ncbi.nlm.nih.gov/books/NBK179... and is responsible for as many as 6 million deaths each year¹1. U.S. National Cancer Institute, World Health Organization (WHO). The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph 21. NIH Publication No. 16-CA-8029A. Washington: U.S. National Cancer Institute, WHO; 2016.. Tobacco use costs about 1.8% of the annual global GDP each year¹1. U.S. National Cancer Institute, World Health Organization (WHO). The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph 21. NIH Publication No. 16-CA-8029A. Washington: U.S. National Cancer Institute, WHO; 2016., which is a major cause for concern, as are the environmental damages such as soil contamination, fires and deforestation⁴4. Guindon GE, Beyer J, Galbraith S. Framework convention on tobacco control: progress and implications for health and the environment. Environ Health Perspect 2003; 111(5):A262-A263.,⁵5. Riquinho DL, Hennington EA. Health, environment and working conditions in tobacco cultivation: a review of the literature. Cien Saude Colet 2012; 17(6):1587-600..

In the 2000s, governments increased and expanded public policies aimed at reducing the negative impacts of tobacco use⁶6. WHO Framework Convention on Tobacco Control. 2016 global progress report on implementation of the WHO Framework Convention on Tobacco Control. Geneva: WHO; 2016.. Brazil is an international reference in tobacco control, and has been implementing appropriate measures for more than three decades⁷7. Romero L, Costa e Silva V. 23 anos de controle do tabaco no Brasil: a Atualidade do Programa Nacional de Combate ao Fumo de 1988. Rev Bras Cancerol 2011; 57:305-314..

This article offers an assessment of thirty years of the Brazilian tobacco control policy - 1986 to 2016 -, and is based on economic policy references⁸8. Freeman R, Moran M. Reforming health care in Europe. West Eur Polit 2000; 23(2):35-58. , analyses of public policies⁹9. Buse K, Mays N, Walt G. Making health policy. 2nd ed. Maidenhead: Open Univ. Press; 2012. (Understanding public health).,¹⁰10. Ham C, Hill MJ. The policy process in the modern capitalist state. Harvester: Harvester Wheatsheaf; 1993. and in particular historical institutionalism¹¹11. Pierson P. Politics in Time: History, Institutions, and Social Analysis. Princeton: Princeton University Press; 2004.,¹²12. Mahoney J, Thelen KA, editors. Explaining institutional change: ambiguity, agency, and power. Cambridge: Cambridge University Press; 2010.. This study is predominantly qualitative and comprises a review of the literature, document analyses, secondary data base analyses, direct observation ofdomestic events and the Brazilian tobacco control policy, and semi-structured interviews with key policy players.

International Scenario: Framework Convention on Tobacco Control

The Framework Convention on Tobacco Control (FCTC) is the first international public health convention negotiated under the auspices of the World Health Organization (WHO)¹³13. World Health Organization (WHO). WHO Framework Convention on Tobacco Control. Geneva: WHO; 2003.. Adopted by consensus by the 56^thWorld Health Assembly in 2004, and effective as of 2005, the FCTC is binding on all 181 signatory states¹⁴14. World Health Organization (WHO). Parties to the WHO Framework Convention on Tobacco Control [Internet]. WHO. [acessado 2017 Out 30]. Disponível em: http://www.who.int/fctc/signatories_parties/en/
http://www.who.int/fctc/signatories_part... . The convention lists measures to reduce the supply and demand of tobacco, scientific and technical cooperation, environmental protection and legislative and legal measures to address criminal and civil liability¹³13. World Health Organization (WHO). WHO Framework Convention on Tobacco Control. Geneva: WHO; 2003.. Stricter implementation of the FCTC has been mentioned as one of the elements on the “2030 Agenda for Sustainable Development”¹⁵15. United Nations (UN). Transforming our world: the 2030 agenda for sustainable development. Resolution A/RES/70/1. New York: UN; 2015.

An assessment in 2016, based on data provided by the signatory states, shows that implementation of the FCTC addressed primarily protection against exposure to tobacco smoke (mentioned by 88% of the signatory states), followed by measures related to packaging and labeling of tobacco products and their sale by and to minors (mentioned by 76% and 71% of the signatory states respectively). However, reports show limited adhesion to some of the FCTC measures, in particular those related to criminal and civil liability (30%). Support and economically feasible options for those who grow, process or sell tobacco were the least mentioned by the signatory states (15%). 87% of the signatory states in the Americas mentioned measures focused on illegal trade in cigarettes and research, surveillance and exchange of information. In all signatory states, support for alternative activities that are economically feasible was the measure cited less frequently - only 13% of the countries in the Americas (Figure 1).

Brazil has played a key role since the start of FCTC negotiations. As a developing nation with a robust tobacco control program already in place, Brazil was made Vice-President of the Working Group open to WHO member states, which prepared the first draft of the convention. In addition to presiding the FCTC Intergovernmental Negotiation Body, Brazil led the working group that prepared the first Conference of Parties, which comprised all states that signed the convention that serves as a guideline for the Secretariat work, and negotiates the bases for implementing the convention at biannual meetings¹⁶16. Saldanha PMC. Convenção do Tabaco na OMS: gênese e papel da presidência brasileira nas negociações. Brasília: FUNAG; 2015.. Brazil remained an international leader for tobacco control in subsequent years, and in 2014 a Brazilian was appointed to head the FCTC Secretariat.

Institutionalizing tobacco control in Brazil

Implementation of tobacco control measures is uneven across countries, and in this regard, Brazil has one of the most advanced policies in the world¹⁷17. World Health Organization (WHO). WHO report on the global tobacco epidemic, 2017: monitoring tobacco use and prevention policies. Geneva: WHO; 2017.,¹⁸18. Portes LH, Machado CV. Convenção-Quadro para o Controle do Tabaco: adesão e implantação na América Latina. Rev Panam Salud Pública 2015; 38(5):370-379.. Brazil is an international reference in tobacco control, and one of the first countries to regulate the description, content and emissions of tobacco products, placing graphic warning images on cigarette packs¹⁹19. Lee K, Chagas LC, Novotny TE. Brazil and the framework convention on tobacco control: global health diplomacy as soft power. PLoS Med 2010; 7(4):e1000232..

From the perspective of economic policy, which considers three dimensions of healthcare policy - social protection, economics and power²⁰20. Freeman R, Moran M. Reforming Health Care in Europe. In: Ferrera M, Rhodes M, editors. Recasting European Welfare States. London: Frank Cass; 2000. p. 34-57. - it is worth pointing out that tobacco control is a complex issue that involves different organizations, strategies, players and interests (Figure 2).

The first movement to control tobacco use in the country started inthe 1960s, with debates on tobacco-related diseases²¹21. Teixeira L, Jaques T. Legislação e Controle do Tabaco no Brasil entre o Final do Século XX e Início do XXI. Revista Brasileira de Cancerologia 2011; 57(3):295-304.. In subsequent efforts, some states focused on implementing activities to control smoking, and organized national events focused on tobacco control as a major policy (1979: “Salvador Letter” and the “National Program Against Smoking”; 1980: “1^st Brazilian Conference toFight Tobacco Use”; 1985: creation of the “Advisory Group of the Ministryof Health for Tobacco Controlin Brazil”)⁷7. Romero L, Costa e Silva V. 23 anos de controle do tabaco no Brasil: a Atualidade do Programa Nacional de Combate ao Fumo de 1988. Rev Bras Cancerol 2011; 57:305-314.,²²22. Rosemberg J. Tabagismo sério problema de saúde pública. 2a ed. São Paulo: Almed; 1987..

Ever since, tobacco control has been embedded in Brazil and marked by more general changes in health policies and specific events related to the theme (Figure 3). The first milestone we point out came in 1986, when the National Program to Fight Smoking (NPFS or PNCF in Portuguese) was created, becoming the guidelines for Federal tobacco control measures when a “Advisory Group” was created. The NPFS is under shared management of the Ministry of Health and the Brazilian Social Security’s National Institute for Medical Care²³23. Costa e Silva R. Programa Nacional de Combate ao Fumo: plano de trabalho para o período 1988-2000. Rev Bras Cancerol 1988; 34(4):245-254..

The 1988 Federal Constitution²⁴24. Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out.was important for tobacco control in the country, and was used to justify subsequent anti-tobacco laws²¹21. Teixeira L, Jaques T. Legislação e Controle do Tabaco no Brasil entre o Final do Século XX e Início do XXI. Revista Brasileira de Cancerologia 2011; 57(3):295-304.. The concept of health as a right of all and duty of the State, and the development of the Unified Health System (SUS) are important backdrops for developing measures to prevent tobacco use and help people stop smoking. The SUS is detailed in the Organic Health Law²⁵25. Brasil. Lei 8.142, de 28 de dezembro de 1990. Dispõe sobre a participação da comunidade na gestão do Sistema Único de Saúde (SUS) e sobre as transferências intergovernamentais de recursos financeiros na área da saúde e dá outras providências. Diário Oficial da União 1990; 31 dez.,²⁵25. Brasil. Lei 8.142, de 28 de dezembro de 1990. Dispõe sobre a participação da comunidade na gestão do Sistema Único de Saúde (SUS) e sobre as transferências intergovernamentais de recursos financeiros na área da saúde e dá outras providências. Diário Oficial da União 1990; 31 dez., and includes health prevention, promotion and recovery measures, as well as health surveillance, vector control and health education. The system is guided by the principles of decentralization, comprehensiveness and community involvement, and includes inter-sector articulation to implement policies and programs in the interests of health²⁶26. Brasil. Lei nº 8.080, de 19 de setembro de 1990. Dispõem sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 19 set..

In this scenario, the National Cancer Institute (INCA), part of the Ministry of Health Healthcare Attention Department, took over coordination of the National Tobacco Control Program nation-wide measures in 1989²⁷27. Cavalcante TM. O controle do tabagismo no Brasil: avanços e desafios. Rev Psiquiatr Clínica 2005; 32(5):283-300.. The Program attempts to reduce the social acceptance of tobacco use by keeping young people from taking up the habit, protecting people from exposure to tobacco smoke and support for those wishing to quit smoking²⁸28. Instituto Nacional de Câncer José Alencar (INCA). Tabagismo um grave problema de saúde pública. Rio de Janeiro: INCA; 2007.. Between 1990 and 1993, the program was coordinated by the central management of the Ministry of Health in Brasília, and returned to the umbrella of the INCA in 1994. In 1996 the National Coordination of Tobacco Control and Primary Cancer Prevention (CONTAPP) was created, covering the National Tobacco Control Program and other programs for prevention against cancer risk factors²⁹29. De Beyer J, Brigden LW, organizadores. Tobacco control policy: strategies, successes, and setbacks. Washington: World Bank: Research for International Tobacco Control; 2003..

Anvisa, the National Health Surveillance Agency created in 1999, enabled more effectivemeasures to control and inspect tobacco products that those previously developed by the Ministry of Health²¹21. Teixeira L, Jaques T. Legislação e Controle do Tabaco no Brasil entre o Final do Século XX e Início do XXI. Revista Brasileira de Cancerologia 2011; 57(3):295-304.. That same year, the National Tobacco Control Committee was created (NTCC or CNCT in Portuguese) to represent Brazil at the international negotiations of the FCTC³⁰30. Brasil. Decreto 3.136, de 13 de Agosto de 1999. Diário Oficial da União 1999; 16 ago.

In the 2000s, events related to the FCTC marked the trajectory of tobacco control in Brazil. In 2003, when the convention was adopted, the NTCC was replaced by the National Commission for the Implementation of the Framework Convention on Tobacco Control (CONICQ), incorporating new bodies in different sectors³¹31. Brasil. Decreto, de 16 de março de 2012. Diário Oficial da União 2012; 19 mar.. Brazil ratified the FCTC in 2005, and it became effective across the country in 2006. Numerous measures focused on tobacco control were then incorporated into the National Tobacco Control Policy (NTCP or PNCT in Portuguese)³²32. Instituto Nacional de Câncer (INCA). A situação do tabagismo no Brasil: dados dos inquéritos do Sistema Internacional de Vigilância do Tabagismo da Organização Mundial da Saúde realizados no Brasil entre 2002 e 2009. Rio de Janeiro: Ministério da Saúde, INCA; 2011.. Thus, an inter-sector State policy was created, articulated between the three Federal levels³³33. Instituto Nacional de Câncer (INCA). Política Nacional de controle do tabaco: relatório de gestão e progresso 2011-2012. Rio de Janeiro: INCA; 2014..

Within the context of a national health policy, some initiatives enabled implementing tobacco control measures in this country. The 2006 Health Pact highlights tobacco use as one of the prioritiesfor health promotion³⁴34. Brasil. Ministério da Saúde (MS). Diretrizes operacionais: pactos pela vida, em defesa do SUS e de gestão: documento pactuado na reunião da Comissão Intergestores Tripartite do dia 26 de janeiro de 2006 e aprovado na reunião do Conselho Nacional de Saúde do dia 09 de fevereiro de 2006. Brasília: MS; 2007. (Série A-Normas e manuais técnicos).. That same year, the National Health Promotion Policy (NHPP or PNPS in Portuguese) included the prevention and control of tobacco use, with education, legislative and economic measures, and measures to foster tobacco-free environments and support for people trying to quit smoking³⁵35. Brasil. Política nacional de promoção da saúde. Brasília: MS; 2006. (Série PACTOS pela saúde 2006).. Education and legislative measures are also part of the 2008 program entitled Mais Saude: Direito de Todos (More Health, the Right of All)³⁶36. Brasil, Ministério da Saúde (MS). Mais saúde: direito de todos: 2008-2011. Brasília: MS; 2008..

Tobacco control remained a strong point of the national health policy throughout the second half of the 21^st century. The “Strategic Action Plan to Combat Chronic Non-communicable Diseases in Brazil, 2011-2022” includes reducing the number of smokers as one of its targets, with measures that include surveillance, research and health promotion related to tobacco use³⁷37. Brasil. Ministério da Saúde (MS). Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil: 2011-2022. Brasília: MS; 2011. (Série B. Textos básicos de saúde).. The 2014 review of the NHPP kept tobacco control as a priority, encouraging educational, legislative, economic, environmental, cultural and social measures³⁸38. Brasil. Ministério da Saúde. Política Nacional de Promoção da Saúde (PNPS): revisão da Portaria MS/GM no 687, de 30 de março de 2006 [Internet]. 2015 [acessado 26 de dezembro de 2016]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pnps_revisao_portaria_687.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... .

The legal and normative framework contributed to embedding tobacco control in the period. Federal Law # 9,294/1996 and its subsequent regulation (Decree # 2.018/1996, Law #10,167/2000, Law # 12,546/2011 and Decree # 8,262/2014) enabled significant progress towards placing warnings, restricting advertising of tobacco products and forbidding smoking in enclosed spaces. We highlight the role of rules and regulations implemented over the past decades in the form of the various Ministry of Health directives and Anvisa resolutions to regulate tobacco products, and Central Bank measures also aiming at regulating tobacco production.

Assessment of the Brazilian tobacco control policy measures

Over the past three decades, Brazil has implemented numerous tobacco control measures, most of them aiming at reducing the demand for tobacco. One of the key measures has been periodic adjustments of the main cigarette taxes and their retail sales price. We stress the changes in 2011 involving the tax on industrialized goods (IPI) and a minimum price for selling cigarettes. Despite the illicit trade in tobacco products, Brazil’s experience shows that higher taxes can increase government revenue and at the same time reduce the number of smokers39.

Promoting tobacco-free environments has been one of the most successful measures of the Brazilian tobacco control policy. Starting in the late 1980s, smoking restrictions advanced, strengthened by city, state and federal laws. Since 2011, smoking has been prohibited in public and private enclosed spaces, with only a handful of exception (churches, tobacco stores, studios and healthcare institutions)⁴⁰40. Brasil. Decreto 8.262, de 31 de maio de 2014. Diário Oficial da União 2014; 02 jun.,⁴¹41. Brasil. Presidência da República. Lei no 12.546, de 14 de dezembro de 2011. Diário Oficial da União 2011; 14 dez..

Warnings of the health hazards of smoking on cigarette packs and advertising, used since 1988, have been reformulated and images added to make the population even more aware. When Anvisa was created in 1999, tobacco product regulation became an important element of Brazilian policy, controlling registration, packaging and content. The Tobacco and Derivatives lab inaugurated in 2012 is the sixth such public lab in the world and the first in Latin America dedicated to the analysis of tobacco-derived products⁴²42. Anvisa. Anvisa inaugura Laboratório de Tabaco - Busca - [Internet]. [acessado 2017 Nov 14]. Disponível em: http://portal.anvisa.gov.br/resultado-de-busca?p_p_id=101&p_p_lifecycle=0&p_p_state=maximized &p_p_mode=view&p_p_col_id=column-1&p_p_col_count=1&_101_struts_action=%2Fasset_publisher%2Fview_content&_101_assetEntryId=2665264&_101_type=content&_101_groupId=219201&_101_urlTitle=anvisa-inaugura-laboratorio-de-tabaco&inherit Redirect=true
http://portal.anvisa.gov.br/resultado-de... .

The fundamental strategy to build awareness and educate the public on the damages caused by tobacco use is to organize campaigns on the main commemorative dates related to tobacco control. The National Day Against Tobacco (August 29, created in 1986), and the World No Tobacco Day (May 31, created in 1987), mobilize players in all three spheres of government to promote activities related to preventing tobacco use and encouraging people to quit smoking. We also point to the development of educational efforts in schools, healthcare units and the work environment, such as Programa Saber Saúde (Know Health Program), which has already reached 2,389,126 students in 14,280 schools in 1,212 cities³³33. Instituto Nacional de Câncer (INCA). Política Nacional de controle do tabaco: relatório de gestão e progresso 2011-2012. Rio de Janeiro: INCA; 2014.. Since the Saber Saúde distance education course was created in 2012, 1,390 professionals in education have been trained all over the country⁴³43. Instituto Nacional de Câncer (INCA). Política Nacional de Controle do Tabaco: Relatório de Gestão e Progresso 2013-2014. Rio de Janeiro: INCA; 2015.. Creating monitoring centers or observatories has helped share knowledge related totobacco control. Since 2011, the National Tobacco Control Policy Monitoring Center has provided updated information on the different sectors involved in implementing the FCTC. The “Tobacco Industry Strategy Monitoring Center”, created in 2016, is a global project created by the FCTC Secretariat to monitor, analyze and disclose tobacco industry activities⁴⁴44. Turci SRB, Medeiros A, Carvalho DCS, Cavalcante TM, Bialous SA, Johns P, Silva VLC. Observatório sobre as Estratégias da Indústria do Tabaco: uma nova perspectiva para o monitoramento da interferência da indústria nas políticas de controle do tabaco no Brasil e no mundo. Cad Saude Publica 2017; 33(Supl. 3).

We also point to the progress made in limiting tobacco product advertising and publicity. Brazil started limiting tobacco advertising in the media in the 1980s, and also prohibited any messages linking tobacco-products and well-being. Federal Law # 10,167/2000 makes it illegal for tobacco brands to sponsor cultural and sports events, and prohibits tobacco advertising in the major media vehicles. Since 2011, advertising has been limited to displays at points of sale⁴¹41. Brasil. Presidência da República. Lei no 12.546, de 14 de dezembro de 2011. Diário Oficial da União 2011; 14 dez..

Support for people to quit smoking is an important component of the FCTC, and is considered a measure to reduce the demand for tobacco. Since 2004, smokers are offered free treatment by the SUS, mostly at the primary healthcare units. The number of units providing treatment, the number of smokers seen and who stopped smoking. abandonment and quitting rates all show major progress. In 2013, 1,308 units provided services to 154,207 smokers, 71,327 of whom quit smoking (Figure 4). Abandonment and quitting rates were 28% and 53% respectively. The supply of medication to help people stop smoking expanded to 77% (Figure 5). Furthermore, the Ministry of Health has provided telephone support for smokers since 2001 - Disque Saúde 136 (health call service 136).

One of the measures used to reduce the supply of tobacco is to fight illegal trade, and diversify the crops planted in traditional tobacco growing areas. Despite interference by tobacco companies to fight measures to reduce tobacco use, major strides have been made in the past 30 years, especially in the south. In the late 1990s, rules were defined for cigarette marketing, including special registration, control seals and export taxes. Starting with combined activities of the Federal Revenue Service and Federal Police to fight cigarette falsification and contraband, in particular a program known as Scorpios - the System to Control and Track Cigarette Production created in 2007, efforts to fight the illegal trade of cigarettes have been quite successful. In 2016, R$ 581 million in cigarettes confiscated due to tax infractions were destroyed⁴⁵45. Brasil. Secretaria da Receita Federal. Regimes e Controles Especiais [Internet]. [acessado 2017 Jan 6]. Disponível em: http://idg.receita.fazenda.gov.br/orientacao/tributaria/regimes-e-controles-especiais/registros-e-controles-especiais
http://idg.receita.fazenda.gov.br/orient... .

Considering that Brazil is the second largest producer and the largest exporter of tobacco leaves in the world⁴⁶46. FAOSTAT [Internet]. [acessado 2017 Dez 11]. Disponível em: http://www.fao.org/faostat/en/#data
http://www.fao.org/faostat/en/#data... , in 2005 it created a Program to Diversity Tobacco Farming Areas, ratified by the FCTC. Between 2011 and 2016 more than R$ 60 million were invested in technical support and farm extension (Ater) in the main tobacco-producing municipalities, affecting over 20 thousand families⁴⁷47. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Secretaria- Executiva da Comissão Nacional para Implementação da Convenção - Quadro para Controle do Tabaco. A importância e a urgência da diversificação de produção em áreas que produzem tabaco no Brasil. Rio de Janeiro: INCA; 2014. (Notas técnicas para o controle do tabagismo).. Among the crop diversification strategies are criteria for approving Family Farming credit (Pronaf) for tobacco farmers working in partnership or as part of a tobacco processor. Starting in 2016/2017 famers have had to show that at least 20% of their gross income came from non-tobacco related activities. For the 2020/2021 harvest the requirement will be 50%⁴⁸48. Banco Central do Brasil. Resolução no 4.513, de 24 de agosto de 2016 [Internet]. 2016. Disponível em: http://alfonsin.com.br/resoluo-n-4-513-de-2482016/
http://alfonsin.com.br/resoluo-n-4-513-d... .

Finally, research and surveillance activities have also been key for the NTCP. Since 1997, the INCA has been the “WHO Collaborating Center for Tobacco Control”, and is a Latin American reference when it comes to producing materials, training human resources and providing technical support for controlling tobacco use⁴³43. Instituto Nacional de Câncer (INCA). Política Nacional de Controle do Tabaco: Relatório de Gestão e Progresso 2013-2014. Rio de Janeiro: INCA; 2015.. A number of studies are performed in Brazil from time to time to monitor tobacco use indicators. One such example is Vigitel (Telephone Survey of Chronic Disease Risk and Protection Factors), which has been conducted since 2006. Other examples include Petab (Special Survey on Tobacco Use) (2008), PeNSE (National Survey on Student Health) (2009, 2012, 2015), PNS (National Health Survey) (2013) and the ITC Project (Assessment of the Tobacco Control Policy) (2009, 2012, 2016/17). In addition to these, the “Strategic Action Plan to Combat Chronic Non-communicable Diseases in Brazil, 2011-2022” includes surveillance, research and health-promotion measures related to tobacco use.

Closing Remarks

In recent decades Brazil has implemented cross-sectoral measures to control tobacco use, leading to a significant reduction in the number of smokers - from 35% of the population in 1989 to 15% in 2012⁴⁹49. Levy D, Almeida LM, Szklo A. The Brazil SimSmoke Policy Simulation Model: The Effect of Strong Tobacco Control Policies on Smoking Prevalence and Smoking-Attributable Deaths in a Middle Income Nation. PLoS Med [Internet] 2012 [acessado 2015 Jan 9]; 9(11). Disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491001/
http://www.ncbi.nlm.nih.gov/pmc/articles...

50. Malta DC, Oliveira TP, Luz M, Stopa SR, Silva Junior JB, Reis AA. Smoking trend indicators in Brazilian capitals, 2006-2013. Cien Saude Colet 2015; 20(3):631-640.

51. Monteiro CA, Cavalcante TM, Moura EC, Claro RM, Szwarcwald CL. Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989-2003). Bull World Health Organ 2007; 85(7):527-534.-⁵²52. Szklo AS, Almeida LM, Figueiredo VC, Autran M, Malta D, Caixeta R, Szklo M. A snapshot of the striking decrease in cigarette smoking prevalence in Brazil between 1989 and 2008. Prev Med 2012; 54(2):162-167.. It is worth pointing out that in the period there has also been a change in the social acceptability of tobacco use, which went from being broadly disseminated in the 1980s and 1990s to being rejected in the 2000s⁵³53. Eckerdt NS, Corradi-Webster CM. Meanings about smoking for women participant in a group for smokers. Rev Lat Am Enfermagem 2010; 18(spe.):641-647.

54. Gomes PGVS, Boiteux EAPC. Convenção-quadro para o controle do tabaco: políticas públicas de implementação [tese]. São Paulo: USP; 2014.-⁵⁵55. Martins KC, Seidl EMF. Change in smoking behavior of participants in tobacco cessation groups. Psicol Teor e Pesqui 2011; 27(1):55-64..

The active involvement of Brazil in designing the FCTC was decisive for its leading role in global control of tobacco use and developing partnerships with international organizations. The insertion of tobacco control policies into a universal public healthcare system, developing a specific legal and legislative framework, policy coordination at the national level and the involvement of different sectors, implementation of the FCTC and policy decentralization have all been essential to institutionalize tobacco control in Brazil.

The creation of Anvisa and its legal mandate to regulate tobacco products in the country and oversee national laws in this area was of particular importance. The consolidation of CONICQ as the strategic body for government coordination of the policy is a commitment of mutual accountability of the different government agencies involved in tobacco control⁵⁶56. Portes L, Machado CV, Turci SRB. Coordenação governamental da Política de Controle do Tabaco no Brasil. Cien Saude Colet 2017;.

We also call attention to the role of civil society and the media, in particular the Alliance to Control Tobacco Use, healthcare organizations (especially medical associations), consumer associations and the associations to defend tobacco growers. These players have been key for the NTCP, conducting surveys on diverse themes, promoting different ways of training the different people involved, campaigns on dates that commemorate tobacco control and continuous advocacy with the Executive, Judiciary and Legislative powers.

However, there remain important policy challenges⁵⁷57. Portes LH, Machado CV, Turci SRB. Trajetória da política de controle do tabaco no Brasil de 1986 a 2016. Cad Saude Publica [Internet]. 2018 [acessado 8 de março de 2018]; 34(2). Disponível em: http://www.scielo.br/scielo.php?script=sci_abstract&pid=S0102-311X2018000205012&lng=en&nrm=iso&tlng=pt
http://www.scielo.br/scielo.php?script=s... . Strengthening the National Program to Diversity Areas Planted with Tobacco, and greater articulation of the players involved in this theme, especially agro government bodies, the civil society and the tobacco-producing municipalities and states are currently limits for tobacco control. In 2016 responsibility was transferred from the Ministry for Agricultural Development to the Special Department for Family Farming and Agrarian Development, under the umbrella of the office of the chief of staff (Casa Civil), presents an additional hurdle to mobilizing human and financial resources for the program.

Fighting illegal cigarette trade and NTCP protection from interference from the tobacco industry are further challenges. We especially mention the urgency for ratifying the Protocol to Eliminate the Illegal Trade in Tobacco Products, allocating financial resources to the players involved with the policy promoted by tobacco processing companies, expansion to new products and policy judicialization, especially as regards product regulation by Anvisa.

It is also important to strengthen CONICQ and its ability to take action. This means addressing limiting factors such as the low priority that tobacco control has on the agenda of some of the Committee agencies, conflicts between the economics and health aspects of tobacco control and resistance on the part of the Tobacco Producing Sector Chamber, part of the Ministry of Agriculture, and organizations linked tothe tobacco industry.

This study reinforces the importance of including the relationship between the domestic and international situation, and articulation between various government and non-government sectors and players when analyzing complex health policies. Brazil has submitted pioneering initiatives and several Brazilian players have influenced tobacco control negotiations at the international level. Since the FCTC was adopted, Brazilian policy has been strongly influenced by the international scenario in a two-way relationshiop⁵⁷57. Portes LH, Machado CV, Turci SRB. Trajetória da política de controle do tabaco no Brasil de 1986 a 2016. Cad Saude Publica [Internet]. 2018 [acessado 8 de março de 2018]; 34(2). Disponível em: http://www.scielo.br/scielo.php?script=sci_abstract&pid=S0102-311X2018000205012&lng=en&nrm=iso&tlng=pt
http://www.scielo.br/scielo.php?script=s... . Also, despite tobacco control in Brazil being based on health sector strategies, control being recognized primarily based on fighting the morbi-mortality related to tobacco use, NTCP advances depend heavily on the commitment of other sectors, in particular those related to agriculture and the economy. Articulation between the Executive, Judiciary and legislative, as well as the media and civil society is essential to ensure that tobacco control is fully embedded in Brazil.

Finally, sustainability of the NTCP is a major challenge, given the dynamics of government agendas and the political and economic instability that the country experiences from time to time. Keeping the theme on the agenda of the healthcare sector and expanding legislative, economic, regulatory and education activities are essential. Facing the economic interests of the tobacco industry is a determinant to ensure progress is made in areas that remain fragile. The continuation and consolidation of a tobacco control policy over the medium and long terms require a persistent and ample institutional framework to guide the activities of the State in social protection, as per the SUS guidelines, where health needs come before economic interests.

Agradecimentos

CV Machado é bolsista de produtividade em Pesquisa do CNPq. A pesquisa que deu origem ao artigo foi apoiada por recursos do Proex-Capes, do Programa de Pós-Graduaçãoo em Saúde Pública da Ensp/Fiocruz.

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