Abstract

This cross-sectional study used data from Brazil’s National Student Health Survey (PeNSE), from 2015 and 2019, to compare consumption of tobacco products among adolescent students in Brazil and identify associated factors. The study variables were current cigarette smoking, use of other tobacco products and use of any tobacco product. Pearson’s Chi-square test was used to ascertain associations between the variables; bivariate and multivariate analyses were performed using logistic regression. Cigarette smoking remained stable between 2015 (6.6%) and 2019 (6.8%), but use of any tobacco product increased (from 10.6% in 2015 to 14.8% in 2019), involving particularly hookahs (7.8%) and e-cigarettes (2.8%). Cigarette smoking was greater among adolescents aged 16 and 17, whose skin colour was black or brown, who missed classes without permission, who reported having no friends, displayed other risk factors, such as drinking alcoholic beverages, or who were passive smokers. The prevalence of smoking has increased over the years and is associated with sociodemographic aspects and other health risk behaviour, highlighting the need for lifelong health promotion actions.

Key words:
Tobacco use disorder; Adolescent; Health surveys; Tobacco products; Risk factors

Introduction

Evidence of the evils of tobacco use is well established in the literature, and includes rising mortality from cardiovascular diseases, cancer (of the lungs, oral cavity and breast), chronic respiratory diseases, intrauterine growth restriction and predisposition to premature births, as well as its being considered one of the main risk factors for non-communicable diseases (NCD)¹1 Malta DC, Flor LS, Machado ÍE, Felisbino-Mendes MS, Brant LCC, Ribeiro ALP, Teixeira RA, Macário EM, Reitsma MB, Glenn S, Naghavi M, Gakidou E. Trends in prevalence and mortality burden attributable to smoking, Brazil and federated units, 1990 and 2017. Popul Health Metr 2020; 18(Supl. 1):24.

2 GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396(10258):1223-1249.^-33 Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, Peto R, Zatonski W, Hsia J, Morton J, Palipudi KM, Asma S; GATS Collaborative Group. Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys. Lancet 2012; 380(9842):668-679..

The Global Burden of Disease study found that smoking, including passive exposure, ranked fourth among the greatest risk factors in the burden of disease worldwide³3 Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, Peto R, Zatonski W, Hsia J, Morton J, Palipudi KM, Asma S; GATS Collaborative Group. Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys. Lancet 2012; 380(9842):668-679. and fourth in Brazil, where it accounted for 167,657 deaths in 2017¹1 Malta DC, Flor LS, Machado ÍE, Felisbino-Mendes MS, Brant LCC, Ribeiro ALP, Teixeira RA, Macário EM, Reitsma MB, Glenn S, Naghavi M, Gakidou E. Trends in prevalence and mortality burden attributable to smoking, Brazil and federated units, 1990 and 2017. Popul Health Metr 2020; 18(Supl. 1):24..

Health risk behaviour often begins or intensifies in adolescence, due to physical, mental, emotional and social changes that take place at that stage of life and can predispose to new experiences, such as licit and illicit substance use⁴4 Patton GC, Coffey C, Cappa C, Currie D, Riley L, Gore F, Degenhardt L, Richardson D, Astone N, Sangowawa AO, Mokdad A, Ferguson J. Health of the world's adolescents: a synthesis of internationally comparable data. Lancet 2012; 379(9826):1665-1675.. Tobacco use by adolescents is also associated with other situations, such as state of mental health and passive smoking at home, together with lack of family supervision and support, and influence of friends⁵5 Barreto SM, Giatti L, Oliveira-Campos M, Andreazzi MA, Malta DC. Experimentation and use of cigarette and other tobacco products among adolescents in the Brazilian state capitals (PeNSE 2012). Rev Bras Epidemiol 2014; 17(Supl. 1):62-76.

6 Chen CY, Wu CC, Chang HY, Yen LL. The effects of social structure and social capital on changes in smoking status from 8th to 9th grade: Results of the Child and Adolescent Behaviors in Long-term Evolution (CABLE) study. Prev Med (Baltim) 2014; 62:148-154.^-77 Malta DC, Oliveira-Campos M, Prado RR do, Andrade SSC, Mello FCM, Dias AJR, Bomtempo DB. Psychoactive substance use, family context and mental health among Brazilian adolescents, National Adolescent School-based Health Survey (PeNSE 2012). Rev Bras Epidemiol 2014; 17(Sup. l 1):46-61..

Behaviour acquired during adolescence tends to persist into adult life and contributes to increased youth morbidity and mortality⁸8 Tobore TO. On the potential harmful effects of E-Cigarettes (EC) on the developing brain: The relationship between vaping-induced oxidative stress and adolescent/young adults social maladjustment. J Adolesc 2019; 76(1):202-209.^,99 Dumith SC, Muniz LC, Tassitano RM, Hallal PC, Menezes AMB. Clustering of risk factors for chronic diseases among adolescents from Southern Brazil. Prev Med (Baltim) 2012; 54(6):393-396.. It is thus important that healthy lifestyles be adopted in adolescence in order to reduce the burden of disease in later life. Therapeutic counselling should be made available, given that there is insufficient evidence to support the use of drug-based therapy among the young¹⁰10 Brasil. Ministério da Saúde (MS). Portaria Conjunta nº 10, de 16 de abril de 2020. Aprova o Protocolo Clínico e Diretrizes Terapêuticas do Tabagismo. Diário Oficial da União; 2020..

Use of tobacco in whatever form is harmful and there is no safe level of exposure to tobacco¹¹11 World Health Organization (WHO). Tobacco. Geneva: WHO; 2020.. Cigarettes are the commonest form of use worldwide, although other products, such as e-cigarettes, hookahs, cigars and pipes, do exist and are also harmful to health¹¹11 World Health Organization (WHO). Tobacco. Geneva: WHO; 2020.. Use of these products, particularly e-cigarettes, has increased considerably among young people¹¹11 World Health Organization (WHO). Tobacco. Geneva: WHO; 2020.^,1212 World Health Organization (WHO). Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS). Geneva: WHO; 2020.. Prevalence of tobacco use by adults is decreasing globally and in Brazil¹³13 Ng M, Freeman MK, Fleming TD, Robinson M, Dwyer-Lindgren L, Thomson B, Wollum A, Sanman E, Wulf S, Lopez AD, Murray CJ, Gakidou E. Smoking Prevalence and Cigarette Consumption in 187 Countries, 1980-2012. JAMA 2014; 311(2):183.^,1414 Malta DC, Silva AG, Machado ÍE, Sá ACMGN, Santos FM, Prates EJS, Cristo EB. Trends in smoking prevalence in all Brazilian capitals between 2006 and 2017. J Bras Pneumol 2019; 45(5):e20180384., but cigarette smoking has held stable among Brazilian adolescents⁹9 Dumith SC, Muniz LC, Tassitano RM, Hallal PC, Menezes AMB. Clustering of risk factors for chronic diseases among adolescents from Southern Brazil. Prev Med (Baltim) 2012; 54(6):393-396., making it a public health concern.

Given that scenario, it is crucial to monitor health risk factors to inform surveillance and planning measures and develop and implement effective policies to promote health and prevent disease, especially in more vulnerable populations, because adolescence is an important stage in establishing healthy life habits.

In that light, this study compared consumption of different tobacco products by adolescent schoolchildren in Brazil, between 2015 and 2019, to identify factors associated with their use.

Methods

This cross-sectional study used data from Brazil’s National Student Health Survey (Pesquisa Nacional de Saúde do Escolar, PeNSE) for 2015 and 2019. The PeNSE is conducted by the official bureau of statistics, the Instituto Brasileiro de Geografia e Estatísticas (IBGE), in partnership with the Ministry of Health and with support from the Ministry of Education. The PeNSE forms part of Brazil’s surveillance of risk and protective factors for non-communicable diseases and is the first national survey to address various aspects of adolescent life including habits, care, risk and protective health factors. The survey was conducted in 2009, 2012, 2015 and 2019¹⁵15 Oliveira MM, Campos MO, Andreazzi MAR, Malta DC. Características da Pesquisa Nacional de Saúde do Escolar - PeNSE. Epidemiol Serv Saude 2017; 26(3):605-616..

In 2015 two distinct sampling plans were used, one contemplating ninth-year students (in the final year of lower secondary school) and the other of schoolchildren from 13 to 17 years old attending years 6 to 9 (lower secondary school) and years 1 to 3 of upper secondary school. That was the sample used in this study, in which 10,926 Brazilian students enrolled in and attending 371 schools and 653 classes, in the country’s five main geographical regions, were investigated, together with the overall total in private and public schools nationwide¹⁶16 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar (PeNSE): 2015. Rio de Janeiro: IBGE; 2016.. In 2019, the IBGE used a single sample of students from 13 to 17 years old in public and private schools, at the following geographical levels: Brazil, major regions, units of the federation, municipalities of state capitals and the Federal District. Data were collected from 4,242 schools, 6,612 classes and 159,245 schoolchildren¹⁷17 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar: 2019. Rio de Janeiro: IBGE; 2021.. Sampling loss from enrolled and non-respondent students was approximately 2.4% in 2015 and 15.4% in 2019. Further details of the samples can be found in other publications¹⁶16 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar (PeNSE): 2015. Rio de Janeiro: IBGE; 2016.^,1717 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar: 2019. Rio de Janeiro: IBGE; 2021..

The sample was scaled to estimate population parameters for students from 13 to 17 years old enrolled and attending public and private schools at the following geographical levels: Brazil, major regions, units of the federation, municipalities of state capitals and the Federal District¹⁷17 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar: 2019. Rio de Janeiro: IBGE; 2021..

The students were informed in advance as to the aims and main characteristics of the survey and that their participation was voluntary and could be interrupted at any time. Those who agreed to take part responded to a structured questionnaire, which was self-applicable on smartphone under supervision of IBGE researchers¹⁷17 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar: 2019. Rio de Janeiro: IBGE; 2021.. The PeNSE data base and questionnaires are available for public access and use on the IBGE website at: https://www.ibge.gov.br/estatisticas/sociais/saude/9134-pesquisa-nacional-de-saude-do-escolar.html?edicao=31442&t=resultados.

This study assessed and compared three indicators of tobacco use in 2015 and 2019: cigarette smoking in the past 30 days (current use), use of other tobacco products (except for cigarettes) and use of any tobacco product, by way of the questions below:

In 2019, the single question on other tobacco products was discontinued and replaced by five different questions: “In the past thirty days, which of these other tobacco products did you use: hookah (water pipe)?”, “In the past thirty days, which of these other tobacco products did you use: e-cigarette?”, “In the past thirty days, which of these other tobacco products did you use: clove cigarettes (Kretek cigarettes)?”, “In the past thirty days, which of these other tobacco products did you use: hand-rolled cigarettes (straw or paper)?”, “In the past thirty days, which of these other tobacco products did you use: others?”. The response options were: Yes or No. If respondents answered “Yes” to at least one of the questions above, that was considered to be “use of other tobacco products”.

The explanatory variables examined were: sociodemographic: sex (male or female), age group (13-15, 16-17 years), skin colour (white, black, yellow, brown or indigenous), living with father or mother (No and Yes); family supervision: parents or guardians really know what the student did in their free time in the past 30 days (Yes or No), missing classes without permission (Yes or No); mental health: feeling that no-one cares about them in the past 12 months (Yes or No), feeling sad (Yes or No), having close friends (one or more or No); substance use: use of alcoholic beverages in the past 30 days (yes: having drunk at least one glass or measure of an alcoholic beverage in the past 30 days prior to the survey and no: none of the previous 30 days) and regular use of drugs in the past 30 days (yes: having used drugs in the last 30 days prior to the survey and no: none of the previous 30 days); influence of people who are close: passive smoker/people who smoke in your presence (Yes or No) or parents or guardians who smoke (Yes or No).

The descriptive analysis included calculating prevalences and respective 95% confidence intervals (95%CIs). The Pearson chi-square test was used to examine for associations between the independent variables, by groups, to statistical significance of p-value≤0.05.

The magnitude of the associations was estimated by odds ratio (OR), with respective 95%CIs. The method used for the multivariate regression was to insert variables to build the multivariate model; all related variables of interest with level of statistical significance of less than 0.05 in the bivariate analysis were included, and were inserted one at a time. The final model also considered variables with p-value≤0.05.

The statistical analysis was performed on Stata software, version 14.1 (StataCorp LP, College Station, United States), using the survey module, which considers post-stratification weights.

The PeNSE complied with Brazil’s guidelines and regulatory standards for research involving human subjects and was approved by the national research ethics commission of the Ministry of Health (CONEP/MS), under ethics assessment application certificates (CAAEs) No. 1.006.487¹⁸18 Brasil. Ministério da Saúde (MS). Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas e Agravos não Transmissíveis no Brasil 2021-2030. Brasília: MS; 2021. and 3.249.268.

Results

In Brazil, in 2015, prevalence of use of any tobacco product was 10.6% (95%CI 9.4-11.8%), with 6.6% (95%CI 5.8-7.3%) of adolescents smoking cigarettes in the prior 30 days and 7.2% (95%CI 6.1-8.2%) using other tobacco products (such as straw or hand-rolled cigarettes, cigars, pipes, cigarillos, Indian or Kretek cigarettes, hookahs, snuff or chewing tobacco) in the prior 30 days. Meanwhile, in 2019 prevalence of consumption of any tobacco product was 14.83% (95%CI 14.22-15.45%), with 6.80% (95%CI 6.32-7.31%) of adolescents smoking cigarettes in the prior 30 days and 12.39% (95%CI 11.85-12.59%) using other tobacco products (Figure 1).

Cigarette smoking in the prior 30 days held stable between 2015 and 2019, although use of other tobacco products increased; of the latter, in 2019, the highest prevalence was use of hookahs, at 7.8% (95%CI 7.3-8.4%), followed by e-cigarettes, at 2.8% (95%CI 2.6-3.0%), and straw cigarettes, at 2.6% (95%CI 2.3-2.8%) (Figure 2).

In 2019, prevalence of cigarette smoking among adolescents was 6.80% (95%CI 6.32-7.31%), but higher among those from 16 to 17 years old (10.02%; 95%CI 9.29-10.79%), those whose skin colour was black (8.33%; 95%CI 7.45-9.31%), who reported not living with their father or mother (10.90%; 95%CI 9.71-12.21%), who were not supervised by the family (11.40%; 95%CI 10.49-12.38%) or who missed classes without parental permission (14.23%; 95%CI 13.14-15.39%). Cigarette smoking was also commoner among those who felt that no-one cared about them (8.28%; 95%CI 7.66-8.94%), felt sad (7.62%; 95%CI 7.02-7.62%) or who had no friends (10.16%; 95%CI 8.26-12.46%), as well as among those who reported using other tobacco products (35,09%; 95%CI 32.81-37.44%), alcoholic beverages (18.97%; 95%CI 17.76-20.25%) and other drugs (57.21%; 95%CI 53.69-60.66%), those who were passive smokers (11.75%; 95%CI 10.81-12.77%) or who had parents who smoked (11.17%; 95%CI 10.04-12.41%) (Table 1).

The highest odds of smoking cigarettes were found among adolescents 16 to 17 years old (OR=1.26; 95%CI 1.08-1.47), those whose skin colour was black (OR=1.21; 95%CI 1.01-1.46) or brown (OR=1.26; 95%CI 1.11-1.43), who missed classes without permission (OR=1.62; 95%CI 1.41-1.85), who reported having no friends (OR=1.43; 95%CI 1.08-1.87%), who used other tobacco products (OR=5.95; 95%CI 5.21-6.80%), alcoholic beverages (OR=3.87; 95%CI 3.37-4.45%) or other drugs (OR=7.04; 95%CI 5.86-8.47%) or who were passive smokers (OR=1.65; 95%CI 1.44-1.89%). On the other hand, the lowest odds of smoking occurred among adolescents who were supervised by their families (OR=0.58; 95%CI 0.51-0.66%) (Table 1).

Prevalence of use of other tobacco products among adolescents was 12.39% (95%CI 11.85-12.95%) and the odds of using these products were higher among those who missed classes without permission (OR=1.39; 95%CI 1.24-1.56%), who felt that no-one cared about them (OR=1.32; 95%CI 1.21-1.44%), who used cigarettes regularly (OR=5.56; 95%CI 4.84-6.39%), drank alcoholic beverages (OR=5.25; 95%CI 4.74-5.82%), used other drugs (OR=4.60; 95%CI 3.91-5.41), were passive smokers (OR=1.23; 95%CI 1.09-1.39%) or whose parents or guardians smoked (OR=1.40; 95%CI 1.22-1.60%). The lowest odds of using these products were among adolescents who were female (OR=0.80; 95%CI 0.72-0.89%) or whose race/skin colour was brown (OR=0.83; 95%CI 0.74-0.93%) or indigenous (OR=0.67; 95%CI 0.50-0.88%) (Table 2).

Prevalence of use of any tobacco product was 14.83% (95%CI 14.22-15.55%), with highest odds among adolescents who missed classes without their parents’ permission (OR=1.71; 95%CI 1.54-1.90%), who felt no-one cared about them (OR=1.21; 95%CI 1.12-1.31%), who had no friends (OR=1.27 95%CI 1.01-1.60%), who drank alcoholic beverages (OR=6.51; 95%CI 5.96-7.10%), used other drugs (OR=12.19; 95%CI 10.13-14.67%), were passive smokers (OR=1.40; 95%CI 1.26-1.55%) or whose parents or guardians smoked (OR=1.41; 95%CI 1.23-1.63%). Once again, the lowest odds of use occurred among adolescents who were supervised by their families (OR=0.73; 95%CI 0.66-0.80%) (Table 3).

Discussion

This study compared consumption of various different tobacco products among adolescent schoolchildren in Brazil between 2015 and 2019 to identify factors associated with their use. In that period, cigarette smoking held stable, but use of any tobacco product increased from 10.6% in 2015 to 14.8% in 2019, involving particularly hookahs and e-cigarettes. Associated factors that returned highest odds of smoking cigarettes were adolescents 16 to 17 years old, whose skin colour was black or brown, who missed classes without permission, who reported having no friends or felt that no-one cared about them, who used other tobacco products, alcoholic beverages or other drugs, or were passive smokers. On the other hand, the lowest odds of smoking were among adolescents who were supervised by their families.

Brazil has managed to make considerable progress in reducing tobacco use, notably in its adhesion to the Framework Convention on Tobacco Control in 2006 and its 2014 tobacco-free environments law, inclusion of health warnings of the dangers of tobacco use, prohibition of publicity, sponsorship and sale to the under-18s, as well as higher taxes on, and prices of, tobacco products. It has also aligned with the Sustainable Development Goals (SDG) goal by committing to reducing prevalence of tobacco use by 40% by 2030¹⁸18 Brasil. Ministério da Saúde (MS). Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas e Agravos não Transmissíveis no Brasil 2021-2030. Brasília: MS; 2021.. These measures have contributed to reducing smoking in Brazil and to low prevalences among adolescents, which have also held stable over the years. However, it is important to alert to the increased use of other tobacco products, particularly hookahs and e-cigarettes¹⁹19 Ribeiro SC, Pires GAR, Charlo PB, Rodrigues TFCS, Paiano M, Radovanovic CAT, Salci MA. O consumo de derivados do tabaco por adolescentes: Revisão integrativa da literatura. Saude Colet (Barueri) 2020; 9(51):2005-2012.. One session of hookah use, which generally lasts 60 minutes, can be equivalent to smoking 100 or more cigarettes²⁰20 World Health Organization (WHO). WHO Study Group on Tobacco Regulation. Advisory note: Waterpipe tobacco smoking: health effects, research needs, and recommended actions by regulators. Geneva: WHO; 2015.. Hookahs have been a factor in introducing young people to smoking, because they are used collectively and involve substances, such as flavouring, to improve acceptance among adolescents²⁰20 World Health Organization (WHO). WHO Study Group on Tobacco Regulation. Advisory note: Waterpipe tobacco smoking: health effects, research needs, and recommended actions by regulators. Geneva: WHO; 2015.. In 2012, Brazil’s national health surveillance agency (Agência Nacional de Vigilância Sanitária, Anvisa) prohibited the use of additives in tobacco products. In 2013, that measure was suspended by a preliminary court order granted to the tobacco industry, which was not revoked until 2018. The prohibition has not yet been implemented, however, and the tobacco industry lobby constitutes a major threat to tobacco control and to efforts to reduce health risks²¹21 Portes LH, Machado CV, Turci SRB. Trajetória da política de controle do tabaco no Brasil de 1986 a 2016. Cad Saude Publica 2018; 34(2):e00017317.. E-cigarettes, besides being harmful to health, are unsafe, in spite of the growing marketing using false arguments that they are not harmful²⁰20 World Health Organization (WHO). WHO Study Group on Tobacco Regulation. Advisory note: Waterpipe tobacco smoking: health effects, research needs, and recommended actions by regulators. Geneva: WHO; 2015.^,2222 Agência Nacional de Vigilância Sanitária (Anvisa). Cigarro eletrônico [Internet]. 2020 [acessado 2023 jun 13]. Disponível em: https://www.gov.br/anvisa/pt-br/assuntos/tabaco/cigarro-eletronico.
https://www.gov.br/anvisa/pt-br/assuntos... . Products such as hookahs and e-cigarettes may be the first step in fixing a tobacco habit and dependence. Accordingly, these new tobacco products must now be the prime concern and health managers and the health profession should make it their priority that new measures be introduced to regulate these products and clear messages used about the harm they cause²³23 Malta DC, Gomes CS, Alves FTA, Oliveira PPV, Freitas PC, Andreazzi M. O uso de cigarro, narguilé, cigarro eletrônico e outros indicadores do tabaco entre escolares brasileiros: dados da Pesquisa Nacional de Saúde do Escolar 2019. Rev Bras Epidemiol 2022; 25:e220014..

Adolescents from 16 to 17 years old returned higher odds of cigarette smoking. The older adolescents were also more likely to accumulate behavioural risk factors²⁴24 Silva AG, Souza JB, Gomes CS, Silva TPR, Sá ACMGN, Malta DC. Multiple behavioral risk factors for non-communicable diseases among the adolescent population in Brazil: the analysis derived from the Brazilian national survey of school health 2019. BMC Pediatr 2024; 24(1):122.. This may be explained by their parents’ or guardians’ relaxing the social constraints placed on them at this stage in their lives, enabling them to make more independent choices, by greater exposure to stressful situations and social pressures in the final stage of adolescence and by the circles they move in, particularly as a result of peer influence²⁴24 Silva AG, Souza JB, Gomes CS, Silva TPR, Sá ACMGN, Malta DC. Multiple behavioral risk factors for non-communicable diseases among the adolescent population in Brazil: the analysis derived from the Brazilian national survey of school health 2019. BMC Pediatr 2024; 24(1):122.

25 Petrou S, Kupek E. Epidemiological trends and risk factors for tobacco, alcohol and drug use among adolescents in Scotland, 2002-13. J Public Health (Bangkok) 2019; 41(1):62-70.^-2626 Cui Y, Forget EL, Zhu Y, Torabi M, Oguzoglu U. The effects of cigarette price and the amount of pocket money on youth smoking initiation and intensity in Canada. Can J Public Health 2019; 110(1):93-102.. All this, in addition to their being more prone to the habit-forming effects of the nicotine in cigarettes, given that experimentation and initiation occur earlier and earlier²⁷27 Xi B, Liang Y, Liu Y, Yan Y, Zhao M, Ma C, Bovet P. Tobacco use and second-hand smoke exposure in young adolescents aged 12-15 years: data from 68 low-income and middle-income countries. Lancet Glob Health 2016; 4(11):e795-e805..

Previous studies have also found higher prevalences of cigarette smoking among adults and adolescents whose skin colour was black or brown²⁸28 Malta DC, Stopa SR, Santos MAS, Andrade SSCA, Oliveira MM, Prado RR, Silva MMA. Fatores de risco e proteção de doenças e agravos não transmissíveis em adolescentes segundo raça/cor: Pesquisa Nacional de Saúde do Escolar. Rev Bras Epidemiol 2017; 20(2):247-259.^,2929 Malta DC, Gomes CS, Andrade FMD, Vasconcelos NM, Prates EJS, Pereira CA, Fagundes Junior AAP. Tabagismo no Brasil: Percepções dos Resultados de Pesquisas Domiciliares. REME 2023; 27:1518.. The variable “race/skin colour” can be considered an important predictor of population state of health, a marker for social inequalities and social determinants of health and thus for those most exposed to risk factors and in worse conditions of health³⁰30 Krieger N, Chen JT, Waterman PD, Rehkopf DH, Subramanian SV. Race/Ethnicity, Gender, and Monitoring Socioeconomic Gradients in Health: A Comparison of Area-Based Socioeconomic Measures - The Public Health Disparities Geocoding Project. Am J Public Health 2003; 93(10):1655-1671.. Note also that smoking may be initiated or intensified as a result of stressful events, many of which occur more often in more vulnerable populations³¹31 García-Álvarez L, Fuente-Tomás LD la, Sáiz PA, García-Portilla MP, Bobes J. Se observarán cambios en el consumo de alcohol y tabaco durante el confinamiento por COVID-19? Adicciones 2020; 32(2):85.. That is why reducing socioeconomic disparities among ethnic groups tends to reduce exposure to health risk factors³²32 Blakely T, Disney G, Valeri L, Atkinson J, Teng A, Wilson N, Gurrin L. Socioeconomic and Tobacco Mediation of Ethnic Inequalities in Mortality over Time. Epidemiology 2018; 29(4):506-516..

Adolescents who reported having no close friends and who felt that no-one cared about them also returned higher odds of using tobacco. These variables are related to mental health and recourse is often made to licit and illicit drugs in order to alleviate pain, sadness, depressive symptoms³¹31 García-Álvarez L, Fuente-Tomás LD la, Sáiz PA, García-Portilla MP, Bobes J. Se observarán cambios en el consumo de alcohol y tabaco durante el confinamiento por COVID-19? Adicciones 2020; 32(2):85. or stress³³33 Bonilha AG, Ruffino-Netto A, Sicchieri MP, Achcar JA, Rodrigues-Júnior AL, Baddini-Martinez J. Correlates of experimentation with smoking and current cigarette consumption among adolescents. J Bras Pneumol 2014; 40(6):634-642.^,3434 Taylor GMJ, Munafò MR. Does smoking cause poor mental health? Lancet Psychiatry 2019; 6(1):2-3..

Tobacco use was associated with use of alcohol and other drugs. Importantly, behavioural risk factors tend to come into play simultaneously, due to the synergic relations among them, and expose individuals to even greater risk of developing various diseases³⁵35 Dumith SC, Muniz LC, Tassitano RM, Hallal PC, Menezes AMB. Clustering of risk factors for chronic diseases among adolescents from Southern Brazil. Prev Med (Baltim) 2012; 54(6):393-396.. The probability of engaging in multiple types of risk behaviour also increases over the course of a lifetime³⁶36 Spring B, Moller AC, Coons MJ. Multiple health behaviours: overview and implications. J Public Health (Bangkok) 2012; 34(Supl. 1):i3-i10.. Tobacco use may also encourage adolescents to use other, even more harmful, substances³⁷37 Oliveira LMFT, Santos ARM, Farah BQ, Ritti-Dias RM, Freitas CMSM, Diniz PRB. Influence of parental smoking on the use of alcohol and illicit drugs among adolescents. Einstein (São Paulo) 2018; 17(1):eAO4377., which can produce dependence³²32 Blakely T, Disney G, Valeri L, Atkinson J, Teng A, Wilson N, Gurrin L. Socioeconomic and Tobacco Mediation of Ethnic Inequalities in Mortality over Time. Epidemiology 2018; 29(4):506-516.. That behaviour is related to characteristics of this age group, which is more willing to run risks and experience new sensations³³33 Bonilha AG, Ruffino-Netto A, Sicchieri MP, Achcar JA, Rodrigues-Júnior AL, Baddini-Martinez J. Correlates of experimentation with smoking and current cigarette consumption among adolescents. J Bras Pneumol 2014; 40(6):634-642..

The adolescents’ family and social context may predispose to health risk factors and exert an adverse influence. The people closest to them, whether parents, guardians or friends, tend to play a fundamental role in their deciding whether or not substance use will start or become established³⁸38 Morais ÉAH, Oliveira BE, Roesberg JMA, Souza PSN, Souza RNB, Costa SF, Marques VDS, Abreu MNS. Fatores individuais e contextuais associados ao tabagismo em adultos jovens brasileiros. Cien Saude Colet 2022; 27(6):2349-2362.. In that regard, adolescents who missed classes without permission and who were passive smokers were associated with greater tobacco use, which may relate to lack of supervision of their life activities by parents or guardians and their frequenting other smokers influencing their life habits. On the other hand, supervision by the family was found to associate with lower odds of tobacco use, which may relate to concern on the part of parents or guardians, pointing to dialogue and the ability to offer children guidance on promoting health and adopting healthier life habits⁷7 Malta DC, Oliveira-Campos M, Prado RR do, Andrade SSC, Mello FCM, Dias AJR, Bomtempo DB. Psychoactive substance use, family context and mental health among Brazilian adolescents, National Adolescent School-based Health Survey (PeNSE 2012). Rev Bras Epidemiol 2014; 17(Sup. l 1):46-61.^,3737 Oliveira LMFT, Santos ARM, Farah BQ, Ritti-Dias RM, Freitas CMSM, Diniz PRB. Influence of parental smoking on the use of alcohol and illicit drugs among adolescents. Einstein (São Paulo) 2018; 17(1):eAO4377..

Given this scenario, it is important to mention that Brazil has gone through periods of political and economic crisis, and austerity policies have been introduced. This has affected health systems and social programmes adversely and, consequently, aggravated inequalities and contributed to worsening population health conditions and lifestyles³⁹39 Silva AG, Teixeira RA, Prates EJS, Malta DC. Monitoramento e projeções das metas de fatores de risco e proteção para o enfrentamento das doenças crônicas não transmissíveis nas capitais brasileiras. Cien Saude Colet 2021; 26(4):1193-1206.. Also the government’s regulatory role has been weakened, as shown by stable tobacco prices and lack of oversight of e-cigarette sales, as well as a growing illicit cigarette trade⁴⁰40 Malta DC, Duncan BB, Barros MBA, Katikireddi SV, Souza FM, Silva AGD, Machado DB, Barreto ML. Medidas de austeridade fiscal comprometem metas de controle de doenças não transmissíveis no Brasil. Cien Saude Colet 2018; 23(10):3115-3122.^,4141 Instituto Nacional do Câncer (INCA). Mercado ilegal de produtos de tabaco [Internet]. 2019 [acessado 2023 jun 13]. Disponível em: https://www.inca.gov.br/en/node/1688.
https://www.inca.gov.br/en/node/1688... . These issues have also contributed to greater exposure to health risk factors, such as tobacco use, especially among adolescents, who are at a stage of intense changes, which is influenced by the political, economic, social, cultural, family and collective context.

These study findings are subject to certain limitations. These relate firstly to the appropriateness of the question about use of other tobacco products, which is estimated by individual questions about each product, unlike the 2015 data obtained by a single question. Asked in this way, the questions may result in overestimation: when asked about consumption of individual tobacco products, adolescents tend to respond more precisely and remember better and, as a result, memory bias may occur³⁷37 Oliveira LMFT, Santos ARM, Farah BQ, Ritti-Dias RM, Freitas CMSM, Diniz PRB. Influence of parental smoking on the use of alcohol and illicit drugs among adolescents. Einstein (São Paulo) 2018; 17(1):eAO4377.. Secondly, under-reporting of tobacco use and other habits is possible, because they constitute risk behaviour, and some are even illegal. However, the PeNSE was based on leading international surveys, such as the Global School-Based Student Health Survey, the Health Behaviour in School-Aged Children and the Youth Risk Behavior Surveillance System, which validated the questionnaire after reproducibility and validity analyses had returned satisfactory results. Lastly, the PeNSE depicts adolescents in school and may thus exclude participation by those out of school and at greater risk of substance use. Even given its limitations, though, the study does portray the realities of adolescents from 13 to 17 years old who are in school.

Although tobacco use held stable between 2015 and 2019, use of other tobacco products, particularly hookahs and e-cigarettes, increased considerably. In addition, tobacco use was associated with sociodemographic factors, such as age and skin colour, the presence of other types of risk behaviour, such as use of drugs and alcoholic beverages, as well as with family context and mental health considerations. Exposure to health risk factors may be influenced by specific conditions. Notable was the Anvisa’s prohibiting the sale of e-cigarettes in 2009, reiterated in 2022. These measures, however, face numerous threats and industry attempts to change the regulatory framework. Here, the position of organised civil society has been fundamental to defending the regulatory framework⁴²42 Scholz JR, Malta DC, Fagundes Júnior AAP, Pavanello R, Bredt Júnior GL, Rocha MS. Posicionamento da Sociedade Brasileira de Cardiologia sobre o Uso de Dispositivos Eletrônicos para Fumar - 2024. Arq Bras Cardiol 2024; 121(2):e20240063.. This highlights the importance of advancing in policies for social protection and tobacco product oversight and regulation, in addition to introducing inter-sector policies to foster improved conditions of life and health, especially among more vulnerable adolescents and their families.

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