ABSTRACT

Objective:

To compare indicators of tobacco use, secondhand smoke, cessation and exposure to pro- and anti-tobacco media in 2013 and 2019, and to describe these indicators according to sociodemographic variables in 2019.

Methods:

Cross-sectional study with data from the National Health Survey. The indicators of use, secondhand smoke, cessation and exposure to tobacco-related media were evaluated. Prevalence and confidence intervals (95%CI) were estimated for the total population in 2013 and 2019 and according to sociodemographic variables for 2019. Poisson regression with robust variance was used to assess differences in prevalence.

Results:

There was an improvement in most of the indicators studied: an increase in ex-smokers, a reduction in secondhand smoke and attempts to quit smoking. All pro- and anti-tobacco media exposure indicators declined. When considering the prevalence according to sociodemographic characteristics in 2019, 43.8% (95%CI 41.6–46.0) of men tried to quit smoking, and 50.8% (95%CI 48.5–53.2) of women. Secondhand smoke at home was higher among women (10.2%; 95%CI 9.7–10.8). Among those who thought about quitting smoking because of warnings, the proportion was higher among women (48.0%; 95%CI 45.3–50.6). Tobacco use was higher among men (43.8%; 95%CI 41.6–46.0), in the population aged 40 to 59 years (14.9%; 95%CI 14.2–15.6), with a lower level of education (17.6%; 95%CI 16.8–18.4).

Conclusion:

The study showed improvement in tobacco-related indicators between the years studied. It is noteworthy that this advance was smaller in relation to the other periods previously analyzed, and therefore, greater investments in public policies to combat and control smoking in Brazil are necessary.

Keywords:
Tobacco use disorder; Smoking; Tobacco use cessation; Smoking prevention; Demography; Brazil

INTRODUCTION

Globally, tobacco use and exposure are considered a threat to public health, responsible for a high and avoidable burden of morbidity and mortality. The World Health Organization (WHO) estimates that around 8 million deaths worldwide have occurred due to tobacco use¹1. World Health Organization. WHO report on the global tobacco epidemic, 2019: offer help to quit tobacco use. Genebra: World Health Organization; 2019.. Approximately 7 million results from direct use of it and 1.2 million from exposure to secondhand smoke²2. World Health Organization. Tobacco: key facts [Internet]. Genebra: World Health Organization; 2020. [accessed on May 16, 2021]. Available at:https://www.who.int/news-room/fact-sheets/detail/tobacco
https://www.who.int/news-room/fact-sheet... .

In Brazil, smoking was responsible, in 2019, for 191,000 deaths and 5,159.945 million years of life lost adjusted for disability (disability-adjusted life years — DALYs)³3. Institute for Health Metrics and Evaluation. GBD Compare, Viz Hub [Internet]. University of Washington; 2019. [accessed on May 16, 2021]. Available at:https://vizhub.healthdata.org/gbd-compare
https://vizhub.healthdata.org/gbd-compar... . In 2017, among the deaths attributed to tobacco were ischemic cardiovascular diseases, chronic respiratory diseases and cancers of the lung, trachea and bronchi⁴4. Malta DC, Flor LS, Machado ÍE, Felisbino-Mendes MS, Brant LCC, Ribeiro ALP, et al. Trends in prevalence and mortality burden attributable to smoking, Brazil and federated units, 1990 and 2017. Popul Health Metr 2020; 18 (Suppl 1): 24. https://doi.org/10.1186/s12963-020-00215-2
https://doi.org/10.1186/s12963-020-00215... .

Combating smoking has been considered a successful action, and Brazil has become a global reference for anti-tobacco initiatives. These advances are attributed to the regulatory measures adopted in the country, such as the prohibition of advertising, promotion and sponsorship of cigarettes (except at points of sale), increase in cigarette prices, warning images on tobacco packages and packages, and banning smoking indoors, among others⁴4. Malta DC, Flor LS, Machado ÍE, Felisbino-Mendes MS, Brant LCC, Ribeiro ALP, et al. Trends in prevalence and mortality burden attributable to smoking, Brazil and federated units, 1990 and 2017. Popul Health Metr 2020; 18 (Suppl 1): 24. https://doi.org/10.1186/s12963-020-00215-2
https://doi.org/10.1186/s12963-020-00215... ,⁵5. World Health Organization. Tobacco control and the sustainable development goals. Genebra: World Health Organization; 2017.,⁶6. Portes LH, Machado CV, Turci SRB, Figueiredo VC, Cavalcante TM, Silva VLDCE. Tobacco control policies in brazil: a 30-year assessment. Cien Saude Colet 2018; 23 (6): 1837-48. https://doi.org/10.1590/1413-81232018236.05202018
https://doi.org/10.1590/1413-81232018236... ,⁷7. Szklo AS, de 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): 162-7. https://doi.org/10.1016/j.ypmed.2011.12.005
https://doi.org/10.1016/j.ypmed.2011.12.... .

Several national and global commitments ensured tobacco monitoring and control. Highlights include the Action Plan to Combat Chronic Non-Communicable Diseases 2011–2022⁸8. Malta DC, Morais Neto OL, Silva Junior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saude 2011; 20 (4): 425-38. http://doi.org/10.5123/S1679-49742011000400002
http://doi.org/10.5123/S1679-49742011000... and the WHO Global Action Plan for the Prevention and Control of Chronic Non-Communicable Diseases, which provides for a 30% reduction in smoking by 2025⁹9. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020. Genebra: World Health Organization; 2013.. Monitoring indicators of tobacco use and exposure is essential for tracking progress on national⁸8. Malta DC, Morais Neto OL, Silva Junior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011 a 2022. Epidemiol Serv Saude 2011; 20 (4): 425-38. http://doi.org/10.5123/S1679-49742011000400002
http://doi.org/10.5123/S1679-49742011000... and global⁹9. World Health Organization. Global action plan for the prevention and control of NCDs 2013-2020. Genebra: World Health Organization; 2013. commitments.

Therefore, this study aimed to: compare indicators of tobacco use, secondhand smoke, quitting and exposure to pro- and anti-tobacco media in 2013 and 2019 and to describe these indicators according to sociodemographic variables in 2019.

METHODS

Study Design

This was a cross-sectional, population-based, descriptive study that used data from the National Health Surveys (NHS) of 2013 and 2019. The NHS is a nationwide household survey carried out by the Brazilian Institute of Geography and Statistics (IBGE) in partnership with the Ministry of Health¹⁰10. Szwarcwald CL, Malta DC, Pereira CA, Vieira ML, Conde WL, Souza Júnior PR, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Cien Saude Colet 2014; 19 (2): 333-42. http://doi.org/10.1590/1413-81232014192.14072012
http://doi.org/10.1590/1413-81232014192.... ,¹¹11. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude 2020; 29 (5): e2020315. http://doi.org/10.1590/S1679-49742020000500004
http://doi.org/10.1590/S1679-49742020000... .

In 2013, the sample size was calculated at approximately 80,000 households, and information was collected from 64,348 households¹⁰10. Szwarcwald CL, Malta DC, Pereira CA, Vieira ML, Conde WL, Souza Júnior PR, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Cien Saude Colet 2014; 19 (2): 333-42. http://doi.org/10.1590/1413-81232014192.14072012
http://doi.org/10.1590/1413-81232014192.... .

In 2019, the sample was determined to be 108,525 households, and data were collected in 94,111, with a response rate of 93.6%¹¹11. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude 2020; 29 (5): e2020315. http://doi.org/10.1590/S1679-49742020000500004
http://doi.org/10.1590/S1679-49742020000... . To allow comparisons between the surveys, in 2019, data on the selected resident aged 18 or over would be analyzed, totaling 88,531 individuals. Further details about the methods can be found in specific publications¹⁰10. Szwarcwald CL, Malta DC, Pereira CA, Vieira ML, Conde WL, Souza Júnior PR, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Cien Saude Colet 2014; 19 (2): 333-42. http://doi.org/10.1590/1413-81232014192.14072012
http://doi.org/10.1590/1413-81232014192.... ,¹¹11. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude 2020; 29 (5): e2020315. http://doi.org/10.1590/S1679-49742020000500004
http://doi.org/10.1590/S1679-49742020000... ,¹²12. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil, grandes regiões e unidades da federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014.,¹³13. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões/IBGE, Coordenação de Trabalho e Rendimento. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020..

Variables

Further details on the construction of the indicators are presented in Supplementary Table 1.

Data Analysis

To assess differences between prevalences, Poisson regression with robust variance was used, and the significance level adopted was 5%. Statistical analyses were performed using the Software for Statistics and Data Science (Stata) version 14.

Ethical Aspects

The study followed the guidelines of Resolution No. 466/2012 of the National Health Council, which deals with research involving human beings. The NHS databases are available for public access and use, and both editions of the NHS were approved by the National Research Ethics Committee of the Ministry of Health, under Reports No. 328.159 (2013) and No. 3.529.376 (2019).

RESULTS

Table 1 shows the prevalence of the indicators analyzed in the years studied. There was an improvement in all tobacco use indicators between 2013 and 2019, with a 15% reduction. Regarding quitting indicators, there was an increase in the prevalence of former smokers (17.5% in 2013 to 26.6% in 2019; prevalence ratio — PR 1.52; 95%CI 1.46–1.58); however, there was a decrease in the prevalence of smokers who tried to quit smoking (51.1% in 2013 to 46.7% in 2019; PR 0.91; 95%CI 0.87–0.96). Secondhand smoke at home and at work also decreased between 2013 and 2019, with emphasis on secondhand smoke at work, which declined by 37% (13.4% in 2013 and 8.4% in 2019; PR 0.63; 95%CI 0.57–0.69). With regard to exposure to pro- and anti-tobacco media, there was a decrease in all indicators: pro-tobacco media (28.7% in 2013 to 18.4% in 2019; PR 0.64; 95%CI 0.61–0.68), anti-tobacco media (52% in 2013 to 39.2% in 2019; PR 0.75; 95%CI 0.73–0.77), smokers exposed to warnings (86.1% in 2013 for 83.2% in 2019; PR 0.97; 95%CI 0.94–0.99) and smokers who thought about quitting because of the warnings (52.1% in 2013 to 44.4% in 2019; PR 0.85; 95%CI 0.81-0.90).

Table 2 describes the indicators by sex in 2019. Women have lower prevalences in most indicators, except for: attempt to quit smoking in the last 12 months (PR 1.16; 95%CI 1.08–1.24); passive smoking at home (PR 1.3 95%CI 1.18–1.42); smokers exposed to warnings (PR 1.03; 95%CI 1.01–1.06); and thinking about quitting smoking because of the warnings (PR 1.14; 95%CI 1.06–1.23). There was no difference in the prevalence of ex-smokers according to sex.

Table 3 presents the indicators according to age group. The PRs were calculated with reference to the population aged 18–24 years, which had lower prevalence of tobacco use. These were higher among individuals aged 40 to 59 years for the use of tobacco derivatives (14.9%; 95%CI 14.2–15.6; PR 1.38; 95%CI 1.23–1.56) and of current tobacco smokers (14.7%; 95%CI 14.015.4; PR 1.38; 95%CI 1.22–1.56). Regarding daily tobacco use and current and daily use of cigarettes, they were higher in the population aged 40 to 59 years (PR 1.61 95%CI 1.41–1.84; PR 1.50 95%CI 1.33 –1.70; and PR 1.76 95%CI 1.53–2.02, respectively) and above 60 (PR 1.26 95%CI 1.10–1.45; PR 1.15 95%CI 1.01 –1.31; and PR 1.35 95%CI 1.17–1.56, respectively). Adults aged 40–59 years and the elderly (60 years and over) were the ones who least tried to quit smoking (PR 0.87 95%CI 0.77–0.98 and PR 0.88 95%CI 0.77–0 .99, respectively) but with a higher prevalence of former smokers (PR 1.44 95%CI 1.31–1.57 and PR 2.27 95%CI 2.07–2.48, respectively). Secondhand smoke at home was high at 18–24 years (15.7%; 95%CI 14.0–17.3) and decreased with increasing age. Exposure to the pack warning was less perceived by the elderly (PR 0.89; 95%CI; 0.84–0.94). Anti-tobacco media exposure was highest among adults aged 40 to 59 years. The proportion of smokers who thought about quitting because of the warnings was higher between 25 and 39 years old (PR 1.31; 95%CI 1.11–1.54) and between 40 and 59 years old (PR 1.33; 95%CI % 1.12–1.58).

Table 4 describes the indicators according to the level of education. The population with no education and incomplete elementary school had the highest prevalence of most indicators: current tobacco use (17.6%; 95%CI 16.8–18.4), almost three times compared to the population with higher education; secondhand smoke at work (14.1%; 95%CI 12.6–15.7), about three times higher. The prevalence of all indicators of tobacco use, ex-smokers and passive smokers at work was lower with increasing schooling. The population with complete higher education or more was the one who least tried to quit smoking, had the least exposure to anti-tobacco media, and who thought the least about quitting because of the warnings on the pack. The prevalence of exposure to pro-tobacco media and the perception of warnings on the pack was higher among the more educated (Table 4).

Table 5 shows the analyses according to race/skin color. People of black and mixed race/color had a higher prevalence of all indicators of tobacco use and secondhand smoke at home and at work, trying to quit smoking and exposure to anti-tobacco media, and less exposure to warnings on the pack. The percentage of former smokers was higher in the population of black race/skin color (28.8%; 95%CI 27.2–30.5). Exposure to the pro-tobacco media was lower among people of mixed race/color.

In the supplementary material, analyses according to regions of Brazil and household income are presented. The worst indicators related to tobacco use, quitting, secondhand smoke and exposure to the media were observed in the North and Northeast regions (Supplementary Table 1). Regarding household income, in general, the worst indicators were found among those with up to 1 MW (Supplementary Table 2).

DISCUSSION

The present study showed that between 2013 and 2019: there was an improvement in most tobacco use indicators; there was a reduction in secondhand smoke at work and at home; there was an increase in the prevalence of ex-smokers, but a reduction in the attempt to quit smoking; and media indicators point to reduced exposure to pro and anti-tobacco media, as well as to warnings. When considering the sociodemographic variables, in 2019, tobacco use was higher in men, aged 40–59 years, in less educated, low-income, blacks and browns, from the South, Midwest and Southeast regions.

In 2019, 20.4 million (12.8%) adults were tobacco users, and smoked tobacco corresponds to almost all of this consumption — about 20 million, that is, 12.6% of users. Thus, only 0.2% reported using chewed tobacco or other forms of consumption of the product. These results differ from those of other Asian countries, such as Bangladesh and India, where chewed or smokeless tobacco, for cultural reasons, has higher prevalence¹⁴14. Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, et al. Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys. Lancet 2012; 380 (9842): 668-79. http://doi.org/10.1016/S0140-6736(12)61085-X
http://doi.org/10.1016/S0140-6736(12)610...

It was found that the prevalence of tobacco use was higher among men, which has been described in most countries¹⁴14. Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, et al. Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys. Lancet 2012; 380 (9842): 668-79. http://doi.org/10.1016/S0140-6736(12)61085-X
http://doi.org/10.1016/S0140-6736(12)610... –¹⁶16. Flor LS, Reitsma MB, Gupta V, Ng M, Gakidou E. The effects of tobacco control policies on global smoking prevalence. Nat Med 2021; 27 (2): 239-43. http://doi.org/10.1038/s41591-020-01210-8
http://doi.org/10.1038/s41591-020-01210-... . A study with data from Global Burden of Disease (GBD) highlights that 933.1 million people smoke daily worldwide, of which more than 80% are men¹⁵15. GBD 2015 Tobacco Collaborators. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet 2017; 389 (10082): 1885-906. http://doi.org/10.1016/S0140-6736(17)30819-X
http://doi.org/10.1016/S0140-6736(17)308... . In Brazil, at the beginning of the 20th century, tobacco use was a male practice, and initiation among women took place around the 1960s and 1970s, associated with the image of female emancipation and gender equality¹⁷17. Apelberg B, Aghi M, Asma S, Donaldson E, Yeong CC, Vaithinathan R. Prevalence of tobacco use and factors influencing initiation and maintenance among women. In: Samet JM, Soon-Young Y, editors. Gender, women, and the tobacco epidemic. Genebra: World Health Organization; 2010.,¹⁸18. Huxley RR, Woodward M. Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies. Lancet 2011; 378 (9799): 1297-305. http://doi.org/10.1016/S0140-6736(11)60781-2
http://doi.org/10.1016/S0140-6736(11)607... ,¹⁹19. Vollset SE, Tverdal A, Gjessing HK. Smoking and deaths between 40 and 70 years of age in women and men. Ann Intern Med 2006;144 (6): 381-9. http://doi.org/10.7326/0003-4819-144-6-200603210-00004
http://doi.org/10.7326/0003-4819-144-6-2... , which explains such differences. However, in recent decades, tobacco use has declined in both sexes²⁰20. Malta DC, Silva AG, Machado ÍE, Sá ACMGN, Santos FMD, Prates EJS, Cristo EB. Trends in smoking prevalence in all Brazilian capitals between 2006 and 2017. J Bras Pneumol 2019; 45 (5): e20180384. http://doi.org/10.1590/1806-3713/e20180384
http://doi.org/10.1590/1806-3713/e201803... ,²¹21. Silva AG, Teixeira RA, Prates EJS, Malta DC. Monitoring and projection of targets for risk and protection factors for coping with noncommunicable diseases in Brazilian capitals. Cien Saude Colet 2021; 26 (4): 1193-206. http://doi.org/10.1590/1413-81232021264.42322020
http://doi.org/10.1590/1413-81232021264.... .

The age group that smokes the most is 40–59 years old, but studies have shown a decline in all age groups²⁰20. Malta DC, Silva AG, Machado ÍE, Sá ACMGN, Santos FMD, Prates EJS, Cristo EB. Trends in smoking prevalence in all Brazilian capitals between 2006 and 2017. J Bras Pneumol 2019; 45 (5): e20180384. http://doi.org/10.1590/1806-3713/e20180384
http://doi.org/10.1590/1806-3713/e201803... . Among young people, the lowest prevalence reflects the role of regulatory measures adopted and the lower use among adolescents⁴4. Malta DC, Flor LS, Machado ÍE, Felisbino-Mendes MS, Brant LCC, Ribeiro ALP, et al. Trends in prevalence and mortality burden attributable to smoking, Brazil and federated units, 1990 and 2017. Popul Health Metr 2020; 18 (Suppl 1): 24. https://doi.org/10.1186/s12963-020-00215-2
https://doi.org/10.1186/s12963-020-00215... ,²²22. Malta DC, Hallal ALC, Machado ÍE, Prado RRD, Oliveira PPV, Campos MO, et al. Factors associated with the use of waterpipe and other tobacco products among students, Brazil, 2015. Rev Bras Epidemiol 2018; 21 (Suppl 1): e180006. http://doi.org/10.1590/1980-549720180006.supl.1
http://doi.org/10.1590/1980-549720180006... . For the elderly, the prevalence has also reduced, which can be attributed to doctors’ guidelines and those of other health professionals to stop smoking²³23. Malta DC, Oliveira TP, Vieira ML, Almeida L, Szwarcwald CL. Use of tobacco and exposure to tobacco smoke in Brazil: results from the National Health Survey 2013. Epidemiol Serv Saude 2015; 24 (2): 239-48. http://doi.org/10.5123/S1679-49742015000200006
http://doi.org/10.5123/S1679-49742015000... .

There was also evidence of higher prevalence of tobacco use in the population with low income and education, which has already been described in studies carried out in Brazil²⁰20. Malta DC, Silva AG, Machado ÍE, Sá ACMGN, Santos FMD, Prates EJS, Cristo EB. Trends in smoking prevalence in all Brazilian capitals between 2006 and 2017. J Bras Pneumol 2019; 45 (5): e20180384. http://doi.org/10.1590/1806-3713/e20180384
http://doi.org/10.1590/1806-3713/e201803... ,²¹21. Silva AG, Teixeira RA, Prates EJS, Malta DC. Monitoring and projection of targets for risk and protection factors for coping with noncommunicable diseases in Brazilian capitals. Cien Saude Colet 2021; 26 (4): 1193-206. http://doi.org/10.1590/1413-81232021264.42322020
http://doi.org/10.1590/1413-81232021264.... and in other countries¹⁴14. Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, et al. Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys. Lancet 2012; 380 (9842): 668-79. http://doi.org/10.1016/S0140-6736(12)61085-X
http://doi.org/10.1016/S0140-6736(12)610... and attributed to lower access to health promotion practices and cessation.

Black and brown individuals had a higher prevalence of tobacco use and exposure to its smoke in the present study, which can be explained by their lower socioeconomic status, their lower access to health promotion practices and their higher exposure to tobacco at work. However, in other countries, such as the United States of America, opposite results were described, with a lower prevalence among blacks²⁴24. Centers for Disease Control and Prevention. Burden of Cigarette Use in the U.S [Internet]. Centers for Disease Control and Prevention; 2019. [accessed on May 16, 2021]. Available at:https://www.cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united-states.html
https://www.cdc.gov/tobacco/campaign/tip... .

Tobacco cessation indicators showed an increase in ex-smokers for the total population, with an increase after 60 years and in the uneducated population. Former smokers in Brazil are twice as numerous (42.3 million) as smokers (20 million). This success can be credited to the anti-tobacco policies of recent years, such as the ban on advertising, the increase in product taxation and warnings⁷7. Szklo AS, de 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): 162-7. https://doi.org/10.1016/j.ypmed.2011.12.005
https://doi.org/10.1016/j.ypmed.2011.12.... ,²⁰20. Malta DC, Silva AG, Machado ÍE, Sá ACMGN, Santos FMD, Prates EJS, Cristo EB. Trends in smoking prevalence in all Brazilian capitals between 2006 and 2017. J Bras Pneumol 2019; 45 (5): e20180384. http://doi.org/10.1590/1806-3713/e20180384
http://doi.org/10.1590/1806-3713/e201803... ,²²22. Malta DC, Hallal ALC, Machado ÍE, Prado RRD, Oliveira PPV, Campos MO, et al. Factors associated with the use of waterpipe and other tobacco products among students, Brazil, 2015. Rev Bras Epidemiol 2018; 21 (Suppl 1): e180006. http://doi.org/10.1590/1980-549720180006.supl.1
http://doi.org/10.1590/1980-549720180006... ,²⁵25. Figueiredo VC, Turci SRB, Camacho LAB. Tobacco control in Brazil: the achievements and challenges of a successful policy. Cad Saude Publica 2017; 33 (Suppl 3): e00104917. http://doi.org/10.1590/0102-311X00104917
http://doi.org/10.1590/0102-311X00104917... . Supporting smoking cessation is one of the milestones of the Framework Convention on Tobacco Control²⁶26. World Health Organization. WHO framework convention on tobacco control. World Health Organization: Genebra; 2003.,²⁷27. Borges LC, Menezes HZ, Souza IML. Dilemmas in the implementation of the World Health Organization Framework Convention on Tobacco Control. Cad Saude Publica 2020; 36 (2): e00136919. http://doi.org/10.1590/0102-311X00136919
http://doi.org/10.1590/0102-311X00136919... .

Furthermore, access to treatment has been expanded, through training of teams, as well as an increase in the acquisition and distribution of medications for cessation. Furthermore, treatment for smoking cessation (or treatment for nicotine dependence) has been offered free of charge by the Unified Health System (SUS) since 2004²⁸28. Brasil. Portaria nº 442, de 13 de agosto de 2004. Atualiza as diretrizes de cuidado à pessoa tabagista no âmbito da Rede de Atenção à Saúde das Pessoas com Doenças Crônicas do Sistema Único de Saúde (SUS) e dá outras providências. Brasil; 2004., updated in 2013, through Ordinance No. 571²⁹29. Brasil. Portaria nº 571, de 5 de abril de 2013. Atualiza as diretrizes de cuidado à pessoa tabagista no âmbito da Rede de Atenção à Saúde das Pessoas com Doenças Crônicas do Sistema Único de Saúde (SUS) e dá outras providências. Brasil; 2013..

Among smokers, nearly half, or 46.6% (10 million), tried to quit smoking. However, this reduction was smaller compared to 2013, which was 51%. Brazil is one of the 23 countries that have adopted the “MPOWER” policy package, part of the WHO Action Plan for the prevention and control of non-communica0ble diseases (NCDs)¹1. World Health Organization. WHO report on the global tobacco epidemic, 2019: offer help to quit tobacco use. Genebra: World Health Organization; 2019.. MPOWER encourages countries to monitor tobacco use and prevention policies, protection from secondhand smoke, cessation support, and regulatory measures¹1. World Health Organization. WHO report on the global tobacco epidemic, 2019: offer help to quit tobacco use. Genebra: World Health Organization; 2019.,³⁰30. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package. Genebra: World Health Organization; 2008..

Secondhand smoke, that is, the inhalation of tobacco smoke and its derivatives, increases the risk of developing the same diseases that active smoking engenders, although to a lesser extent³¹31. Tilloy E, Cottel D, Ruidavets JB, Arveiler D, Ducimetière P, Bongard V, et al. Characteristics of current smokers, former smokers, and second-hand exposure and evolution between 1985 and 2007. Eur J Cardiovasc Prev Rehabil 2010; 17 (6): 730-6. http://doi.org/10.1097/HJR.0b013e32833a9a0c
http://doi.org/10.1097/HJR.0b013e32833a9... . In 2019, in Brazil, 27 thousand deaths (1.9% of the total deaths) and 771,000 DALYs (1.1% of the total DALYs) were attributed to secondhand smoke³3. Institute for Health Metrics and Evaluation. GBD Compare, Viz Hub [Internet]. University of Washington; 2019. [accessed on May 16, 2021]. Available at:https://vizhub.healthdata.org/gbd-compare
https://vizhub.healthdata.org/gbd-compar... . Secondhand smokers at work are mostly men, young people, blacks with low education and low income³²32. Passos VM, Giatti L, Barreto SM. Tabagismo passivo no Brasil: resultados da Pesquisa Especial Do Tabagismo, 2008. Cien Saude Colet 2011; 16 (9): 3671-8. http://doi.org/10.1590/s1413-81232011001000004
http://doi.org/10.1590/s1413-81232011001... . This characterization is possibly the result of exposure to jobs with less regulation³²32. Passos VM, Giatti L, Barreto SM. Tabagismo passivo no Brasil: resultados da Pesquisa Especial Do Tabagismo, 2008. Cien Saude Colet 2011; 16 (9): 3671-8. http://doi.org/10.1590/s1413-81232011001000004
http://doi.org/10.1590/s1413-81232011001... ,³³33. Cavalcante TM. O controle do tabagismo no Brasil: avanços e desafios. Rev Psiquiatr Clín 2005; 32 (5): 283-300. http://doi.org/10.1590/S0101-60832005000500006
http://doi.org/10.1590/S0101-60832005000... . In 2011, Law No. 12,546 and, in 2014, Presidential Decree No. 8.262 prohibited the practice of smoking in public places³⁴34. Brasil. Lei nº 12.546, de 14 de dezembro de 2011. Institui o Regime Especial de Reintegração de Valores Tributários para as Empresas Exportadoras (Reintegra); dispõe sobre a redução do Imposto sobre Produtos Industrializados (IPI) à indústria automotiva; altera a incidência das contribuições previdenciárias devidas pelas empresas que menciona; altera as Leis nº 11.774, de 17 de setembro de 2008, nº 11.033, de 21 de dezembro de 2004, nº 11.196, de 21 de novembro de 2005, nº 10.865, de 30 de abril de 2004, nº 11.508, de 20 de julho de 2007, nº 7.291, de 19 de dezembro de 1984, nº 11.491, de 20 de junho de 2007, nº 9.782, de 26 de janeiro de 1999, e nº 9.294, de 15 de julho de 1996, e a Medida Provisória nº 2.199-14, de 24 de agosto de 2001; revoga o art. 1º da Lei nº 11.529, de 22 de outubro de 2007, e o art. 6º do Decreto-Lei nº 1.593, de 21 de dezembro de 1977, nos termos que especifica; e dá outras providência. Brasil; 2011.,³⁵35. Brasil. Decreto nº 8.262, de 31 de maio de 2014. Altera o Decreto nº 2.018, de 1º de outubro de 1996, que regulamenta a lei n.º 9.294, de 15 de julho de 1996.Brasília; Distrito Federal, 2014.. There was also a greater reduction in the prevalence of secondhand smoke at work than at home between 2013 and 2019, an effect of this regulatory framework³⁴34. Brasil. Lei nº 12.546, de 14 de dezembro de 2011. Institui o Regime Especial de Reintegração de Valores Tributários para as Empresas Exportadoras (Reintegra); dispõe sobre a redução do Imposto sobre Produtos Industrializados (IPI) à indústria automotiva; altera a incidência das contribuições previdenciárias devidas pelas empresas que menciona; altera as Leis nº 11.774, de 17 de setembro de 2008, nº 11.033, de 21 de dezembro de 2004, nº 11.196, de 21 de novembro de 2005, nº 10.865, de 30 de abril de 2004, nº 11.508, de 20 de julho de 2007, nº 7.291, de 19 de dezembro de 1984, nº 11.491, de 20 de junho de 2007, nº 9.782, de 26 de janeiro de 1999, e nº 9.294, de 15 de julho de 1996, e a Medida Provisória nº 2.199-14, de 24 de agosto de 2001; revoga o art. 1º da Lei nº 11.529, de 22 de outubro de 2007, e o art. 6º do Decreto-Lei nº 1.593, de 21 de dezembro de 1977, nos termos que especifica; e dá outras providência. Brasil; 2011.–³⁶36. Brasil. Lei nº 9.294, de 15 de julho de 1996. Dispõe sobre as restrições ao uso e à propaganda de produtos fumígeros, bebidas alcoólicas, medicamentos, terapias e defensivos agrícolas, nos termos do § 4° do art. 220 da Constituição Federal. Brasil; 1996.. The prevalence of passive smokers at home, in addition to being higher than at work, covers 12.7 million non-smoking adults, mostly women, younger, with low education and income, black and brown. These results show that passive smokers at home represent a more vulnerable population with less protection by legislation, which refers to public collective places³⁴34. Brasil. Lei nº 12.546, de 14 de dezembro de 2011. Institui o Regime Especial de Reintegração de Valores Tributários para as Empresas Exportadoras (Reintegra); dispõe sobre a redução do Imposto sobre Produtos Industrializados (IPI) à indústria automotiva; altera a incidência das contribuições previdenciárias devidas pelas empresas que menciona; altera as Leis nº 11.774, de 17 de setembro de 2008, nº 11.033, de 21 de dezembro de 2004, nº 11.196, de 21 de novembro de 2005, nº 10.865, de 30 de abril de 2004, nº 11.508, de 20 de julho de 2007, nº 7.291, de 19 de dezembro de 1984, nº 11.491, de 20 de junho de 2007, nº 9.782, de 26 de janeiro de 1999, e nº 9.294, de 15 de julho de 1996, e a Medida Provisória nº 2.199-14, de 24 de agosto de 2001; revoga o art. 1º da Lei nº 11.529, de 22 de outubro de 2007, e o art. 6º do Decreto-Lei nº 1.593, de 21 de dezembro de 1977, nos termos que especifica; e dá outras providência. Brasil; 2011.–³⁶36. Brasil. Lei nº 9.294, de 15 de julho de 1996. Dispõe sobre as restrições ao uso e à propaganda de produtos fumígeros, bebidas alcoólicas, medicamentos, terapias e defensivos agrícolas, nos termos do § 4° do art. 220 da Constituição Federal. Brasil; 1996..

There was a reduction in smokers exposed to anti-tobacco media, which in 2013 were approximately half of the population, while in 2019 they totaled about 40%. WHO recommends investing in risk communication, anti-tobacco communication campaigns and other risk factors for NCDs³⁷37. World Health Organization. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Genebra: World Health Organization; 2011.. The perception of reduction may be due to less investment in government social communication actions in the health area⁴4. Malta DC, Flor LS, Machado ÍE, Felisbino-Mendes MS, Brant LCC, Ribeiro ALP, et al. Trends in prevalence and mortality burden attributable to smoking, Brazil and federated units, 1990 and 2017. Popul Health Metr 2020; 18 (Suppl 1): 24. https://doi.org/10.1186/s12963-020-00215-2
https://doi.org/10.1186/s12963-020-00215... . On the other hand, it is noteworthy that there was a reduction in exposure to the pro-tobacco media, which is positive, and that the regulatory framework for banning advertising³⁴34. Brasil. Lei nº 12.546, de 14 de dezembro de 2011. Institui o Regime Especial de Reintegração de Valores Tributários para as Empresas Exportadoras (Reintegra); dispõe sobre a redução do Imposto sobre Produtos Industrializados (IPI) à indústria automotiva; altera a incidência das contribuições previdenciárias devidas pelas empresas que menciona; altera as Leis nº 11.774, de 17 de setembro de 2008, nº 11.033, de 21 de dezembro de 2004, nº 11.196, de 21 de novembro de 2005, nº 10.865, de 30 de abril de 2004, nº 11.508, de 20 de julho de 2007, nº 7.291, de 19 de dezembro de 1984, nº 11.491, de 20 de junho de 2007, nº 9.782, de 26 de janeiro de 1999, e nº 9.294, de 15 de julho de 1996, e a Medida Provisória nº 2.199-14, de 24 de agosto de 2001; revoga o art. 1º da Lei nº 11.529, de 22 de outubro de 2007, e o art. 6º do Decreto-Lei nº 1.593, de 21 de dezembro de 1977, nos termos que especifica; e dá outras providência. Brasil; 2011.–³⁶36. Brasil. Lei nº 9.294, de 15 de julho de 1996. Dispõe sobre as restrições ao uso e à propaganda de produtos fumígeros, bebidas alcoólicas, medicamentos, terapias e defensivos agrícolas, nos termos do § 4° do art. 220 da Constituição Federal. Brasil; 1996. has worked⁴4. Malta DC, Flor LS, Machado ÍE, Felisbino-Mendes MS, Brant LCC, Ribeiro ALP, et al. Trends in prevalence and mortality burden attributable to smoking, Brazil and federated units, 1990 and 2017. Popul Health Metr 2020; 18 (Suppl 1): 24. https://doi.org/10.1186/s12963-020-00215-2
https://doi.org/10.1186/s12963-020-00215... ,⁷7. Szklo AS, de 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): 162-7. https://doi.org/10.1016/j.ypmed.2011.12.005
https://doi.org/10.1016/j.ypmed.2011.12.... .

The WHO also recommends the implementation of warning images on cigarette packages in order to increase knowledge about the harm caused by their use³⁰30. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package. Genebra: World Health Organization; 2008.,³⁸38. D’Ornellas MCGDS, Brust-Renck PG. Plain packaging of tobacco products in Brazil: the contribution of science to the decision to safeguard the human right to health. Cad Saude Publica 2017; 33 (7): e00210216. http://doi.org/10.1590/0102-311X00210216
http://doi.org/10.1590/0102-311X00210216... . This indicator was measured among smokers and showed that they were less exposed to warnings between 2013 and 2019; the images had less impact among them, affecting 52% of them in 2013 and 44% in 2019, that is, less than half of smokers thought about quitting because of the warnings in the last survey.

Although there was an improvement in most indicators related to tobacco consumption in the country, the advances were less expressive in the analyzed period. This result has been confirmed by telephone surveys carried out in capitals, which showed that between 2015 and 2019 there was a smaller reduction in the prevalence of smokers, which may indicate flaws in regulation and pricing policies⁴4. Malta DC, Flor LS, Machado ÍE, Felisbino-Mendes MS, Brant LCC, Ribeiro ALP, et al. Trends in prevalence and mortality burden attributable to smoking, Brazil and federated units, 1990 and 2017. Popul Health Metr 2020; 18 (Suppl 1): 24. https://doi.org/10.1186/s12963-020-00215-2
https://doi.org/10.1186/s12963-020-00215... ,²¹21. Silva AG, Teixeira RA, Prates EJS, Malta DC. Monitoring and projection of targets for risk and protection factors for coping with noncommunicable diseases in Brazilian capitals. Cien Saude Colet 2021; 26 (4): 1193-206. http://doi.org/10.1590/1413-81232021264.42322020
http://doi.org/10.1590/1413-81232021264.... . Another study, with data from the National Adolescent Health Survey (PeNSE), showed an increase in the use of other tobacco products, in particular the hookah, showing recent changes in the behavior of tobacco in the country among the young population²²22. Malta DC, Hallal ALC, Machado ÍE, Prado RRD, Oliveira PPV, Campos MO, et al. Factors associated with the use of waterpipe and other tobacco products among students, Brazil, 2015. Rev Bras Epidemiol 2018; 21 (Suppl 1): e180006. http://doi.org/10.1590/1980-549720180006.supl.1
http://doi.org/10.1590/1980-549720180006... . Since 2015, Brazil has been going through a political and economic crisis and has implemented fiscal austerity measures, budget cuts, with the approval of Constitutional Amendment No. 95³⁹39. Brasil. Presidência da República. Emenda constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Brasil; 2016., in addition to less investment in public policies and regulation²¹21. Silva AG, Teixeira RA, Prates EJS, Malta DC. Monitoring and projection of targets for risk and protection factors for coping with noncommunicable diseases in Brazilian capitals. Cien Saude Colet 2021; 26 (4): 1193-206. http://doi.org/10.1590/1413-81232021264.42322020
http://doi.org/10.1590/1413-81232021264.... . These measures have contributed to the deterioration of the population’s health, also resulting in an increase in poverty²¹21. Silva AG, Teixeira RA, Prates EJS, Malta DC. Monitoring and projection of targets for risk and protection factors for coping with noncommunicable diseases in Brazilian capitals. Cien Saude Colet 2021; 26 (4): 1193-206. http://doi.org/10.1590/1413-81232021264.42322020
http://doi.org/10.1590/1413-81232021264.... ,⁴⁰40. Paes-Sousa R, Schramm JMA, Mendes LVP. Fiscal austerity and the health sector: the cost of adjustments. Cien Saude Colet 2019; 24 (12): 4375-84. http://doi.org/10.1590/1413-812320182412.23232019
http://doi.org/10.1590/1413-812320182412... ,⁴¹41. Malta DC, Duncan BB, Schmidt MI, Teixeira R, Ribeiro ALP, Felisbino-Mendes MS, et al. Trends in mortality due to non-communicable diseases in the Brazilian adult population: national and subnational estimates and projections for 2030. Popul Health Metr 2020; 18 (Suppl 1): 16. http://doi.org/10.1186/s12963-020-00216-1
http://doi.org/10.1186/s12963-020-00216-... ,⁴²42. Souza LE, Rasella D, Barros R, Lisboa E, Malta D, Mckee M. Smoking prevalence and economic crisis in Brazil. Rev Saude Publica 2021; 55: 3. http://doi.org/10.11606/s1518-8787.2021055002768
http://doi.org/10.11606/s1518-8787.20210... ,⁴³43. Vieira FS. Health financing in Brazil and the goals of the 2030 Agenda: high risk of failure. Rev Saude Publica 2020; 54: 127. http://doi.org/10.11606/s1518-8787.2020054002414
http://doi.org/10.11606/s1518-8787.20200... . There was less investment in the regulatory role of the Brazilian government, less inspection of tobacco products and an increase in illegal trade⁴⁴44. Malta DC, Duncan BB, Barros MBA, Katikireddi SV, Souza FM, Silva AG, et al. Fiscal austerity measures hamper noncommunicable disease control goals in Brazil. Cien Saude Colet 2018; 23 (10): 3115-22. http://doi.org/10.1590/1413-812320182310.25222018
http://doi.org/10.1590/1413-812320182310... ,⁴⁵45. Instituto Nacional de Câncer. Mercado ilegal de produtos de tabaco [Internet]. Rio de Janeiro: Instituto Nacional de Câncer; 2021. [accessed on May 16, 2021]. Available at:https://www.inca.gov.br/observatorio-da-politica-nacional-de-controle-do-tabaco/mercado-ilegal
https://www.inca.gov.br/observatorio-da-... . In this sense, there is the possibility of a plateau of prevalences or, worse, of an increasing trend. The maintenance and progress in fighting the tobacco epidemic depend on the expansion of the regulatory framework, such as the adoption of generic packaging, as well as support for small farmers in the diversification of their crops in order to achieve the goals of the 2030 Agenda for Sustainable Development Goals⁵5. World Health Organization. Tobacco control and the sustainable development goals. Genebra: World Health Organization; 2017..

Among the limitations of this study, the cross-sectional design is highlighted, which makes it impossible to establish a causal relationship between the findings. However, the NHS is the gold standard in population-based surveys and is used as a basis for other estimates from other surveys. Another issue refers to the fact that the information is self-reported by the participants, which may be subject to information bias. However, studies that compare self-reported with measured data show that the former have good reliability⁴⁶46. Lima-Costa MF, Peixoto SV, Firmo JO, Uchoa E. Validade do diabetes auto-referido e seus determinantes: evidências do projeto Bambuí. Rev Saude Publica 2007; 41 (6): 947-53. http://doi.org/10.1590/s0034-89102007000600009
http://doi.org/10.1590/s0034-89102007000... .

In summary, the findings show improvement in indicators of tobacco use, cessation, secondhand smoke and media exposure between 2013 and 2019, but the reduction was smaller than in other periods analyzed. Consequently, it is imperative to invest more in public policies to fight and control the use of tobacco and its derivatives in Brazil.

REFERENCE

ACKNOWLEDGMENTS

DC Malta and FTA Alves thank the National Council for Scientific and Technological Development (CNPq) for the productivity grant. EJS Prates thanks the National Health Fund of the Ministry of Health for the research grant. FMD Andrade thanks the Coordination for the Improvement of Higher Education Personnel (CAPES) for the doctoral scholarship.

Publication Dates

History