Smoking trend indicators in Brazilian capitals, 2006-2013

Deborah Carvalho Malta Tais Porto Oliveira Micheline Luz Sheila Rizzato Stopa Jarbas Barbosa da Silva Junior Ademar Arthur Chioro dos Reis About the authors

Abstracts

This study aims to analyze the trend of indicators related to smoking in the capitals of Brazil from 2006 to 2013. Information on smoking trends extracted from the survey of risk and protective factors for chronic non-communicable diseases (NCDs) are analyzed through telephone interviews - VIGITEL conducted from 2006-2013 for the adult population in Brazilian capitals. To estimate the trend, the simple linear regression model was used. The prevalence of smokers in Brazil showed a relative reduction of 0.62% for each year of the survey, ranging from 15.6% in 2006 to 11.3% in 2013. A decrease was observed in both sexes in all age ranges except between 55 and 64 years in all education levels and regions. The total population of former smokers remained stable, with a reduction for men. Smoking 20 or more cigarettes per day decreased from 4.6% (2006) to 3.4% (2013), or 0.162 percentage points per year. Passive smoking at home decreased among women 13.4% (2009) to 10.7% (2013), a reduction of 0.72% per annum. Passive smoking at work has remained stable over the period. The smoking trend reduced in the period in most indicators, reflecting the importance of the tobacco control actions in the country.

Smoking; Chronic non-communicable diseases; Trend; Survey; Passive smoking


Introduction

Noncommunicable diseases (NCDs) are the leading cause of death worldwide, accounting for approximately 36 million deaths per year, mainly in low- and middle-income countries11. World Health Organization (WHO). Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011..

Despite major increases in morbidity and mortality associated with NCDs and their significantly unequal distribution, some studies indicate that a large part of such deaths may be prevented by means of health promotion activities aiming at modifying the exposure to risk factors11. World Health Organization (WHO). Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.. Smoking, alcohol use, obesity, inadequate nutrition and physical inactivity stand out among the risk factors for most NCDs11. World Health Organization (WHO). Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.

2. World Health Organization (WHO). Preventing chronic diseases: a vital investment. Geneva: WHO; 2005.
- 33. World Health Organization (WHO). Report on the Global tobacco epidemic, 2013. Enforcing bans on tobacco advertising, promotion and sponsorship. Geneva: WHO; 2013..

Contact with tobacco exposes the body to several carcinogens, resulting in a predisposition to several types of cancer (e.g., lung, oral cavity and breast), in addition to cardiac diseases, hypertension and other conditions11. World Health Organization (WHO). Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.

2. World Health Organization (WHO). Preventing chronic diseases: a vital investment. Geneva: WHO; 2005.
- 33. World Health Organization (WHO). Report on the Global tobacco epidemic, 2013. Enforcing bans on tobacco advertising, promotion and sponsorship. Geneva: WHO; 2013.. Smoking is estimated to cause approximately 71% of the deaths by lung cancer, 42% of chronic respiratory diseases and almost 10% of cardiovascular diseases11. World Health Organization (WHO). Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.. Smoking is also a significant risk factor for communicable diseases, such as tuberculosis11. World Health Organization (WHO). Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.. According to estimates by the World Health Organization (WHO), there are one billion smokers worldwide, and approximately six million deaths per year are associated with smoking, corresponding to 6% of deaths among women and 12% among men44. World Health Organization (WHO). Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: WHO; 2009.. The health risks posed by smoking derive from both direct tobacco use and passive exposure to tobacco smoke11. World Health Organization (WHO). Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.

2. World Health Organization (WHO). Preventing chronic diseases: a vital investment. Geneva: WHO; 2005.

3. World Health Organization (WHO). Report on the Global tobacco epidemic, 2013. Enforcing bans on tobacco advertising, promotion and sponsorship. Geneva: WHO; 2013.
- 44. World Health Organization (WHO). Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: WHO; 2009..

According to the WHO, if no global high-impact measures are implemented, tobacco-related deaths will increase to approximately eight million by 2030, corresponding to 10% of the deaths worldwide11. World Health Organization (WHO). Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011. , 33. World Health Organization (WHO). Report on the Global tobacco epidemic, 2013. Enforcing bans on tobacco advertising, promotion and sponsorship. Geneva: WHO; 2013..

The prevalence of tobacco use is high worldwide, especially in Europe, where it reaches approximately 29%, while the lowest prevalence is in Africa. Men smoke more than women globally, and the gender difference is largest in the Western Pacific Region, where the prevalence of smokers is 46% among men and 15 times higher compared to women, followed by Southeast Asia, where men smoke up to 10 times more than women. The highest prevalence of female smokers is found in Europe (20%)11. World Health Organization (WHO). Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011., and the smallest disparity between men and women occurs in the Americas, where approximately 1.5 times more men smoke than women11. World Health Organization (WHO). Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011..

The first studies on the prevalence of smoking in Brazil were conducted in 1989; the Health and Nutrition National Survey reported a 34.8% prevalence of smoking among adults55. 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). Bulletin of the World Health Organization 2007; 85(7):527-534.. Subsequently, the World Health Survey (2003) found that the prevalence of smoking had fallen to 22.4%55. 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). Bulletin of the World Health Organization 2007; 85(7):527-534.; according to the 2008 Special Research on Tobacco (Pesquisa Special de Tabagismo - PETab)66. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Especial de Tabagismo (PETab). Rio de Janeiro: IBGE; 2009, to 17.2%. Some studies attributed such success to the leading role played by Brazil in reducing tobacco use by means of educational, preventive and regulatory actions55. 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). Bulletin of the World Health Organization 2007; 85(7):527-534. , 77. Almeida L, Szklo A, Sampaio M, Souza M, Martins LF, Szklo M, Malta DC, Caixeta R. Global Adult Tobacco Survey Data as a Tool to Monitor the WHO Framework Convention on Tobacco Control (WHO FCTC) Implementation: The Brazilian Case. Int. J. Environ. Res. Public Health 2012; 9(7):2520-2536. , 88. Malta DC, Iser BPM, Sá NNB, Yokota RTC, Moura L, Claro RM, Luz MG, Bernal RI. Trends in tobacco consumption from 2006 to 2011 in Brazilian capitals according to the Vigitel survey. Cad Saude Publica 2013; 29(4):812-822..

The Brazilian Health Ministry established a system of surveillance of risk factors for NCDs based on household, telephone and school surveys. Within that context, the 2006 establishment of the National System of Surveillance of Chronic Diseases by Telephone Survey (Sistema Nacional de Vigilância de Doenças Crônicas por Inquérito Telefônico - Vigitel), encompassing all 26 state capitals and the Federal District, was important. Vigitel performs continuous annual surveillance of risk factors for NCDs99. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Vigitel Brasil 2013: Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2014. , 1010. Malta DC, Lima MFF, Leal MC, Neto OLM. Inquéritos Nacionais em Saúde: a experiência acumulada e a proposta do Inquérito Nacional de Saúde. Rev Brasileira de Epidemiologia 2008; 11(Supl. 1):159-167..

The aim of the present study was to describe the trends exhibited by indicators of tobacco use corresponding to the Brazilian state capitals and the Federal District from 2006 to 2013.

Methods

A study on the trends exhibited by tobacco use was performed based on data on risk factors (RFs) and protective factors extracted from Vigitel NCD telephone surveys of adults (≥ 18 years old) residing in all 26 Brazilian state capitals and the Federal District, conducted from 2006 to 2013.

Vigitel surveys probabilistic samples of the adult population (≥ 18 years old) based on the registry of landline owners provided by the main telephone operating companies every year. Five thousand landlines are randomly selected from each city by means of the lottery method, which are then divided into replicates (or subsamples) with 200 landlines each to identify the eligible ones, i.e., the active landlines. After the eligibility of each landline is established, the resident to be interviewed is selected.

Post-stratification weights were applied to extend the surveillance results to the overall adult population of each investigated city. . The final weight attributed to each individual interviewed by Vigitel seeks to equate the estimated sociodemographic composition of the adult population with access to landlines - based on the sample selected at each investigated city - to the estimated sociodemographic composition of the total adult population of the same city in the year of data collection.

The initial weight attributed to each individual from all 27 cities interviewed by Vigitel takes two factors into consideration. One is the inverse of the number of landlines at the interviewee's home, which corrects for the higher odds of individuals residing in households with more than one landline to be selected for sampling. The second factor corresponds to the number of adults residing in the interviewee's home, which corrects for the lower odds of individuals residing in households inhabited by a larger number of people to be selected for sampling. The product of these two factors provides a sampling weight that allows obtaining reliable estimates of the adult population with access to landlines in each city. The variables considered to characterize the sociodemographic composition of both the total population and the population with access to landlines were gender (female and male), age range (18-24, 25-34, 35-44, 45-54, 55-64 and 65 years old or older) and educational level (no formal schooling or incomplete primary education; complete primary education or incomplete secondary education; complete secondary education or incomplete higher education; and complete higher education).

Starting in 2012, the 'raking'1111. Bernal RTI. Inquéritos por telefone: inferências válidas em regiões com baixa taxa de cobertura de linhas residenciais [tese]. São Paulo: USP; 2011. technique has been used to establish the post-stratification weight of each individual included in Vigitel samples through the application of a specific SAS macro1212. Izrael D, Hoaglin DC, Battaglia MP. A SAS Macro for Balancing a Weighted Sample. Proceedings of the Twenty-Fifth Annual SAS Users Group International Conference, Paper 275, 2000.. The raking technique involves iterative procedures that take into account successive comparisons between estimates of the distribution of each sociodemographic variable in both a Vigitel sample and the total population of the corresponding city. Such comparisons allow detecting the weights useful to equate the sociodemographic distribution of a Vigitel sample to the one estimated for the total population of the corresponding city.

The distributions of each estimated sociodemographic variable per city and year were obtained based on projections that took into account the distribution of each such variable in demographic censuses and its mean annual variation (geometric rate) during the inter-census period. The post-stratification weight was used to generate all of the estimates provided by the system relative to all 27 cities both together and on an individual basis99. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Vigitel Brasil 2013: Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2014..

The Vigitel questionnaire consists of approximately 94 questions distributed across several modules: i) individuals' demographic and socioeconomic characteristics; ii) dietary and physical activity patterns; iii) reported body weight and height; iv) tobacco and alcohol use; and v) self-assessed state of health and reported morbidity; in the case of women, the performance of cancer screening tests is also included99. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Vigitel Brasil 2013: Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2014..

The time trends exhibited by the following indicators of tobacco use from 2006 to 2013 were analyzed. i) Smokers: the indicator prevalence of smokers was constructed, i.e., individuals who reported being "current smokers". The individuals who answered the question Do you smoke? in the affirmative were considered to be smokers, independently from the number of cigarettes smoked, frequency and duration of smoking habit. ii) Ex-smokers: the prevalence of ex-smokers was established, for which purpose the individuals who answered the question Have you ever smoked?in the affirmative were considered to be non-smokers, independently from the number of cigarettes smoked and duration of smoking habit. iii) Percentage of individuals who smoke 20 or more cigarettes per day: the proportion of individuals who smoke 20 or more cigarettes per day relative to the total number of interviewees was established based on the answer to question How many cigarettes do you smoke per day?

Starting in 2009, questions on passive smoking were included; thus, the trends exhibited by two additional indicators are described for the period from 2009 to 2013. iv) Indicator passive smoking at home: the ratio of the number of non-smokers who reported at least one smoker in the household to the number of interviewees was established based on the answer to question Does someone you live with smoke in the house? v) Percentage of passive smokers in the workplace: the ratio of the number of non-smokers who reported at least one smoker in the workplace to the number of interviewees was established based on the answer to the question Does any colleague smoke at your workplace?

The trend analysis of the time series of indicators of tobacco use was stratified per educational level and geographical region. The indicator was expressed as the proportion of adults who answered yes to the question on the consumption of tobacco indicators per year included in the survey. The trends were estimated by means of a simple linear regression model, in which the response variable (Yi) is the indicator proportion and the explanatory variable (Xi) is time (survey year). A negative regression coefficient (ß, slope) indicates that indicator and time have a decreasing relationship; otherwise, they exhibit an increasing relationship. A positive β value represents the mean annual increase of the indicator proportion per unit of time; otherwise, it represents the mean drop of that proportion per year1212. Izrael D, Hoaglin DC, Battaglia MP. A SAS Macro for Balancing a Weighted Sample. Proceedings of the Twenty-Fifth Annual SAS Users Group International Conference, Paper 275, 2000..

The proportions corresponding to the period from 2006 to 2013, the trends as expressed by the regression coefficient and their level of significance are presented. The measures of model adequacy used were residual analysis and 5% significance level. Data processing and statistical analysis were performed using the application Stata version 11.11313. Stata Corporation. Stata Statistical Software: 11.1. Texas, USA: College Station, TX 77845-4512; 2009.. The commands for proportions were used, taking the weights attributed to the individuals included in Vigitel surveys into consideration99. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Vigitel Brasil 2013: Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2014..

The present study was approved by the National Commission on Ethics in Research with Humans (Comissão Nacional de Ética em Pesquisa em Seres Humanos - CONEP). Instead of signing informed consent forms, the participants expressed their agreement to participation verbally upon being contacted by phone.

Results

This study identified differences in the prevalence of smoking as a function of gender, age range and educational level. The highest prevalence rates throughout the entire investigated period corresponded to males, individuals with low educational levels and age range 45 to 54 years old.

In the trend analysis, the indicator prevalence of smokers in Brazil exhibited an average 0.62% decrease per year, varying from 15.6% in 2006 to 11.3% in 2013. The prevalence of male smokers decreased by an average of 0.71% during the investigated period, varying from 19.3% (2006) to 14.4% (2013). The prevalence of female smokers exhibited an average 0.55% decrease, varying from 12.4% (2006) to 8.6% (2013) (Table 1). The number of smokers decreased in all of the investigated age ranges, except for the 55- to 64-year-old range. The largest mean reduction corresponded to the 45- to 54-year-old age range (1.01%) and the lowest to the 25- to 34-year-old (0.36) and 65-year-old and older (0.28) age ranges (Table 2).

Table 1.
Smoking trend indicators, by gender, in Brazilian capitals, Vigitel 2006 to 2013.
Table 2.
Smoking trend indicators, by age bracket, in Brazilian capitals, Vigitel 2006 to 2013.

The regression analysis detected a decreasing trend in the prevalence of smokers in all educational levels. The prevalence of smokers decreased from 10.9% in 2006 to 7.4% in 2013 among the interviewees with the highest educational level. Among the interviewees with eight or fewer years of formal education, although higher, the prevalence of smokers also decreased, from 19.1% in 2006 to 15% in 2013 (Table 3).

Table 3.
Smoking trend indicators, by schooling level, in Brazilian capitals, Vigitel 2006 to 2013.

The prevalence of smoking exhibited a decreasing trend among the following categories of ex-smokers: males, 25- to 54-year-old age range, and 12 or more years of formal education . The prevalence of smoking exhibited an increasing trend among the individuals aged 55 years old and older. Relative to the remainder of the categories, the prevalence of smoking exhibited a stable trend (Tables 1, 2 and 3).

The prevalence of individuals who smoked 20 or more cigarettes per day exhibited a decreasing trend from 4.6% (2006) to 3.4% (2013), corresponding to a 0.16% mean annual decrease. Although this reduction was detected in both genders, it was more pronounced among males. Reduced prevalence was also detected among the interviewees aged 35 to 54 years old and those with the highest educational level.

The proportion of passive smokers at home decreased among women from 13.4% in 2009 to 10.7% in 2013, corresponding to 0.72% mean annual decrease. A decreasing trend was also detected among the interviewees aged 45 to 54 years old and in all of the investigated educational levels.

The percentages of passive smokers in the workplace were the highest during the entire investigated period: 14.1% among the men and 6.1% among the women in 2013. The prevalence of passive smokers in the workplace exhibited stable trends in both genders and all educational levels, except for the one corresponding to 9 to 11 years of formal education.

All of the investigated indicators decreased in the Northern and Northeastern regions of the country, except for the prevalence of ex-smokers, which remained stable. The percentage of smokers in the North varied from 15.1% in 2006 to 8.1% in 2013, corresponding to a 0.98% mean annual decrease. The proportion of smokers in the Northeast varied from 13.1% in 2006 to 7.4% in 2013, corresponding to a 0.77% mean annual decrease. Relative to the Center-West, the total numbers of smokers and individuals who smoked 20 or more cigarettes per day exhibited decreasing trends. In the Southeastern region, the numbers of smokers, smokers of 20 cigarettes or more per day and passive smokers in the home decreased. In the Southern region, the numbers of smokers, smokers of 20 cigarettes or more per day and passive smokers in the workplace decreased. Although the highest prevalence of smokers corresponded to the Southern region - 18.8% in 2006 and 14.6% in 2013 - the total numbers of smokers, smokers of 20 or more cigarettes per day and passive smokers in the workplace exhibited decreasing trends (Table 4).

Table 4.
Smoking trend indicators, by Regions, Vigitel, 2006 to 2013.

Discussion

The results of the present study indicate improvement in the indicators of tobacco consumption in Brazil. The prevalence rates of smokers decreased in both genders and in all categories of education and geographical areas during the investigated period. The prevalence of tobacco use decreased among men and women, as did the numbers of male ex-smokers, heavy smokers of both genders, and passive smokers at home among both females and the overall population.

As concerns the fight against smoking, Brazil is an example for the rest of the world. One comparative study conducted by the WHO showed that among 16 countries with a total combined population of approximately three billion people, including China, Russia, Thailand, Bangladesh, Egypt, India, Mexico, Philippines, Poland, Turkey, Ukraine and Vietnam, among others, Brazil exhibited the lowest prevalence of smokers1414. Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, Peto R, Zatonski W, The 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..

Improving the indicators of tobacco use depends on countless factors, including the regulatory measures adopted by the country, which are in agreement with the best evidence designated by the WHO as "best buy"11. World Health Organization (WHO). Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.. The following are considered to be cost-effective measures for prevention of NCDs: a) increases in the taxes on and price of tobacco products; b) banning smoking in public areas; c) warnings on the dangers associated with tobacco use; and d) banning tobacco advertising, sponsorship and promotion. Brazil has enacted important legislation to regulate tobacco products, a process that was consolidated through Law no. 12,546/20111515. Brasil. Lei No 12.546, de 14 de novembro 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 providências. Diário Oficial da União 2011; 15 dez. on tobacco-free environments, which increased the tax on tobacco to 85% and established a minimum price for cigarettes. In addition, presidential decree no. 8,262/2014 regulated measures such as banning smoking in enclosed areas, restricting cigarette displays to points of sale only, and expanding the space occupied by sanitary warnings1616. Brasil. Decreto da Presidência da República 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 nº 9.294 de 15 de julho de 1996. Diário Oficial da União 2014; 2 jun.. Thus, all of the "best buy" evidence was implemented in Brazil. One further factor that improved the governance of actions was Brazil's adherence to the Framework Convention on Tobacco Control in 200555. 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). Bulletin of the World Health Organization 2007; 85(7):527-534. , 88. Malta DC, Iser BPM, Sá NNB, Yokota RTC, Moura L, Claro RM, Luz MG, Bernal RI. Trends in tobacco consumption from 2006 to 2011 in Brazilian capitals according to the Vigitel survey. Cad Saude Publica 2013; 29(4):812-822..

The Program for Crop Diversification in Tobacco-Growing Areas, established in 2005, is an intersectoral initiative with great importance, which provides technical assistance for tobacco family farmers to shift to food production1717. Vargas MA, Oliveira BF. Estratégias de diversificação em áreas de cultivo de tabaco no Vale do Rio Pardo: uma análise comparativa. Revista de Economia e Sociologia Rural 2012; 50(1):157-174..

The goals established in the Plan of Strategic Actions Against NCDs 2011-20221818. 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. Saúde 2011; 20(4):425-438.

19. Malta DC, Dimech CPN, Morais L, Silva Junior JB. Balanço do primeiro ano da implantação do Plano de Ações Estratégicas para o enfrentamento das Doenças Crônicas Não Transmissíveis no Brasil, 2011 a 2022. Epidemiol. Serv. Saúde 2013; 22(1):171-178.
- 2020. Malta DC, Silva Júnior JB. O plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil e a definição das metas globais para o enfrentamento dessas doenças até 2025: uma revisão. Epidemiologia e Serviços de Saúde 2013; 22(1):151-164. and the Global NCD Plan2121. World Health Organization. WHO. Global Action Plan for the Prevention and Control of NCDs 2013-2020 [Internet]. WHA66.10 ed. Geneva: World Health Organization; 2013 [cited 2014 Jan 27]. 55 p. Available from: http://www.who.int/nmh/events/ncd_action_plan/en/
http://www.who.int/nmh/events/ncd_action...
include reducing the prevalence of smokers in Brazil by 30% in 10 years. The prevalence rates analyzed here and the continuous decline in the number of smokers in Brazil indicate that this goal will be met and exceeded.

According to studies conducted in Brazil55. 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). Bulletin of the World Health Organization 2007; 85(7):527-534. , 66. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Especial de Tabagismo (PETab). Rio de Janeiro: IBGE; 2009 and worldwide1414. Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, Peto R, Zatonski W, The 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 frequency of smokers is higher among males compared to females, as also found in the present study. This higher prevalence of male smokers has historical reasons, as in the beginning of the 20th century, smoking was associated with virility, strength and power88. Malta DC, Iser BPM, Sá NNB, Yokota RTC, Moura L, Claro RM, Luz MG, Bernal RI. Trends in tobacco consumption from 2006 to 2011 in Brazilian capitals according to the Vigitel survey. Cad Saude Publica 2013; 29(4):812-822. , 2222. Tilloy E, Cottel D, Ruidavets J-B, Arveiler D, Ducimetière P, Bongard V, Haas B, Ferrières J, Wagner A, Bingham A, Amouyel P, Dallongeville J. Characteristics of current smokers, former smokers, and second-hand exposure and evolution between 1985 and 2007. Eur J Cardiovasc Prev Rehabil 2010; 17(6):730-736.. Later on, the spread of smoking to women during the 1960s and 1970s was associated with the myths of independence, freedom and self-affirmation2323. Amos A, Haglund M. From social taboo to "torch of freedom": the marketing of cigarettes to women. Tob Control 2000; 9(1):3-8.

24. 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. Geneva: World Health Organization; 2010. p. 29-50.

25. Centers for Disease Control and Prevention. Differences by sex in tobacco use and awareness of tobacco marketing - Bangladesh, Thailand, and Uruguay, 2009. MMWR Morb Mortal Wkly Rep 2010; 59(20):613-618.
- 2626. Malta DC, Moura EC, Silva SA, Oliveira PP, Silva VL. Prevalência do tabagismo em adultos residentes nas capitais dos estados e no Distrito Federal, Brasil, 2008. J Bras Pneumol 2010; 36(1):75-83.. These cultural influences account for the lower prevalence of smokers among females, along with its slower reduction rate due to its later introduction2626. Malta DC, Moura EC, Silva SA, Oliveira PP, Silva VL. Prevalência do tabagismo em adultos residentes nas capitais dos estados e no Distrito Federal, Brasil, 2008. J Bras Pneumol 2010; 36(1):75-83. , 2727. Azevedo e Silva G, Valente JG, Malta DC. Tendências do tabagismo na população adulta das capitais brasileiras: uma análise dos dados de inquéritos telefônicos de 2006 a 2009. Rev Bras Epidemiol 2011; 14(Supl. 1):103-114.. In other countries, as reported by the Global Adults Tobacco Survey, the frequency of smokers tends to be lower among females. In countries such as Egypt and Bangladesh, as a function of strong religious and cultural influences, the prevalence of smokers is less than 2% among women versus approximately 30% among men1414. Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, Peto R, Zatonski W, The 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 present study is the first to report decreasing trends in the prevalence of smokers from both genders, albeit faster among males. Vigitel first detected the decline in the prevalence of female smokers in 2013; this finding makes the current scenario quite favorable for the goal of reducing the prevalence of smokers by 30% in 10 years1818. 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. Saúde 2011; 20(4):425-438.

19. Malta DC, Dimech CPN, Morais L, Silva Junior JB. Balanço do primeiro ano da implantação do Plano de Ações Estratégicas para o enfrentamento das Doenças Crônicas Não Transmissíveis no Brasil, 2011 a 2022. Epidemiol. Serv. Saúde 2013; 22(1):171-178.
- 2020. Malta DC, Silva Júnior JB. O plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brasil e a definição das metas globais para o enfrentamento dessas doenças até 2025: uma revisão. Epidemiologia e Serviços de Saúde 2013; 22(1):151-164..

According to the literature, low income and low educational levels are associated with higher prevalence rates of tobacco use in Brazil66. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Especial de Tabagismo (PETab). Rio de Janeiro: IBGE; 2009 , 2828. Opaleye ES, Sanchez ZM, Moura YG, Galduróz JCF, Locatelli DP, Noto AR. The Brazilian smoker: a survey in the largest cities of Brazil. Rev Bras Psiquiatr 2012; 34:43-51. and other countries1414. Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, Peto R, Zatonski W, The 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.. This association was confirmed in the present study, as the prevalence of smokers among the interviewees with the lowest educational level (eight or fewer years of formal education) was approximately twice as high compared to the ones with the highest educational level (12 or more years). Nevertheless, the results of the present study showed not only that the prevalence of smokers decreased in all educational levels, but that the rate of reduction was similar in all of them - approximately 0.5% per year.

Analysis per geographical area revealed that the prevalence of smokers exhibited a decreasing trend in all of the Brazilian regions, though with differences in magnitude, as the frequency of smokers is highest in the South and Southeast. The higher prevalence of smokers in the South has been associated with the fact that this Brazilian region concentrates most of the tobacco production2929. Vargas MA, Campos RR. Crop substitution and diversification strategies: empirical evidence from selected Brazilian municipalities. Washington: The International Bank for Reconstruction Development, The World Bank; 2005.. Cultural issues also control these numbers, such as the strong influence of immigrant populations from Europe and bordering countries, such as Argentina and Uruguay, where the prevalence of smoking is over 30%3030. Mercado Común del Sur. Primer reporte de vigilância de enfermedades no transmisibles (ENT): situación epidemiologica de las ENT y lesiones en Argentina, Brasil, Chile, Paraguay y Uruguay. Buenos Aires: Mercado Común del Sur; 2011.. In turn, the lower prevalence of smokers in the North and Northeast has been associated with cultural issues and local market characteristics, such as the smaller role the tobacco industry plays.

Passive smoking, which is another global concern, may result in high risks for the exposed population and can cause the same types of diseases as direct smoking2222. Tilloy E, Cottel D, Ruidavets J-B, Arveiler D, Ducimetière P, Bongard V, Haas B, Ferrières J, Wagner A, Bingham A, Amouyel P, Dallongeville J. Characteristics of current smokers, former smokers, and second-hand exposure and evolution between 1985 and 2007. Eur J Cardiovasc Prev Rehabil 2010; 17(6):730-736.. Data from PETab 2008 show that 24.4% of the adult population was exposed to passive smoking in the workplace66. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Especial de Tabagismo (PETab). Rio de Janeiro: IBGE; 2009. Vigitel detected decreased prevalence rates of passive smoking at home among females and in the overall population, while the exposure to passive smoking at the workplace remained stable, affecting almost one-tenth of the Brazilian population. As a function of the decree that bans smoking in public places, the decrease in the prevalence of passive smoking in the workplace is expected to intensify in the next few years1616. Brasil. Decreto da Presidência da República 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 nº 9.294 de 15 de julho de 1996. Diário Oficial da União 2014; 2 jun..

The prevalence of heavy smoking (20 or more cigarettes per day) decreased in both genders. Although the prevalence of heavy smokers was almost twice as high among males compared to females, the reduction rate was larger among the former. Some studies showed that heavy smoking is associated with a higher risk of lung cancer among individuals who are more exposed, exhibiting a dose-response gradient3131. Lilienfeld AM, Lilienthal DE. Foundations of epidemiology. New York: Oxford University Press; 1980..

Due to the methods used by Vigitel, one of the limitations of the present study is the fact that the population interviewed was restricted to adults residing in state capitals and the Federal District with access to landlines, as it made the sample representativeness limited. However, that problem was minimized by the use of weighting factors to equate the demographic composition of the Vigitel sample to the ones of the overall adult population according to the 2010 Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística - IBGE) census data1010. Malta DC, Lima MFF, Leal MC, Neto OLM. Inquéritos Nacionais em Saúde: a experiência acumulada e a proposta do Inquérito Nacional de Saúde. Rev Brasileira de Epidemiologia 2008; 11(Supl. 1):159-167..

Starting in 2012, Vigitel updated the post-stratification data using the 2010 census; thus, the full trend analysis relative to the set of indicators of tobacco use was performed again with those novel data. Additionally, the "raking" technique was used, which represented an advancement that further approximated the population-based estimates99. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Vigitel Brasil 2013: Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2014. , 1212. Izrael D, Hoaglin DC, Battaglia MP. A SAS Macro for Balancing a Weighted Sample. Proceedings of the Twenty-Fifth Annual SAS Users Group International Conference, Paper 275, 2000..

Conclusion

The results described here indicate significant improvement of the indicators of tobacco use in Brazil both as a whole and categorized per educational level, age range, gender and geographical area. These results point to the relevance of measures against smoking in public policies, such as the Plan to Combat Chronic Diseases and the Policy of Health Promotion3232. Malta DC, Silva MMA, Albuquerque GM, Lima CM, Cavalcante T, Jaime PC, Silva Júnior JB. A implementação das prioridades da Política Nacional de Promoção da Saúde, um balanço, 2006 a 2014. Cien Saude Colet 2014; 19(11):4301-4312., on the improvement of the indicators of tobacco use among the adult and the adolescent population3333. Barreto SM, Giatti L, Casado L, Moura L, Crespo C, Malta DC. Exposição ao tabagismo entre escolares no Brasil. Cien Saude Colet 2010; 15(Supl. 2):3027-3034.. Thus, the relevance of Vigitel's annual monitoring of the indicators of tobacco use for the combat of NCD is reaffirmed, and it can be concluded that Brazil made significant advances towards the accomplishment of the globally agreed goals of tobacco use reduction.

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Publication Dates

  • Publication in this collection
    Mar 2015

History

  • Received
    30 Sept 2014
  • Accepted
    13 Nov 2014
ABRASCO - Associação Brasileira de Saúde Coletiva Rio de Janeiro - RJ - Brazil
E-mail: revscol@fiocruz.br