Maternal smoking prevalence in Brazil in 2013 and 2019: not what we expected when they were expecting!

INTRODUCTION: Monitoring tobacco use during pregnancy is critical for achieving the United Nations Sustainable Development Goals. We examined changes between 2013 and 2019 in the relative differences in smoking prevalence rates between pregnant and non-pregnant women aged 18-49 years. METHODS: We used data from a nationally representative health survey conducted in Brazil in 2013 and 2019. A generalized linear model with binomial family and logarithmic link function was used to estimate, for each year of analysis, the crude and adjusted (by age-group, educational attainment, place of residence, and status of protection from passive smoking at home) relative differences. RESULTS: In 2013,the proportion point estimate of tobacco use among pregnant women was lower than that observed among non-pregnant women (4.7% vs. 9.6%). However, in 2019 proportion point estimates were virtually the same (8.5% vs. 8.4%). After adjustment for selected variables, in 2013, smoking prevalence among pregnant women was 42% (p-value≤0.05) lower than that observed among non-pregnant women. On the other hand, in 2019, maternal smoking prevalence was 13% (p-value>0.05) higher than that found among non-pregnant women. CONCLUSIONS: Ongoing tobacco industry interference and the marketing of tobacco products to vulnerable populations pose serious threats to public health and likely contributed to increasing maternal smoking prevalence. The fact that women smoke in such an important phase of their and their unborn children's lives reinforces the need to strengthen the implementation of concurrent tobacco control actions, including tobacco excise tax policy and pre-natal tobacco prevention and cessation interventions as part of health professionals' routine consultation. IMPLICATIONS: The decline in smoking prevalence among non-pregnant women between 2013 and 2019 was accompanied by an increase in maternal smoking prevalence. Monitoring tobacco use during pregnancy is critical for achieving the United Nations Sustainable Development Goals. Ongoing tobacco industry interference and the marketing of tobacco products to vulnerable populations in Brazil pose serious threats to public health. The fact that women smoke in such an important phase of their and their unborn children's lives reinforces the need to strengthen the implementation of concurrent tobacco control actions, including tobacco excise tax policy and primary healthcare professionals´ tobacco-related assistance during interaction with their patients.

The cigarette market in Brazil: new evidence on illicit practices from the 2019 National Health Survey.

OBJECTIVE: To explore new evidence on illicit practices, such as selling legal brands below the minimum legal price (MLP), and smugglers selling illicit brands at or above the MLP. METHODS: For the first time in Brazil, self-reported information on cigarette brand name and price paid per pack in smokers' last purchase from a nationally representative survey conducted in 2019 was used to distinguish the illicit and the legal markets. We estimated the proportion of illicit cigarette consumption, using the combination of brand and price. RESULTS: The proportion of smuggled illicit cigarette consumption based on brands not approved on the Brazilian market was estimated at 38.6% (95% CI: 35.8% to 41.5%). When we added legal brands not paying taxes, it increased to 47.1% (95% CI: 44.2% to 49.9%). Around 25% of illicit brand cigarettes were sold at or above MLP. CONCLUSIONS: In Brazil, since 2017 there is a lack of adjustment in tobacco taxes and the MLP for inflation and income growth. The increase in cigarette affordability and the presence on the market of a segment of 'higher-priced' illicit brands suggest patterns of illicit brand loyalty and/or perceived 'brand quality' among smokers of illicit cigarettes. The evidence also shows that a sizeable proportion of legal brand cigarettes were sold below the MLP. This study offers insight into what happened in circumstances in which a government failed to keep current with tax policies and the monitoring of domestic manufacturing. Brazil has been a world leader in the monitoring of the tobacco epidemic, and this study also offers an innovative use of data that an increasing number of countries are collecting.

Straw cigarette branding: misleading descriptors and a new Marlboro man.

BACKGROUND: Straw cigarettes are hand-rolled tobacco in a corn straw, common in Brazil and believed to be less harmful by consumers. Traditionally consumed in rural areas and by men, a recent increase in use among young people in urban areas was observed. This study assessed marketing appeals of straw cigarette packaging in Brazil. METHODS: Following a systematic protocol, unique straw cigarette packs were purchased in 2013, 2016 and 2019 from three cities: Manaus, Salvador and São Paulo. Packs were double-coded for the absence/presence of marketing appeals (ie, luxury/quality, masculinity, classic/timeless, flavours and less harm). RESULTS: The number of unique straw cigarette packs purchased as part of the overall sample increased in the most recent collection: 2.3% (n=3), 1.3% (n=2) and 15.5% (n=27) in 2013, 2016 and 2019, respectively. Across the years, all packs presented luxury/quality elements (eg, images of crests); 93.8% (n=30) included the word 'artisanal'. Masculine appeal (eg, images of men) was present on 56.3% (n=18) of packs. Almost half had classic/timeless elements, including the words 'tradition'/'original'. In 2019, 59.3% (n=16) of the packs were flavoured compared with none in previous years. Over a quarter of all packs presented a less harm appeal (eg, 'smooth'). CONCLUSION: We identified an increase in availability of unique straw cigarette packs, strong branding and use of misleading descriptors on the packs. The adoption of plain packaging and the implementation of Brazil's additive ban could help to reduce the appeal of straw cigarettes and curb the current increase in use among youth.

Brazilian smokers are ready for the ban on flavour additives in tobacco to be implemented.

Brazil became the first country to approve a national policy to ban all flavour additives in all tobacco leaf products in 2012. However, as of February 2022, the policy remained to be implemented. Cross-sectional data come from the International Tobacco Control (ITC) Brazil Wave 3 Survey among adult smokers (N = 1216) in 2016-2017. The majority of smokers supported a ban on menthol (56.0%; 95%CI: 51.7-60.2%) and a ban on all additives (61.7%; 57.5-65.8%), with no significant differences across sociodemographic groups in adjusted logistic regression models. More than half of menthol smokers reported they would either quit or reduce the amount they smoked if menthol cigarettes were banned. Findings suggest that there is support for Brazil's ban on flavour additives, which is a determinant of successful policy implemented. Continued delays will postpone an important measure with demonstrated public health gains.

Cigarette butts in two urban areas from Brazil: Links among environmental impacts, demography and market.

Environmental impacts are currently linked to smoking cigarette behavior, as cigarette butts (CBs) represent the most common litter item in natural areas. Despite this, even the best ranked Brazilian cities, in terms of urban cleaning, have no information about urban littered CBs. Thus, CBs were monitored in Santos and Niterói cities, aiming to assess contamination, Cigarette Butt Pollution Index (CBPI) and the illegal market size. CBs were collected in 36 walkways considering different land usage types and urban density levels. The CBPI was calculated, and brands were used to identify the size of the illegal market. CBs contamination in Santos (0.25 CBs/m2) was three times higher than Niterói (0.08 CBs/m2) and their occurrence and distribution presented no relationship with land usage types and urban population densities levels. CBPI = 17.6 was severe and the highest so far reported. A total of 28 cigarette brands were found both studied cities. Further, illegal cigarette consumption in Santos and Niteroi was estimated, based on brands of collected CBs, at 25.2% and 36.8%, respectively. Such data may be valuable for implementation of logistic reverse actions seeking to environmentally sustainable and socially resilient cities. Cigarette consumption threatens human life and the environment, and tobacco companies should be accountable for the pollution they generate.

Cross-validation of four different survey methods used to estimate illicit cigarette consumption in Brazil.

OBJECTIVE: To cross-validate estimates of the size of the illicit cigarette trade based on the results of four different survey methods. METHODS: In 2018/2019, four non-industry-funded, large-scale studies were conducted in selected Brazilian cities: packs discarded in household garbage/PDG (1 city), packs littered in the streets/PLS (5 cities), a phone survey of tobacco users' purchase behaviors/VIGITEL (5 cities), and a face-to-face household survey of tobacco users' purchase behaviors/FTF-household (2 cities). The proportions of illicit cigarettes consumed were based on the price paid by smokers in their last purchase (VIGITEL or FTF-household) and/or direct observation of brand names and health warnings (PDG, PLS or FTF-household). RESULTS: Based on PLS, the share of packs that avoided taxation ranged from 30.4% (95% CI 25.6% to 35.7%) in Rio de Janeiro to 70.1% (95% CI 64.6% to 75.0%) in Campo Grande; and PDG conducted in Rio de Janeiro found an even lower proportion point estimate of illicit cigarette use (26.8%, 95% CI 25.1% to 28.6%). In FTF-household, the share of illicit cigarette consumption based on the self-reported price ranged from 29.1% (95% CI 22.4% to 35.7%) in Rio de Janeiro to 37.5% (95% CI 31.2% to 43.7%) in São Paulo, while estimates based on pack observation ranged from 29.9% (95% CI 23.3% to 36.5%) in Rio de Janeiro to 40.7% (95% CI 34.3% to 47.0%) in São Paulo. For all cities, VIGITEL presented the lowest levels of illicit consumption, and most illicit brands were produced in Paraguay. CONCLUSIONS: Small differences in the estimated levels of illicit trade across methods were found, except for the phone survey. The cross-validation of estimates from independent studies is important to help effectively implement tobacco excise tax policy in Brazil and other low-income and middle-income countries.

Recent evidence on the illicit cigarette trade in Latin America.

The tobacco industry continues to present the illicit trade of tobacco products as a reason to slow, stop, or reverse tobacco control efforts in Latin America, including increasing tobacco excise taxes. In most cases, industry estimates of illicit trade, usually non-transparent and flawed, dwarf those of independent, rigorous research. Often, independent studies find that the levels of illicit trade are mostly non-consequential or easily manageable (<12%). Almost always, industry findings grossly overestimate the illicit market. Fortunately, a burgeoning empirical literature in the region-including Argentina, Brazil, Chile, Colombia, Mexico, and Uruguay-is illuminating the genuine levels and nature of this trade, typically employing gap analysis that compares tax-paid sales to consumption and/or pack inspection studies using packs shown by smokers in surveys or discarded in the streets or garbage. Additional research in countries including Brazil, Colombia, Ecuador, and Paraguay examines supply chains to help identify the illicit sources. This research is already helping governments to address any real problems with illicit trade and to reassure stakeholders that tobacco control efforts should be strengthened, not diminished.

La industria tabacalera sigue presentando el comercio ilícito de los productos derivados del tabaco como argumento para ralentizar, detener o revertir las actividades de control del tabaco en América Latina, como el aumento de los impuestos especiales al consumo de tabaco. En la mayoría de los casos, las estimaciones de la industria sobre el comercio ilícito, que generalmente tienen fallas y son poco transparentes, son pequeñas frente a las estimaciones hechas mediante investigaciones independientes y rigurosas. A menudo, los estudios independientes concluyen que los niveles de comercio ilícito son en su mayoría inconsecuentes o fácilmente manejables (< 12 %). Casi siempre, los resultados de la industria sobreestiman de manera considerable el mercado ilícito. Afortunadamente, una floreciente bibliografía empírica en la región, en países como Argentina, Brasil, Chile, Colombia, México y Uruguay, está arrojando luz sobre la verdadera naturaleza y los niveles reales de este comercio, generalmente empleando análisis de brechas que comparan las ventas que generan impuestos con el consumo, así como estudios de inspección de paquetes mostrados por fumadores encuestados o paquetes desechados en las calles o en la basura. En otras investigaciones en países como Brasil, Colombia, Ecuador y Paraguay se examinan las cadenas de suministro para ayudar a identificar las fuentes ilícitas. Esta investigación ya está ayudando a los gobiernos a abordar cualquier problema real con el comercio ilícito y reafirmar ante las partes interesadas que los esfuerzos de control del tabaco deben fortalecerse, no minimizarse.

A indústria do tabaco continua a apresentar o comércio ilícito de produtos derivados do tabaco como um motivo para retardar, interromper ou reverter os esforços para controlar o tabagismo na América Latina, incluindo o aumento dos impostos específicos sobre o consumo de tabaco. Na maioria dos casos, as estimativas do comércio ilícito feitas pela indústria, de modo geral falhas e pouco transparentes, fazem com que os resultados de pesquisas independentes e rigorosas pareçam menores. Não raro, estudos independentes constatam que os níveis do comércio ilícito são, na maioria dos casos, pouco significativos ou facilmente administráveis (<12%). Quase sempre, as constatações da indústria superestimam grosseiramente o mercado ilícito. Felizmente, uma bibliografia empírica crescente na região ­ abrangendo Argentina, Brasil, Chile, Colômbia, México e Uruguai ­ está lançando luz sobre os níveis efetivos e a natureza desse comércio, normalmente empregando uma análise de lacunas que compara as vendas tributadas com o consumo e/ou estudos baseados na inspeção das embalagens, usando embalagens mostradas por fumantes em levantamentos ou descartadas nas ruas ou no lixo. Outros estudos em países como Brasil, Colômbia, Equador e Paraguai examinam as cadeias de fornecimento para ajudar a identificar as fontes ilícitas. Este estudo já está ajudando os governos a abordar problemas reais com o comércio ilícito e a assegurar às partes interessadas que os esforços para controlar o tabagismo devem ser reforçados em vez de reduzidos.

Smoke-free legislation and neonatal and infant mortality in Brazil: longitudinal quasi-experimental study.

OBJECTIVE: To examine the associations of partial and comprehensive smoke-free legislation with neonatal and infant mortality in Brazil using a quasi-experimental study design. DESIGN: Monthly longitudinal (panel) ecological study from January 2000 to December 2016. SETTING: All Brazilian municipalities (n=5565). PARTICIPANTS: Infant populations. INTERVENTION: Smoke-free legislation in effect in each municipality and month. Legislation was encoded as basic (allowing smoking areas), partial (segregated smoking rooms) or comprehensive (no smoking in public buildings). Associations were quantified by immediate step and longer term slope/trend changes in outcomes. STATISTICAL ANALYSES: Municipal-level linear fixed-effects regression models. MAIN OUTCOMES MEASURES: Infant and neonatal mortality. RESULTS: Implementation of partial smoke-free legislation was associated with a -3.3 % (95% CI -6.2% to -0.4%) step reduction in the municipal infant mortality rate, but no step change in neonatal mortality. Comprehensive smoke-free legislation implementation was associated with -5.2 % (95% CI -8.3% to -2.1%) and -3.4 % (95% CI -6.7% to -0.1%) step reductions in infant and neonatal mortality, respectively, and a -0.36 (95% CI -0.66 to-0.06) annual decline in the infant mortality rate. We estimated that had all smoke-free legislation introduced since 2004 been comprehensive, an additional 10 091 infant deaths (95% CI 1196 to 21 761) could have been averted. CONCLUSIONS: Strengthening smoke-free legislation in Brazil is associated with improvements in infant health outcomes-particularly under comprehensive legislation. Governments should accelerate implementation of comprehensive smoke-free legislation to protect infant health and achieve the United Nation's Sustainable Development Goal three.

Trends in Illicit Cigarette Use in Brazil Estimated From Legal Sales, 2012-2016.

OBJECTIVES: To estimate the proportions of illicit cigarette consumption in Brazil from 2012 to 2016, a period of sharp increases in cigarette taxes. METHODS: We used an approach based on legal sales provided by the Secretariat of Federal Revenues and self-reported consumption data from an annually conducted telephone survey (VIGITEL) to estimate the changes over time in illegal cigarette use in Brazil. For that purpose, we also used available information on the proportion of illegal cigarette consumption from a nationwide household survey conducted in 2013 to calculate a constant proportion of underreporting from VIGITEL in relation to total consumption and sales in Brazil. RESULTS: There was an increase in the estimated proportion of illicit cigarette use from 2012 to 2013 (from 28.6% to 32.3%), then a decrease from 2013 to 2014 (32.3% to 28.8%), and then a sustained trend of increase from 2014 to 2016 (28.8% to 42.8%). CONCLUSIONS: Novel and feasible approaches to estimate changes over time in the illegal market are important for helping the effective implementation of tobacco excise tax policy.

Assessing the relationship between smoking and abdominal obesity in a National Survey of Adolescents in Brazil.

Abdominal obesity is even a stronger risk factor than overall obesity for noncommunicable chronic diseases. We examined the association between smoking and abdominal obesity among adolescents. Analyses were based on 38,813 subjects aged 15-17 years from the Study of Cardiovascular Risks in Adolescents (ERICA), a Brazilian school-based national survey. Abdominal obesity was defined considering waist circumference (WC) percentiles. Statistical analyses, stratified by sex, considered the sample complex design. Poisson regression with robust variance was used to estimate smoker-to-nonsmoker abdominal obesity prevalence ratio (PR), adjusting by sociodemographic and lifestyle variables. Higher prevalence of abdominal obesity was observed among adolescents who consumed >1 cigarettes/day, comparing to nonsmokers: considering WC >80th percentile, adjusted-PR for boys was 1.27 [95%CI:1.05,1.52] and, for girls, 1.09 [95%CI:1.00,1.19]; using the 90th percentile, adjusted-PR were 2.24 [95%CI:1.70,2.94] and 1.27 [95%CI:1.12,1.46], respectively for male and female adolescents. Our findings suggest a positive association between cigarette consumption and the prevalence of abdominal obesity, for both boys and girls. Although other studies had found this association in adults, our study contributes to this discussion by assessing it in adolescents using a nationwide representative sample of medium and large municipalities.

Cigarette flavors, package shape, and cigarette brand perceptions: an experiment among young Brazilian women.

OBJECTIVE: In 2012, a new Brazilian regulation prohibited the use of flavor additives in tobacco products. To better understand the potential impact of this regulation, this study examines how flavor descriptors on cigarette packaging influence brand perceptions among young Brazilian women. METHODS: An online cross-sectional experiment was conducted with Brazilian women aged 16-26 (N = 640: 182 smokers and 458 nonsmokers) who rated 10 cigarette packages from one of three conditions: 1) branded packs; 2) packs with the same size, shape, and verbal descriptions as in condition 1, but without brand imagery (i.e., "plain pack"); and 3) packs from condition 2 but without brand descriptors (i.e., "plain pack, no descriptors"). Mixed-effects linear regression models were utilized to determine what associations that pack features (i.e., experimental condition; flavor descriptor vs. not; slim pack vs. not) had with participant ratings of nine characteristics, including appeal, taste, smoothness, and attributes of people who smoke the brand. RESULTS: Flavored branded packs were rated as more appealing, better tasting, and smoother than flavored plain packs with descriptors. Compared to flavored plain packs with descriptors, the same packs without descriptors were rated less positively on eight of the nine characteristics. Compared to nonsusceptible nonsmokers, susceptible nonsmokers rated flavored packs more positively on eight of the nine characteristics. Slim packs were rated more positively than regular packs on eight of the nine characteristics. CONCLUSIONS: Slim packs and brands highlighting tobacco flavors appear to increase positive perceptions of tobacco products. Banning tobacco flavorings and slim packs may reduce the appeal of smoking for young Brazilian women, as well as for other vulnerable populations.

Understanding the relationship between sales of legal cigarettes and deaths: A case-study in Brazil.

Brazil has experienced a large decline in cigarette consumption in the last 25years. However, the most recent annual reports from the tobacco industry market leader in Brazil did not show a decrease in its gross profits. This is particularly important because tobacco industry donations/sponsorships come directly from the industry's reported gross-profits and are used to subvert health policies. The aim of the present study was to estimate (i) tobacco industry's gross-profit from legal cigarettes sales, and (ii) all-cause smoking-attributable deaths (SADs) among current Brazilian smokers who consumed legal cigarettes in 2013. We collected information on prevalence of legal cigarette use, cigarette consumption, price per cigarette pack among individuals aged ≥35years from the Global Adult Tobacco Survey, legal cigarettes sales (e.g., average costs and total volume of sales) provided by the Federal Secretariat of Revenues, and population mortality from the available vital statistics. With a gross-profit of US$1.378 billion (1.307-1.434) from sales of 54.6 billion sticks of cigarettes (53.4-55.5) to 8,424,510 smokers aged 35years and older in Brazil in 2013, cumulative SADs were estimated at 96,012 (85,647-107,654) (around 34% of cumulative SADs also including current smoking of illegal cigarettes and past smoking), i.e., one SAD was equivalent to a gross-profit of US$14,352 (12,140-16,743). Our results revealed the association between sales of cigarettes, gross-profits, and deaths in Brazil. As tobacco industry donations/sponsorships originate from industry's gross profits, which, in turn, depend on cigarette sales, our findings may be useful for increasing "moral pressure" on individuals and institutions and help countries in stopping tobacco industry interference in health policies.

Estimating the size of illicit tobacco consumption in Brazil: findings from the global adult tobacco survey.

BACKGROUND: Brazil experienced a large decline in smoking prevalence between 2008 and 2013. Tax rate increases since 2007 and a new tobacco tax structure in 2012 may have played an important role in this decline. However, continuous tax rate increases pushed up cigarette prices over personal income growth and, therefore, some consumers, especially lower income individuals, may have migrated to cheaper illicit cigarettes. OBJECTIVE: To use tobacco surveillance data to estimate the size of illicit tobacco consumption before and after excise tax increases. METHODS: We defined a threshold price and compared it with purchasing prices obtained from two representative surveys conducted in 2008 and 2013 to estimate the proportion of illicit cigarette use among daily smokers. Generalised linear model was specified to understand whether the absolute difference in proportions over time differed by sociodemographic groups and consumption levels. Our findings were validated using an alternative method. RESULTS: Total proportion of illicit daily consumption increased from 16.6% to 31.1% between 2008 and 2013. We observed a pattern of unadjusted absolute decreases in cigarette smoking prevalence and increases in the proportion of illicit consumption, irrespective of gender, age, educational level, area of residence and amount of cigarettes consumed. CONCLUSIONS: The strategy of raising taxes has increased government revenues, reduced smoking prevalence and resulted in an increased illicit trade. Surveillance data can be used to provide information on illicit tobacco trade to help in the implementation of WHO Framework Convention on Tobacco Control (FCTC) article 15 and the FCTC Protocol to Eliminate Illicit Trade in Tobacco Products.

Smokers in Brazil: who are they?

BACKGROUND: Brazil has experienced a large decline in smoking prevalence due to several tobacco control policies that were implemented in the past 25 years. Previous population-wide studies found a consistent reduction over time in daily cigarette consumption among all socioeconomic groups. OBJECTIVE: To examine changes between 2008 and 2013 in tobacco behaviours and health-related conditions of smokers. METHODS: We used data obtained from two nationally-representative surveys conducted in 2008 and 2013 to estimate the prevalence of self-reported psychological and physical morbidity, and nicotine dependence markers, stratified by gender and sociodemographic groups. Generalised linear models were used to understand whether absolute differences in prevalence rates over time differed by categories of selected variables. RESULTS: For both genders, as smoking prevalence declined in Brazil, there has been an increase in the proportion of ever smokers who have quit. In addition, remaining smokers seem to be making more quitting attempts. Among men with low educational level or younger than 25 years-old, as compared to their counterparts, cessation rate showed an even greater increase over time. Moreover, the proportion of light smokers, which represent the vast majority of smokers, did not decrease. The percentage of poor health-conditions among remaining smokers nevertheless increased, particularly among women, which can make future cessation more challenging. CONCLUSIONS: In Brazil, quitting rate is increasing, thus suggesting that tobacco control interventions implemented in Brazil in the past years seem to be effectively reaching the smoking population. This is strong evidence against the 'hardening hypothesis', which posits that remaining smokers decrease their willingness and ability to quit.

[What does the Brazilian National Health Survey have to say about the influence of cigarette spending on household income?] / O que a Pesquisa Nacional de Saúde tem a dizer sobre a influência do gasto com cigarro no rendimento domiciliar?

In a country whose indicators of population impoverishment continue to increase, it is concerning that individuals spend money to buy cigarettes instead of using this resource in actions that strengthen aspects of the well-being of their lives and that of their families. Based on the Brazilian National Health Survey conducted in 2019, the influence of spending on manufactured cigarettes on the family budget in households with at least one smoker was estimated, stratified by sociodemographic characteristics. Brazilian smokers allocated around 8% of their average per capita monthly household income to the purchase of manufactured cigarettes. The percentage of average monthly expenditure on cigarettes reached almost 10% of this income among smokers aged 15 to 24 and was even higher for those with incomplete elementary education (approximately 11%). In the North and Northeast regions of the country, this expenditure exceeded 9%. The state with the most significant impact on household income was Acre (13.6%), followed by Alagoas (11.9%), Ceará, Pará, and Tocantins (all with approximately 11%). Our findings, therefore, reinforce the importance of strengthening the implementation of effective measures, such as tax policy, to reduce the proportion of smokers. Thus, the money that individuals currently allocate to purchase cigarettes can be used to meet their basic needs, contributing to the promotion of health and improving the quality of life.

Em um Brasil no qual os indicadores de empobrecimento da população seguem aumentando, preocupa o fato de que indivíduos gastem dinheiro para comprar cigarro em vez de usarem esse recurso em ações que fortaleçam aspectos do bem-estar de suas jornadas de vida e de suas famílias. Estimou-se, a partir da Pesquisa Nacional de Saúde de 2019, a influência que o gasto com cigarro industrializado teve no orçamento familiar nos domicílios com pelo menos um fumante, estratificada por características sociodemográficas. Os fumantes brasileiros destinaram cerca de 8% do rendimento médio mensal domiciliar per capita para a compra de cigarros industrializados. O percentual do gasto médio mensal chegou a quase 10% desse rendimento, entre os fumantes de 15 a 24 anos, e foi ainda maior para aqueles com Ensino Fundamental incompleto (aproximadamente 11%). Nas regiões Norte e Nordeste do país, esse gasto ultrapassou os 9%. O estado com o maior comprometimento da renda domiciliar foi o Acre (13,6%), seguido por Alagoas (11,9%), Ceará, Pará e Tocantins (todos com aproximadamente 11%). Nossos achados reforçam, portanto, a importância de fortalecer a implementação de medidas efetivas de redução da proporção de fumantes, tal como a política tributária. Dessa forma, o dinheiro que atualmente é destinado pelos indivíduos à compra de cigarros poderá ser revertido no atendimento de suas necessidades básicas, contribuindo para a promoção da saúde e melhoria da qualidade de vida.

En un Brasil donde los indicadores de empobrecimiento de la población siguen aumentando, es preocupante el hecho de que las personas gasten dinero para comprar cigarrillo en lugar de usarlo en acciones para fortalecer los aspectos del bienestar de sus vidas y la de sus familias. A partir de la Encuesta Nacional de Salud brasileña realizada en 2019, se estimó la influencia del gasto en cigarrillo industrializado en el presupuesto familiar de los hogares donde vivía al menos un fumador, estratificado por características sociodemográficas. Los fumadores brasileños destinaron alrededor del 8% del ingreso per cápita mensual promedio del hogar para la compra de cigarrillos industrializados. El porcentaje del gasto mensual promedio en cigarrillos alcanzó casi el 10% de este ingreso entre los fumadores de 15 a 24 años y fue aún mayor para los que tenían educación primaria incompleta (aproximadamente el 11%). En el Norte y Nordeste del país, ese gasto superó el 9%. El estado con un mayor compromiso con los ingresos del hogar fue Acre (el 13,6%), seguido por Alagoas (el 11,9%), Ceará, Pará y Tocantins (todos con aproximadamente el 11%). Por lo tanto, nuestros resultados resaltan la importancia de fortalecer la implementación de medidas efectivas para reducir la proporción de fumadores, tal como la política tributaria. Así, el dinero que actualmente las personas destinan a la compra de cigarrillos podría utilizarse en la atención de sus necesidades básicas, contribuyendo a promover la salud y la mejora de la calidad de vida.

Smoking and adverse maternal and child health outcomes in Brazil.

INTRODUCTION: Numerous studies from high-income countries document the causal relationship between cigarette smoking during pregnancy and adverse maternal and child health (MCH) outcomes. Less research has been conducted in low and middle income countries, but a burgeoning literature can be found for Brazil. METHODS: We review Brazilian studies of the prevalence of maternal smoking, the relative risk of smoking-attributable adverse MCH outcomes, and present new estimates for these outcomes, using the attributable fraction method. RESULTS: We found that Brazilian studies of the relative risks of smoking-attributable adverse MCH outcomes were broadly consistent with previous reviews. Based on a comparison of maternal smoking over time, smoking during pregnancy has declined by about 50% over the last 20 years in Brazil. For 2008, we estimate that 5,352 cases of spontaneous abortion, 10,929 cases of preterm birth, 20,717 cases of low birth weight, and 29 cases of sudden infant death syndrome are attributable to maternal smoking. Between 1989 and 2008, the percent of smoking-attributable adverse MCH outcomes in Brazil was at least halved. CONCLUSIONS: The results show that over a 20-year period, during which Brazil implemented numerous effective tobacco control measures, the country experienced a dramatic decrease in both maternal smoking prevalence and smoking-attributable adverse MCH outcomes. Countries that implement effective tobacco control measures can expect to reduce both maternal smoking and adverse MCH outcomes, thereby improving the public health.

[The sale of single cigarettes in Brazil from 2008 to 2019: one more cause of concern?] / A venda de cigarros avulsos no Brasil entre 2008 e 2019: mais um motivo de preocupação?

In Brazil, the sale of cigarettes is only allowed in closed packages with 20 units. The evolution over time of the proportion of adult smokers who purchased single manufactured cigarettes in their last purchase was evaluated. Data from the Global Adult Tobacco Survey conducted in 2008 and the Brazilian National Health Survey conducted in 2013 and 2019 were used. A generalized linear model was used to calculate the differences in the proportion of single cigarette purchases between the survey years, adjusted for sociodemographic and smoking behavior variables. Considering 2013 as the reference year, the relative differences in the proportions were, respectively, -15.3% (adjusted p-value ≤ 0.05) when compared to 2008, and +13.3 (adjusted p-value = 0.08) when compared to 2019. Approximately 20% of young adult smokers reported buying single cigarettes in 2019 and the difference in the proportion of single cigarette purchases between individuals aged 18 to 24 and those older likely increased from 2013 to 2019 (adjusted interaction p-value = 0.08). There are reasons for concern, as the strengthening of tax policy from 2008 to 2013 was accompanied by an increase in the proportion of purchases of single cigarettes. Despite the decrease in the real price of cigarette packs from 2017, a context of low effectiveness of implementation of other anti-smoking measures likely accentuated the difference in the proportion of purchase of single cigarettes between young people and adults. The continued presence of single cigarettes as a mode of acquisition contributes to economically vulnerable population subgroups becoming and/or remaining dependent on smoking behavior.

No Brasil, a venda de cigarros é permitida apenas em embalagens fechadas com 20 unidades. Avaliou-se a evolução ao longo do tempo da proporção de fumantes adultos que adquiriram cigarros industrializados avulsos na última compra. Utilizaram-se os dados da Pesquisa Especial de Tabagismo conduzida em 2008 e da Pesquisa Nacional de Saúde conduzida em 2013 e 2019. Modelo linear generalizado foi usado para calcular as diferenças na proporção de compra de cigarros avulsos entre os anos das pesquisas, ajustadas por variáveis sociodemográficas e de comportamento de fumar. Considerando 2013 como ano de referência, as diferenças relativas entre as proporções foram, respectivamente, -15,3% (valor de p ajustado ≤ 0,05) na comparação com 2008, e +13,3 (valor de p ajustado = 0,08) na comparação com 2019. Cerca de 20% dos jovens adultos fumantes relataram comprar cigarro avulso em 2019 e a diferença na proporção de compra de cigarro avulso entre indivíduos de 18 a 24 anos e aqueles mais velhos provavelmente aumentou entre 2013 e 2019 (valor de p interação ajustado = 0,08). Há motivos de preocupação, pois o fortalecimento da política tributária entre 2008 e 2013 foi acompanhado de um aumento na proporção de compra de cigarros avulsos. Apesar da queda do preço real do maço de cigarros a partir de 2017, um contexto de baixa efetividade de implementação de outras medidas antitabagismo acentuou provavelmente a diferença da proporção de compra de cigarros avulsos entre jovens e adultos. A presença permanente do cigarro avulso como modalidade de aquisição contribui para que subgrupos populacionais mais vulneráveis do ponto de vista econômico se tornem e/ou permaneçam dependentes do comportamento de fumar.

En Brasil, la venta de cigarrillos está permitida solo en paquetes cerrados que llevan veinte unidades cada. Se evaluó la evolución a lo largo del tiempo de la proporción de fumadores adultos que adquirieron cigarrillos industrializados sueltos en la última compra. Se utilizaron los datos de la Encuesta Especial de Tabaquismo realizada en 2008 y de la Encuesta Nacional de Salud realizada en 2013 y 2019. Se utilizó un modelo lineal generalizado para calcular las diferencias en la proporción de compra de cigarrillos sueltos entre los años de las encuestas, ajustada por variables sociodemográficas y de comportamiento de fumar. Considerando 2013 como año de referencia, las diferencias relativas entre las proporciones fueron, respectivamente, -15,3% (valor de p ajustado ≤ 0,05) en comparación con 2008, y +13,3 (valor de p ajustado = 0,08) en comparación con 2019. Cerca del 20% de los fumadores jóvenes adultos informaron haber comprado cigarrillos sueltos en 2019, y es probable que la diferencia en la proporción de la compra de cigarrillos sueltos entre indivíduos de 18 y 24 años y aquellos más adultos haya aumentado entre 2013 y 2019 (valor de p de interacción ajustado = 0,08). Hay motivos de preocupación, ya que el fortalecimiento de la política fiscal entre 2008 y 2013 estuvo acompañado de un aumento en la proporción de compra de cigarrillos sueltos. Aunque el precio real del paquete de cigarrillos a partir de 2017, un contexto de baja efectividad en la implementación de otras medidas contra el tabaquismo probablemente acentuó la diferencia en la proporción de compra de cigarrillos sueltos entre jóvenes y adultos. La presencia continua de cigarrillos sueltos como modalidad de adquisición contribuye a que los subgrupos de la población económicamente más vulnerables se vuelvan y/o permanezcan dependientes del comportamiento de fumar.

Law compliance, why do we need it? Comparative data from the Brazilian National Survey of School Health (PeNSE) on adolescents' access to cigarettes. / Lei, para que te quero? Dados comparativos da Pesquisa Nacional de Saúde do Escolar (PeNSE) sobre acesso a cigarros por adolescentes.

In recent decades, Brazil has made significant progress in fighting the tobacco epidemic. However, recent national data suggest a probable stagnation in the reduction of smoking initiation among youth and adolescents. The objective of this study was to evaluate the evolution over time of compliance with the law that prohibits the sale of cigarettes to minors in Brazil. To this end, data from the Brazilian National Survey of School Health conducted in 2015 and 2019 were used. Percentages were estimated for "sequential" indicators created by combining answers to the questions "Did anyone refuse to sell you cigarettes?" and "How did you obtain your cigarettes?" There was a decrease between 2015 and 2019 in the percentage of smokers aged 13 to 17 who tried to buy cigarettes in the 30 days prior to the survey (72.3% vs. 66.4%; p-value ≤ 0.05). However, regardless of the survey year, approximately 9 out of 10 adolescent smokers were successful in an attempt to buy cigarettes. Of those, approximately 7 out of 10 used direct purchase as the main method of obtaining cigarettes, with purchases at licensed commercial establishments (vs. street vendors) increasing between 2015 and 2019 (81.1% vs. 89.6%; p-value ≤ 0.05). In 2019, 70% of teenagers who bought cigarettes at licensed commercial establishments purchased single cigarettes. Non-compliance with laws aimed at preventing smoking initiation is a huge obstacle to reducing the proportion of smokers. Increased implementation of legislative measures and oversight of cigarettes sales, combined with educational and awareness actions with retailers, is key to protecting new generations from the harmful effects of tobacco use.

Nas últimas décadas, o Brasil obteve importantes avanços no combate à epidemia de tabaco. No entanto, dados recentes nacionais apontam para uma provável estagnação na queda da iniciação ao tabagismo entre jovens e adolescentes. O objetivo deste estudo foi avaliar a evolução no tempo do cumprimento da lei que proíbe a venda de cigarros para menores de idade no Brasil. Para tal, utilizaram-se os dados da Pesquisa Nacional de Saúde do Escolar das edições de 2015 e 2019. Foram estimadas proporções para indicadores "sequenciais" criados da combinação das respostas às perguntas "alguém se recusou a lhe vender cigarros?" e "como conseguiu seus próprios cigarros?". Houve uma queda, entre 2015 e 2019, na proporção de fumantes entre 13 e 17 anos que tentaram comprar cigarros nos 30 dias anteriores à pesquisa (72,3% vs. 66,4%; valor de p ≤ 0,05). Contudo, independentemente do ano da pesquisa, cerca de 9 em cada 10 adolescentes fumantes tiveram sucesso em alguma tentativa de compra de cigarros. Desses, aproximadamente 7 em cada 10 utilizaram a compra ativa como a principal modalidade de acesso ao cigarro, sendo que a respectiva compra em estabelecimentos comerciais autorizados (vs. com ambulantes) aumentou entre 2015 e 2019 (81,1% vs. 89,6%; valor de p ≤ 0,05). Em 2019, 70% dos adolescentes que compraram cigarros em estabelecimentos comerciais autorizados realizaram a compra avulsa. O descumprimento de leis voltadas à prevenção da iniciação ao fumo é um enorme obstáculo para a redução da proporção de fumantes. O fortalecimento das ações legislativas e de fiscalização, aliado a ações educativas e de sensibilização junto aos varejistas, é fundamental para proteger as novas gerações quanto aos efeitos nocivos do uso do tabaco.

En las últimas décadas, Brasil ha logrado importantes avances en el combate a la epidemia del tabaquismo. Pero, recientes datos nacionales apuntan a un probable estancamiento en la recucción de la iniciación tabáquia entre jóvenes y adolescentes. El objetivo de este estudio fue evaluar la evolución en el tiempo de cumplimiento de la ley que prohíbe la venta de cigarrillos a menores en Brasil. Para ello, se utilizaron datos de la Encuesta Nacional de Salud del Escolar de 2015 y 2019. Se estimaron proporciones para los indicadores "secuenciales" creados desde una combinación de las respuestas a las preguntas "alguien se negó a venderte cigarrillos" y "cómo conseguiste cigarrillos". Hubo una disminución entre 2015 y 2019 en la proporción de fumadores de entre 13 y 17 años que intentaron comprar cigarrillos en los treinta días antes de la encuesta (72,3% vs. 66,4%; valor de p ≤ 0,05). Sin embargo, independientemente del año de la encuesta, alrededor de 9 de cada 10 adolescentes fumadores tuvieron éxito en algún intento de comprar cigarrillos. De estos, aproximadamente 7 de cada 10 utilizaron la compra activa como el principal método de acceso a cigarrillos, y la respectiva compra en establecimientos comerciales autorizados (vs. con vendedores ambulantes) aumentó entre 2015 y 2019 (81,1% vs. 89,6%; valor de p ≤ 0,05). En 2019, el 70% de los adolescentes que compraron cigarrillos en establecimientos comerciales autorizados los compraron sueltos. El incumplimiento de la ley destinada a prevenir la iniciación al tabaquismo es un gran obstáculo para reducir la proporción de fumadores. El fortalecimiento de las acciones legislativas y de fiscalización, sumado a acciones educativas y de sensibilización con los comerciantes, es fundamental para proteger a las nuevas generaciones de los efectos nocivos del consumo de tabaco.