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Print version ISSN 0042-9686
Bull World Health Organ vol.87 n.11 Genebra Nov. 2009
Brazil and tobacco use: a hard nut to crack
Brazil is pushing to enforce smoking bans and backing nicotine replacement therapies in an attempt to keep chipping away at tobacco-use statistics. Raising the price of cigarettes would also help. Claudia Jurberg reports.
Taxes on tobacco products generated income of around US$ 2.2 billion for the Brazilian government in 2008, but that doesn't mean the Brazilian government is going easy on the tobacco industry.
For the past two decades, Brazil has been at the forefront of global tobacco control initiatives. Vera da Costa e Silva, a public health specialist who advises the government on tobacco control, is proud to note that Brazil was the first country to ban the use of misleading adjectives such as "light" and "mild" from cigarette packages back in 2001. That move was in line with a law passed a year earlier requiring cigarette manufacturers to include pictorial health warnings covering at least 100% of one of the two main sides of a pack. These warnings often depict people in advanced stages of tobacco-related illness.
As a result of such initiatives, smoking prevalence has come down in the past two decades from 34% of the adult population in 1989 to 15% last year, according to the Brazilian Ministry of Health. But the declining trend has tailed off over the past few years as tobacco companies target new consumers, notably women. Meanwhile, 200 000 Brazilians die every year from tobacco-related diseases, according to the National Cancer Institute (INCA).
One area in which Brazilian tobacco control has faltered is in the enforcement of other key tobacco control measures, such as smoking bans in enclosed public places. Although Brazil ratified the WHO Framework Convention on Tobacco Control in 2005, requiring the country to pass laws to restrict tobacco, it has not done this. For that reason, many states and municipalities have taken matters into their own hands by passing their own laws banning smoking from public places with no separate places designated for smokers. However, these by-laws have been challenged as "unconstitutional" by the hospitality industry and could be overturned by the supreme court.
So far four states and eight municipalities have introduced smoking bans in a process that Costa e Silva characterizes as "a domino effect".
In August, a big "domino" went down when the state of São Paulo passed its own law banning smoking in enclosed public places. Previous attempts to ban smoking in São Paulo have failed as a result of weak enforcement and public apathy, but this time things may be different. São Paulo state health secretary, Luiz Roberto Barradas Barata, says that 99.5% of the state's pubs, restaurants and hotels are committed to upholding the law. "In the last month, we monitored 37 000 places and applied only 198 fines," he says. Establishments in breach of the ban are fined up to US$ 750 for a first offence, with the fine doubling for a repeat offence. A third breach entails closure of the business for 48 hours and a fourth shuts it down for 30 days.
Not everyone is happy about the bans. Alexandre Sampaio, president of the Pubs, Restaurants and Hotels Syndicate in the state of Rio de Janeiro claims that such initiatives are unconstitutional. He says that Rio's hospitality industry has suffered a 20% decline in visits to restaurants and bars as a result of the ban, which the state legislature passed into law but that has yet to come into force. He also argues that the government should be committing resources to informing the public, teenagers in particular, about the dangers of smoking, rather than restricting the spaces in which people can smoke. "In a few years we would have fewer smokers," he says.
Of course, while banning smoking in public places protects the health of non-smokers, many smokers need more than bans to help them quit. On the cessation front, Brazil is throwing its weight behind nicotine replacement therapies - a move strongly endorsed by the World Health Organization (WHO), which in May of this year put nicotine replacement therapy on the Essential Medicines List (EML).
"This is a public health victory," according to Costa e Silva, who believes that this recent decision by WHO will encourage Brazil and other countries to see nicotine replacement therapy as equally important as any other drug used for prevention purposes and promote cheaper commercial forms of nicotine replacement therapies.
Currently, 10% of the more than 5000 municipalities in Brazil offer cessation treatment based on psychological counselling that is sometimes combined with nicotine replacement therapy, such as patches, gum and the antidepressant bupropion. Since 2002, this cessation treatment has been available free through the public health system, and according to Costa e Silva, 40% of people who received nicotine replacement therapy say they had quit smoking by the end of the first month - although she thinks the true figure is closer to 30%.
The assistance department at INCA runs a Nicotine Addiction Research Center (NARC) that tests methods and drugs to help cancer patients quit. It also helps patients' families and INCA workers quit smoking. Head of the centre Cristina Cantarino says it gives 75 new patients a six-month course of treatment that includes six counselling sessions of 90 minutes combined with either nicotine gum, patches or bupropion. Cantarino claims the programme enjoys a 67% success rate.
Edson Santos is one of NARC's success stories. The 71-year-old is one of a group of 13 people receiving treatment there. He has smoked since he was 10 years old and says that when he arrived at INCA, he thought he would have to stay there for the rest of his life because he weighed only 39 kilos and suffered from severe shortness of breath. "I gained six kilos in a few weeks, because before this treatment I only drank coffee and smoked at breakfast, lunch and dinner. Now my breathing is much better and I can climb the stairs. I am another person," he says.
Of course not everyone does so well. People like Eliane Belleza, a journalist specializing in health issues, who has been a regular smoker for the last 27 years: "I did five different treatments," Belleza says. However, they did not work for her and she has since given up trying. "I know that I am a sick person, because smoking cigarettes is a disease, but I cannot abandon this pleasure."
What would it take for an educated person like Belleza to give up? Even harsher images on cigarette packages? Some are calling for both sides of a pack to carry such images, arguing that smokers simply put their pack image face-down when they want to enjoy a cigarette.
According to a recent World Bank report on tobacco control, the last steep drop in tobacco use in Brazil was between the first quarter of 1991 and the fourth quarter of 1993, when real prices increased by 78.6% and consumption dropped by over a fifth. The report recommends a return to 1993 pricing policy, estimating that such an increase would reduce consumption by about 11% or roughly 100 legal cigarettes per capita per year. Tania Cavalcante, National Coordinator of the Brazilian Programme to Control Tobacco also believes significant reductions in consumption might follow a price hike. She says that over the last two years Brazil has increased taxes, which in turn have made cigarettes more expensive. "The excise tax on cigarettes increased by 30% and this was reflected in a 24% increase in cigarette prices," Cavalcante says, adding: "Hopefully this will encourage people to smoke less, but we can still do more in this respect - cigarettes sold in Brazil are still some of the cheapest in the world."
Costa e Silva argues that Brazil needs to enforce key tobacco control measures to succeed in stopping more people from starting to smoke, helping smokers quit and protecting non-smokers from second-hand smoke but she says that national legislation on this has been thwarted by Brazil's tobacco interests.
"We need to stop industry interfering in Brazil's national anti-tobacco policies," says Costa e Silva, explaining that industry interference - such as creating front groups in the hospitality industry - is also covered by the WHO Framework Convention on Tobacco Control. She says that it should be made more difficult for tobacco industry lobbyists to gain access to government ministries. "The relationships need to be more transparent. When the industry has a meeting with a government minister, this should be announced. There are rules for all kinds of contributions to politicians. But we believe that many donations are not publicly disclosed."