Contributions of the analysis of discarded cigarette packages in household waste in the Brazilian city of Rio de Janeiro, Brazil, to estimate the illegal market

Alessandra Trindade Machado Roberto Magno Iglesias Felipe Lacerda Mendes Luís Felipe Leite Martins Ana Paula Leal Teixeira Tânia Maria Cavalcante André Luiz Ferreira Menescal Conde Sérgio de Oliveira Cordeiro Andréa Ramalho Reis Cardoso Liz Maria de Almeida André Salem Szklo About the authors

Abstract:

The illicit trade of tobacco products, by enabling access to cheaper cigarettes, favors smoking initiation and hinders its cessation, minimizing the effects of price policy and taxes on reducing the demand for tobacco. This is especially the case among populations with lower income and schooling, where smoking is concentrated. Its confrontation requires multisectoral actions, aligned with the World Health Organization Framework Convention on Tobacco Control, supported by estimates of the illicit trade magnitude and the analysis of its characteristics. This study analyzes, based on samples of household solid waste collected in 2018 in the city of Rio de Janeiro, Brazil, the conformity of discarded cigarette packages with criteria for their regular commercialization in Brazil, classifying them as legal or illegal. The evaluation was also carried out for the 15 Planning Areas (PA) of the municipality. The Social Progress Index (SPI) was chosen to represent heterogeneities among PA. The average percentage of illegal cigarette packs found was 26.79%, ranging from 3.36% to 46.29% among PA. The PAs with high illegality presented lower Social Progress Index and lower percentages of legal cigarette packages with a price equal to or greater than BRL 7.25. Among the illegal packages, 98.07% were manufactured in Paraguay. The study contributes methodologically to measure the consumption of illegal cigarettes in the second economic capital of Brazil, supporting the National Tobacco Control Policy in the struggle against illicit trade of tobacco products and in the effective implementation of the pricing and tax policy on these products.

Keywords:
Tobacco Products; Tobacco Use Disorder; Health Policy

Introduction

Tobacco consumption and the exposure to its smoke are significant risk factors for chronic non-communicable diseases and health inequalities 11. GBD 2015 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1659-724., accounting annually for eight million deaths worldwide. It is estimated globally that approximately 80% of the 1.1 billion smokers live in low- and middle-income countries, where the burden of smoking-associated diseases is higher 22. World Health Organization. Who report on the global tobacco epidemic, 2019. Offer to quit tobacco use. https://www.paho.org/bra/index.php?option=com_content&view=article&id=5641:folha-informativa-tabaco&Itemid=1097 (acessado em 22/Jul/2020).
https://www.paho.org/bra/index.php?optio...
.

The understanding of the great effects of active and passive smoking resulted in the negotiation in 2003 of the first international public health treaty: the World Health Organization Framework Convention on Tobacco Control (WHO-FCTC) 33. Figueiredo VC, Turci SRB, Camacho LAB. Controle do tabaco no Brasil: avanços e desafios de uma política bem sucedida. Cad Saúde Pública 2017; 33 Suppl 3:e00104917.. The treaty proposes a broad set of intersectoral and cooperation-related measures aimed to reduce the demand and supply of tobacco products, and it is an significant instrument for protecting health with equity.

Brazil has been a Party State to the WHO-FCTC since 2005, when the treaty was ratified by the Brazilian National Congress 44. Brasil. Decreto nº 5.658, de 2 de janeiro de 2006. Promulga a Convenção-Quadro sobre Controle do Uso do Tabaco, adotada pelos países membros da Organização Mundial da Saúde em 21 de maio de 2003 e assinada pelo Brasil em 16 de junho de 2003. Diário Oficial da União 2006; 3 jan.. Since then, the commitment to the internalization of its measures has become the map of the Brazilian National Policy for Tobacco Control (PNCT in Portuguese).

Thanks to the actions previously adopted by the country and the consequent implementation of measures foreseen in the WHO-FCTC 55. Portes LH, Machado CV, Turci SB. Trajetória da política de controle do tabaco no Brasil de 1986 a 2016. Cad Saúde Pública 2018; 34:e00017317., Brazil stood out in the world scenario for the significant reduction in the prevalence of smoking between 1990 and 2015 66. GBD 2015 Risk Factors Collaborators. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet 2017; 389:1885-906..

Despite the advances achieved, the absolute number of smokers in Brazil is high: 21.5 million 77. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde, 2013: percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, grandes regiões e Unidades da Federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014., which is reflected in high health, economic, social, and environmental burden to the country. Every year, smoking is responsible for the deaths of more than 156,000 Brazilians. In economic terms, the annual cost to Brazil due to medical expenses and loss of productivity attributable to smoking is approximately BRL 57 billion. On the other, the tax collection on the sale of cigarettes covers only 23% of the expenses caused by smoking in the country 88. Pinto M, Bardach A, Palacios A, Biz A, Alcaraz A, Rodriguez B, et al. Carga do tabagismo no Brasil e benefício potencial do aumento de impostos sobre os cigarros para a economia e para a redução de mortes e adoecimento. Cad Saúde Pública 2019; 35:e00129118..

Sustained tax policies to increase prices and taxes on tobacco products (Art. 6 of the WHO-FCTC) are recognized as the most cost-effective measures to reduce the prevalence of smokers, especially among young people and the population with lower income and schooling, where smoking is concentrated, besides contributing to the increase in tax collection 99. Instituto Nacional de Câncer José Alencar Gomes da Silva; Secretaria Executiva da Comissão Nacional para a Implementação da Convenção-Quadro para o Controle do Tabaco. Diretrizes para implementação do artigo 6º da Convenção-Quadro da Organização Mundial da Saúde para o Controle do Tabaco: medidas financeiras e fiscais para reduzir a demanda por tabaco. Rio de Janeiro: Instituto Nacional de Câncer José Alencar Gomes da Silva; 2016.. However, it is recommended that these policies must be aligned with measures to decrease illicit trade of tobacco products (Art. 15 of the WHO-FCTC) 1010. Instituto Nacional de Câncer José Alencar Gomes da Silva; Secretaria-Executiva da Comissão Nacional para Implementação da Convenção-Quadro para Controle do Tabaco. Convenção-Quadro para Controle do Tabaco: texto oficial. Rio de Janeiro: Instituto Nacional de Câncer José Alencar Gomes da Silva; 2015.. The low prices of illegal cigarettes ease the access to the product, favoring the initiation of children and adolescents in smoking. Such prices also hinder smoking cessation by providing the regular legal cigarette smoker with a cheaper option. Therefore, they weaken the effect of tax policy on reducing the prevalence of smokers, contributing to the health inequities generated by smoking. Furthermore, illicit trade of tobacco products burdens public coffers considering the tax evasion and spending on security actions, including border control 1111. U.S. National Cancer Institute; World Health Organization. The economics of tobacco and tobacco control. Bethesda: U.S. Department of Health and Services, National Institutes of Health, National Cancer Institute/Geneva: World Health Organization; 2016. (National Cancer Institute Tobacco Control Monograph, 21). (NIH Publication, 16-CA-8029A)..

It is estimated that 1/9 of the cigarettes consumed worldwide are illegal 1212. Joossens L, Raw M. From cigarette smuggling to illicit tobacco trade. Tob Control 2012; 21:230-4., and the market is dominated by organized crime factions attracted by profitability and impunity resulting from lenient penalties imposed on illicit crime 1313. World Bank Group. Confronting illicit tobacco trade: a global review of country experiences. https://www.worldbank.org/en/topic/tobacco/publication/confronting-illicit-tobacco-trade-a-global-review-of-country-experiences (acessado em 23/Jul/2020).
https://www.worldbank.org/en/topic/tobac...
. As part of the international agenda to combat the illegal market for tobacco products, the Protocol to Eliminate Illicit Trade in Tobacco Products1414. World Health Organization. Protocol to eliminate illicit trade in tobacco products. https://www.who.int/fctc/protocol/en/ (acessado em 23/Jul /2020).
https://www.who.int/fctc/protocol/en/...
was negotiated between the Member States to the WHO-FCTC, which has as its central axes the control of the production chain and distribution of tobacco products, the adequacy of penalties to crimes related to illicit trade in tobacco products, and international cooperation for the exchange of information and assistance between the fighting forces against the illegal tobacco market. The country officially adhered to the protocol in 2018 1515. Brasil. Decreto nº 9.516, de 1º de outubro de 2018. Promulga o Protocolo para Eliminar o Comércio Ilícito de Produtos de Tabaco. Diário Oficial da União 2018; 2 out..

A significant heterogeneity of estimates of illicit trade in tobacco products is observed in Brazil according to the agent-researcher and the methodology used. The tobacco industry, for example, presents analyses with trends in oversizing the consumption of illegal cigarettes in order to advocate the non-increase in taxation on its products 1616. Cabral M, Ruedas P, Possamai M. Comércio ilegal de cigarros - aspectos nacionais e internacionais. In: Seminário Internacional sobre Fraudes no Setor de Cigarros. Brasília: Escola Nacional de Administração Fazendária; 2001. p. 51-105.,1717. Instituto de Desenvolvimento Econômico e Social de Fronteiras. A lógica econômica do contrabando. http://www.idesf.org.br/wp-content/uploads/2018/03/A-L%C3%B3gica-econ%C3%B4mica-do-contrabando-portugu%C3%AAs.pdf (acessado em 23/Jul/2020).
http://www.idesf.org.br/wp-content/uploa...
,1818. Fórum Nacional Contra a Pirataria e Ilegalidade. Manual de combate ao mercado ilegal. http://www.fncp.org.br/manual-de-combate-ao-cigarro/manualcigarroilegal_final.pdf (acessado em 23/Jul/2020).
http://www.fncp.org.br/manual-de-combate...
. On the other hand, government agencies have produced studies based on solid national research, with estimates lower than those presented by the tobacco industry 1919. Iglesias RM, Szklo AS, Souza MC, Almeida LM. Estimating the size of illicit tobacco trade consumption in brazil: findings from the Global Adult Tobacco Survey. Tob Control 2017; 26:53-9.,2020. Szklo AS, Iglesias RM, Souza MC, Szklo M, Almeida LM. Trends in illicit cigarette use in Brazil estimated from legal sales, 2012-2016. Am J Public Health 2018; 2:265-69..

Based on this perspective of systematization of knowledge supported by statistically consistent research, this study analyzes - with samples of cigarette packets from household solid waste collected in 2018 in the city of Rio de Janeiro - the conformity of discarded packets with objective criteria established nationally for their commercialization and regular importation in the country, aiming to classify them as legal or illegal.

Materials and methods

This is a cross-sectional study, using as probabilistic sample the household solid waste collected from January to November 2018, and its quantitative samples were selected proportionally to the collection of 15 Planning Areas (PA) of the municipality of Rio de Janeiro, composed of 16 PA. Due to the distribution of household solid waste collection in the city, two PA were aggregated (PA 5.3 and 5.4). These areas are composed of a set of neighborhoods and they have peculiarities related to their history of occupation, geographical and topographic characteristics, urban conformation, structure of the health care network, as well as distinct socioeconomic profiles (DataRio. Regiões de planejamento - indicadores 2016. https://www.data.rio/datasets/regi%C3%B5es-de-planejamento-indicadores-2016/data, accessed on 23/Jul/2020).

Cigarette packets collection and separation were performed by professionals from the Municipal Urban Cleaning Company (COMLURB - Companhia Municipal de Limpeza Urbana), in parallel to regular research on recycling behavior and characterization of household solid waste components generated in the city. The quantity and type of household solid waste are correlated with significant sociodemographic characteristics of the population (e.g., income and schooling) 2121. Silva H, Barbieri AF, Monte-Mor RL. Demografia do consumo urbano: um estudo sobre a geração de resíduos sólidos domiciliares no Município de Belo Horizonte. Rev Bras Estud Popul 2012; 29:421-49..

Trucks were allocated to cover the most populous residential streets in each neighborhood, having followed a predetermined route and moved block by block until the defined household solid waste sample size was reached.

The sampling plan consisted of a probabilistic sample stratified with proportional allocation. The strata were the PAs. The sample was designed to be representative of the amount of household solid waste collected in the city of Rio de Janeiro. The total household solid waste collected in the city in 2018 was 144,875.01 tons. In terms of costs and logistics, a sample size of 24,000kg was established. The sample was distributed proportionally in the amount of household solid waste collected by neighborhood and PA. All districts of the PA had collection, except eight: two neighborhoods due to the low generation of household solid waste (Lapa and Grumari) and six neighborhoods due to difficulty in access (Paquetá, Rocinha, Maré, Jacarezinho, Cidade de Deus, and Complexo do Alemão) (Table 1).

Table 1
Number of cigarette packages collected, excluded, and classified, according to the Planning Area (PA) of the municipality of Rio de Janeiro, Brazil, 2018.

The primary packages of cigarettes (packet or box) collected were separated according to the 15 PA in the city of Rio de Janeiro. The initial sample consisted of 2,720 packages. Out of these, nine had no record on the source PA; four were ineligible, and two were not eligible for evaluation due to the degree of destruction. Thus, 2,705 cigarette packs were analyzed (Table 1).

The Social Progress Index (SPI) was chosen to represent the heterogeneities among the 15 PAs, since it aggregates situations related to both household and people who live in it (e.g., percentage of permanent private households connected to the general distribution network, connected to the general sewage or rainwater network and with household solid waste collected directly by cleaning service or placed in a cleaning service bucket; average number of toilets per resident; percentage of illiteracy of residents from 10 to 14 years; per capita income of permanent private households; percentage of private households, with per capita household income up to one minimum wage and higher than 5 minimum wages) 2222. Instituto Municipal de Urbanismo Pereira Passos. Índice de Desenvolvimento Social - IDS: comparando as realidades microurbanas da cidade do Rio de Janeiro. Rio de Janeiro: Instituto Municipal de Urbanismo Pereira Passos; 2008. (Coleção Estudos Cariocas)..

The following information was collected from the direct observation of the cigarette packages discarded in the household solid waste: (i) content, size, and format of the health warnings (image and/or text) on the back, front and/or side faces of the packages; (ii) brand of cigarettes; (iii) “visibility” of a seal, produced or not by the Special Department of the Federal Revenue Service of Brazil, based on four classification options (“the package has a visible seal”, “only seal fragments are visible”, “there is no seal or fragment of seal, but it is possible to visualize traces of seal glue”, “there is no seal and no fragment of seal or trace of it is visible”); and (iv) the country of origin of manufacture of cigarette packages.

To classify cigarette package as legal, the objective criterion of presenting all attributes listed in (i) according to the specifications of Brazilian regulation was used, in addition to having the brand duly registered in the list of legal trademarks of the Brazilian National Agency of Sanitary Monitoring (Anvisa) 2323. Agência Nacional de Vigilância Sanitária. Registro de produto fumígeno - dados cadastrais. Relação de marcas de cigarros. http://portal.anvisa.gov.br/documents/106510/106612/Marcas+de+Cigarros_2020_07_23_AM.pdf/5a6151dd-4a7d-43f3-8ea0-06b0dce59301 (acessado em 23/Jul/2020).
http://portal.anvisa.gov.br/documents/10...
(criterion ii).

The proportions of illegal cigarette packages found were estimated for the total municipality of Rio de Janeiro and stratified by PA. The two PA with the lowest and with the highest proportions of illegal cigarette consumption were grouped and classified, respectively, as “very low” or “very high” illegality.

Due to the quantities and names of the legal cigarette brands found in the PA, the average price paid for the legal cigarette in the municipality of Rio de Janeiro (BRL 7.25) 2424. Receita Federal. Marcas e preços de venda a varejo de cigarros. https://www.receita.economia.gov.br/orientacao/tributaria/regimes-e-controles-especiais/cigarros-marcas-e-precos-de-venda-a-varejo-de-cigarros (acessado em 23/Jul/2020).
https://www.receita.economia.gov.br/orie...
was estimated. The respective proportions of legal cigarette packages consumed, that presented a price equal to or higher than the average amount paid were estimated in order to better understand the behavior of smokers of legal cigarettes living in the “very low” or “very high” illegality of the municipality.

All analyses were performed using the Stata SE version 15.1 (https://www.stata.com) statistical package, where the sample weights were considered.

Results

Planning Area

The prevalence of illegal cigarette packs ranged from 3.36% (95%CI: 1.27-8.62) to 46.29% (95%CI: 39.03-53.71) among the PA of the municipality, with 26.79% (95%CI: 25.08-28.57) as the average percentage (Table 2).

Table 2
Distribution of illegal and legal cigarette packages with a price equal to or greater than BRL 7.25 in the Planning Areas (PA) of the municipality of Rio de Janeiro, Brazil, 2018.

In the PA classified as “very low” illegality (PA 2.2 and PA 2.1), 81.2% (95%CI: 80.97-81.4) of legal cigarette packs had a price equal to or greater than BRL 7.25. On the other hand, in the PAs with “very high” illegality (PA 5.1 and PA 3.6), 49.06% (95%CI: 48.61-49.51) of the legal cigarette packages consumed had a price equal to or greater than BRL 7.25, that is, 32.14% fewer packages of legal cigarettes consumed with a price equal to or greater than BRL 7.25 compared to the PA “very low” illegal (Table 2).

It could be observed that the PA with higher SPI presented lower percentages of illegality, which are PA 2.2 (3.36%); PA 2.1 (8.21%), and PA 4.2 (10.14%). On the other hand, the PA with lower SPI presented higher percentages of illegality (Table 2).

The verification of the conformity of cigarette packages with the objective criteria used to assess their legality or illegality allowed the results described below.

Registration of the brand of cigarettes in Anvisa

Among the packages of illegal cigarettes, the brand “Gift” 2525. Szklo AS, Silva MRF, Quintaes BR, Machado AT. What is the link between household garbage and tobacco control? The case of Brazil. J Bras Pneumol 2020; 46:e20200094. (96.7%; 95%CI: 95.0-97.9) prevailed, which also has a version duly registered with Anvisa and sold regularly in the country. Out of the 727 “Gift” packages found, most (92.22%; 95%CI: 89.93-94.03) were illegal and only 7.78% (95%CI: 5.97-10.07) were legal.

Health warnings

All packages classified as legal cigarettes presented health warnings on the front, sides, and back sides in accordance with the Brazilian regulation. Out of these, 51.73% (95%CI: 49.47-53.98) presented health warnings in the back side with images corresponding to the third group of warnings 2626. Nascimento BEM, Gamba Jr. N, Pereira LOMG, Spitz R, Gleiser S, Perez C, et al. Neurociências, artes gráficas e saúde pública: as novas advertências sanitárias para maços de cigarros. Hist Ciênc Saúde-Manguinhos 2010; 17 Supp 1:243-52. (in force between 2008 and May 2018) and 48.27% (95%CI: 46.02-50.53) with images corresponding to the fourth group 2727. Agência Nacional de Vigilância Sanitária. Advertências sanitárias nas embalagens de produtos fumígenos derivados de tabaco: manual de aplicação. http://portal.anvisa.gov.br/documents/106510/106594/Manual+de+Aplica%C3%A7%C3%A3o+das+Advert%C3%AAncias+Sanit%C3%A1rias/5bc7317c-bd47-4cd9-9572-44c8408f3a82 (acessado em 25/Jul/2020).
http://portal.anvisa.gov.br/documents/10...
(effective from May 25, 2018, and the deadline has been extended to some companies, by legal decision, for 15th December of the same year 2828. Agência Nacional de Vigilância Sanitária. Cigarros: termina o prazo para adequação de embalagens. http://portal.anvisa.gov.br/noticias/-/asset_publisher/FXrpx9qY7FbU/content/cigarros-termina-o-prazo-para-adequacao-de-embalagens/219201/pop_up?_101_INSTANCE_FXrpx9qY7FbU_viewMode=print&_101_INSTANCE_FXrpx9qY7FbU_languageId=pt_BR (acessado em 25/Jul/2020).
http://portal.anvisa.gov.br/noticias/-/a...
). Among the illegal cigarette packages, 43.61% (95%CI: 39.8-47.5) presented health warnings with images in the back side, however they were divergent from those established by the Brazilian regulation.

Manufacturing country

Most legal cigarette packages (98.95%; 95%CI: 98.41-99.31) were as a manufactured in Brazil and 1.05% (95%CI: 0.69-1.59) were imported from Germany. On the other hand, 98.07% (95%CI: 96.69-98.88) of illegal cigarette packages indicated Paraguay as a manufacturing country and 0.39% (95%CI: 0.12-1.20) originated in the United Kingdom or Indonesia (Table 3).

Table 3
Country of origin of legal and illegal cigarette packages. Municipality of Rio de Janeiro. Brazil, 2018.

Tax control seal

Among the legal cigarette packages, 55.97% (95%CI: 53.71-58.19) presented a visible seal, preserved and compatible with the fiscal control specifications of the Special Department of the Federal Revenue Service. On the other hand, among the illegal cigarette packages, 96.75% (95%CI: 94.88-97.96) did not have any type of seal, seal fragments or even traces of glue from some seal, which could be a falsified seal of the Special Department of the Federal Revenue Service or a seal of its own (Table 4).

Table 4
Characterization of the presence or absence of tax control seal in the packages of legal and illegal cigarettes. Municipality of Rio de Janeiro, Brazil, 2018.

Discussion

In addition to the cartographic aspects, the PA with its heterogeneous arrangements and its socio-economic, cultural, and environmental diversities, as well as structural and organizational peculiarities, including the conformation of the health care network, available educational equipment, urban mobility, degree of social cohesion, support networks, etc., constitute distinct vivid territories, in constant historical and social movement, constituting themselves as spaces of life consisting of social and political subjects 2929. Monken M, Barcellos C. Vigilância em saúde e território utilizado: possibilidades teóricas e metodológicas. Cad Saúde Pública 2005; 21:898-906. who establish relationships and where health-illness processes are socially produced 3030. Haesbaert R. Des-caminhos e perspectivas do território. In: Ribas AD, Sposito ES, Saquet MA, organizadores. Território e desenvolvimento: diferentes abordagens. Francisco Beltrão: Editora da UNIOESTE; 2005. p. 87-120.,3131. Buss PM, Pellegrini Filho A. A saúde e seus determinantes sociais. Physis (Rio J.) 2007; 17:77-93..

The local specificities of each planning area contribute to the design of different consumption patterns of its resident population, even regarding tobacco products. Thus, estimates of illegal cigarettes consumed varied significantly according to PA, from 3.36% in PA 2.2 to 46.29% in PA 3.6. This heterogeneity can be influenced by the very local diversities mentioned that also encompass the characteristics of the local trade organization, including greater presence of informal market, and variables such as the state’s surveillance presence, whether in health surveillance or public security issues.

Based on data on the legal production of cigarettes provided by the Special Department of the Federal Revenue Service and a continuous and integrated system of monitoring smoking of the Brazilian Ministry of Health, two adequate methodologies were developed to estimate the size of illegal cigarette market in the country 2020. Szklo AS, Iglesias RM, Souza MC, Szklo M, Almeida LM. Trends in illicit cigarette use in Brazil estimated from legal sales, 2012-2016. Am J Public Health 2018; 2:265-69. (DataRio. Regiões de planejamento - indicadores 2016. https://www.data.rio/datasets/regi%C3%B5es-de-planejamento-indicadores-2016/data, accessed on 23/Jul/2020). One of these methodologies is based on the purchase prices of cigarettes obtained from two household surveys conducted by the Brazilian government in 2008 and 2013 to estimate the consumption of illegal cigarettes that did not pay taxes (16.9% vs. 32.3%). In 2013, this consumption of illegal cigarettes was concentrated among individuals with incomplete primary education (42.1%) and among those living in border states (40.8%) 2020. Szklo AS, Iglesias RM, Souza MC, Szklo M, Almeida LM. Trends in illicit cigarette use in Brazil estimated from legal sales, 2012-2016. Am J Public Health 2018; 2:265-69.. More recently, a methodology based on the information available on official legal sales of cigarettes (Federal Revenue Service) was used, as well as on the consumption of cigarettes from an annual telephone survey of the Brazilian Ministry of Health 3232. Szklo AS, Souza MC, Szklo M, Almeida LM. Smokers in Brazil: who are they? Tob Control 2016; 25:564-70.,3333. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Vigitel Brasil 2017. Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2017. Brasília: Ministério da Saúde; 2018., allowing the finding that since 2013 the participation of illegal cigarettes in the total consumption of cigarettes has fluctuated: 28.6% (2012), 28.8% (2014), 42.8% (2016) (DataRio. Regiões de planejamento - indicadores 2016. https://www.data.rio/datasets/regi%C3%B5es-de-planejamento-indicadores-2016/data, accessed on 23/Jul/2020) and, more recently, 38.5% (2017) 3434. Szklo AS, Iglesias RM. Decrease in the proportion of illicit cigarette use in Brazil: what does it really mean? Tob Control 2020; 29 Suppl 4:s287-8. and 31.4% (2018) 3535. Gomes R. As verdades que você precisa saber sobre o contrabando de cigarros. http://blog.actbr.org.br/controle-do-tabagismo/asverdades-que-voce-precisa-saber-sobre-o-contrabando-de-cigarros/2145 (acessado em 06/Out/2020).
http://blog.actbr.org.br/controle-do-tab...
. Although the methodologies are not comparable, the estimate of our study (26.79%), for Brazil’s second most populous capital does not differ from the national average for 2018.

On the other hand, the oversized estimates presented by the tobacco industry for the percentage of illegal cigarettes consumed in Brazil indicate an increase in consumption (48% in 2017 vs. 54% in 2018) 3636. Instituto Brasileiro de Ética Concorrencial. A reforma tributária que o Brasil precisa. https://www.etco.org.br/publicacoes/revista-etco/revista-etco-edicao-24/ (acessado em 02/Out/2020).
https://www.etco.org.br/publicacoes/revi...
.

Since smoking is more prevalent in populations with lower education and lower income 3434. Szklo AS, Iglesias RM. Decrease in the proportion of illicit cigarette use in Brazil: what does it really mean? Tob Control 2020; 29 Suppl 4:s287-8., the presence of tobacco products in the daily consumption of these individuals compromises a significant portion of their monthly income. In order to balance the family budget, they would have as alternatives the search for treatments for smoking cessation or the migration to the consumption of cheaper cigarettes, such as illegal ones.

Based on this perspective, the local SPI, by incorporating indicators such as per capita income and illiteracy percentage, can contribute to possible correlations between characteristics of the population living in the different PA and its profile of illegal cigarette consumption.

Generally, it could be observed that in PA with lower SPI and, therefore, those PA that concentrate a population with lower per capita income and lower literacy degree, higher percentages of illegal cigarette packages were found. Smokers of these PA with lower SPI seem to be opting for cheaper illegal cigarettes, as well as the general consumption of legal brands with lower prices, since a higher percentage of legal cigarette packs with a price of less than BRL 7.25 (Table 2) were also found in them.

Considering that the price of cigarettes consumed is a significant predictor for smokers to think about quitting smoking, as well as to hinder young people’s access to cheaper cigarettes, by preventing their initiation into smoking 3737. U.S. National Cancer Institute; World Health Organization. The economics of tobacco and tobacco control. Bethesda: National Cancer Institute/Geneva: World Health Organization; 2016. (National Cancer Institute Tobacco Control Monograph, 21)., the populations of such PA could be particularly benefited with advances in the implementation of national policies and local actions aimed to reduce the supply and demand for cheaper illegal and legal cigarettes, in line with the measures of the WHO-FCTC, such as price increases and taxes on tobacco products, inspection actions, educational measures, expansion of the supply of treatment for smoking cessation in the public health network, among others.

Since the end of the 1980s, Brazil has implemented policies to increase taxes on cigarettes, generating successive increases in the prices of these products to the final consumer. From 1989 to 2010 the country experienced a reduction of approximately 46% in the prevalence of smoking, and almost half of this reduction was attributed to the policy of price increase on tobacco products implemented in the period 3838. Levy D, Almeida LM, Szklo A. The Brazil Sim Smoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med 2012; 9:e1001336..

Subsequently, Federal Law n. 12,546 of 2011 changed the system of taxation of the Tax on Industrialized Products (IPI in Portuguese) and instituted a policy of minimum prices for cigarettes. Both measures resulted in a significant increase in their retail sales prices and a substantial reduction in the prevalence of smokers. Furthermore, they generated an increase in the tax revenue of cigarettes 3939. Iglesias RM. Increasing excise taxes in the presence of an illegal cigarette market: the 2011 Brazil tobacco tax reform. Rev Panam Salud Pública 2016; 40:243-9.. However, when considering price differences of the best-selling cigarette brand in the world, it is observed that Brazilian cigarettes are still one of the cheapest 4040. World Health Organization. WHO report on the global tobacco epidemic, 2019. https://www.who.int/tobacco/global_report/en/ (acessado em 23/Jul/2020).
https://www.who.int/tobacco/global_repor...
. The last increases in IPI rates, as well as an adjustment of the minimum price of cigarettes, occurred in 2016. Indicators suggest the need to evaluate new adjustments in cigarette prices so that they return to function as an effective economic barrier against initiation and/or greater stimulus for smoking cessation 3434. Szklo AS, Iglesias RM. Decrease in the proportion of illicit cigarette use in Brazil: what does it really mean? Tob Control 2020; 29 Suppl 4:s287-8..

The success of macro policies to raise taxes on tobacco products - which can provide benefits to the populations of PA with high prevalence of illegal cigarette consumption and higher consumption of cheaper legal brands - requires that such measures be followed by coordinated multisectoral actions to combat illicit trade of cigarettes at the national and local level, because , otherwise, lower-income smokers will be able to migrate to cheaper illegal cigarettes, undermining the effect of increased health taxation, in addition to the tax evasion generated. These PA may have a lower level of organization of the local structure due to the lower presence of the state, which favors the circulation of illegal products, including cigarettes.

It is also essential that the public health system of PA guarantees individuals who smoke and wish to quit smoking timely and qualified access to the health care network of the Brazilian Unified Health System (SUS in Portuguese) and programs for smoking cessation in the basic health units (UBS in Portuguese) to which they are enrolled, or follow-up in other points of the health care network.

One of the requirements for classifying the packages of cigarettes as to the legality of the packaged product is the verification of the registration of the brand in Anvisa. In the sample analyzed, the presence of cigarette brands without registration in the agency implies that the packages correspond to products that do not meet the national regulatory requirements for their regular marketing in the country, therefore, they were classified as illegal.

Among the illegal cigarette packages found, 96.87% were “Gift” brand, meeting the reality of the municipality from information on seizures disclosed 4141. Côrrea D. Rio: mais de 800 mil maços de cigarros contrabandeados são apreendidos. Agência Brasil 2019; 25 abr. https://agenciabrasil.ebc.com.br/geral/noticia/2019-04/rio-mais-de-800-mil-macos-de-cigarros-contrabandeados-sao-apreendidos (acessado em 29/Out/2020).
https://agenciabrasil.ebc.com.br/geral/n...
,4242. Polícia apreende cigarros contrabandeados escondidos em carregamento de tangerinas no RJ. Portal G1 2019; 07 ago. https://g1.globo.com/rj/rio-de-janeiro/noticia/2019/08/07/policia-apreende-cigarros-contrabandeados-escondidos-em-carregamento-de-tangerinas-no-rj.ghtml (acessado em 29/Out/2020).
https://g1.globo.com/rj/rio-de-janeiro/n...
, corroborating the accuracy of the criteria used to characterize - based on direct observation of the package - its illegality. Produced by the Paraguayan company, The Uriom, the illegal “Gift” in Brazil were classified as such by the absence of health warnings regulated by Anvisa. It is noteworthy that the brand “Gift” has regular registration in Anvisa and it is produced by two companies located in the municipality of Duque de Caxias, state of Rio de Janeiro: Cia Sulamericana de Tabacos S/A and Quality in Tabacos Ind. and Com. de Cigarros e Importação e Exportação Ltda (Consulta à registro: relação das marcas de cigarros. http://portal.anvisa.gov.br/tabaco/consulta-a-registro, accessed on 24/Jul/2020).

One of the significant measures for the reduction of smoking, established by the WHO-FCTC in article 11, is the use of packages as a form to communicate to the population about the several harms of smoking with health warnings, using the packages as a product advertising tool 4343. Huang J, Chaloupka FJ, Fong GT. Cigarette graphic warning labels and smoking prevalence in Canada: a critical examination and reformulation of the FDA regulatory impact analysis. Tob Control 2014; 23 Suppl 1:i7-12.,4444. Environics Research Group. Wave 9 surveys: the health effects of tobacco and health warning messages on cigarette packages. Survey of adults and adults smokers. Ontario: Health Canada; 2005..

In Brazil, the first sentences of sanitary warnings on cigarette packages date back to the 1980s. The insertion of warnings with images, proven to be more effective in motivating non-initiation and smoking cessation, occurred in the country from 2001, making Brazil the second country in the world to adopt the measure 4545. Coordenação de Prevenção e Vigilância, Instituto Nacional de Câncer. Brasil: advertências sanitárias nos produtos de tabaco - 2009. Rio de Janeiro: Instituto Nacional de Câncer; 2008..

The rotation of images ensures renewal of the content of sentences and photos, which become inefficient after a long period of delivery 4646. Instituto Nacional de Câncer José Alencar Gomes da Silva; Secretaria Executiva da Comissão Nacional para a Implementação da Convenção-Quadro para o Controle do Tabaco. Diretrizes para implementação do artigo 11 da Convenção-Quadro da Organização Mundial da Saúde para o Controle do Tabaco: embalagem e rotulagem dos produtos do tabaco. Rio de Janeiro: Instituto Nacional de Câncer José Alencar Gomes da Silva; 2016.. The collections in different PA occurred throughout 2018, precisely in the year that a transition between the third and fourth group of images of Brazilian health warnings was carried out. This fact was reflected in the circulation of the two groups of images in the analyzed sample.

All packages classified as legal cigarettes presented frontal, lateral and back health warnings in accordance with the standards established by Anvisa: no divergences were found regarding their size in the respective face, regarding the language of the message (Portuguese) and the graphic pattern of the images.

Based on back side of the package (packet or box) of legal cigarettes, which contains the health warning image, it was observed that in 88.37% of the legal marks the side warnings prevailed on the left side of the package, regardless of the group of warnings used. Considering that the majority of the population is right-handed, it would be significant to develop studies that evaluate the patterns of handling the cigarette packages in order to determine in which of its lateral faces (right or left) the smoker would tend to view more frequently the warnings inserted there. As the Brazilian regulation does not establish on which side the warning should be placed, these studies could support regulatory changes in order to ensure greater effectiveness of lateral messages.

The packages corresponding to illegal cigarettes were non-compliant with the standards established by Anvisa for health warnings: when present, they were different from official images and with phrases in Spanish or another language. Also, among those packages that displayed images of health warning (43.6% of illegal ones), in addition to those regulated by the agency, presented proportion of the graphic set divergent from that stipulated by the Brazilian regulation. Thus, itwas found that the manufacturers of these products did not “bother” to develop an “imitation” of Brazilian warnings, which could reduce the perception of illegality by the consumer. However, even the presence of images different from those recommended by national legislation can lead consumers to the erroneous perception of acquiring a legal product, whereas cigarette packages without health warning images are more easily identifiable as illegal.

Most illegal cigarette packages included Paraguay as the manufacturer country (98.07%). As there are no cigarette brands from this country registered with Anvisa and, therefore, authorized to be imported and regularly marketed in Brazil, the Paraguayan origin of the cigarette packet reiterates the data that indicate Paraguay as the main supplier of illegal cigarettes to Brazil.

Only 1.05% of the legal cigarette packages presented another country as a manufacturer (Germany), other than Brazil, indicating that the product was imported, since the German manufacturing brands found were registered with Anvisa ensuring their permission for importation, in addition to health warnings in accordance with Brazilian regulation.

In alignment with measures recommended by the Protocol to Eliminate Illicit Trade in Tobacco Products1414. World Health Organization. Protocol to eliminate illicit trade in tobacco products. https://www.who.int/fctc/protocol/en/ (acessado em 23/Jul /2020).
https://www.who.int/fctc/protocol/en/...
, since 2007 Brazil has a System for Control and Tracking of Cigarette Production: SCORPIOS (Sistema de Controle e Rastreamento da Produção de Cigarros. https://receita.economia.gov.br/interface/lista-de-servicos/regimes-e-registros-especiais/cigarros/acessar-scorpios). The system reads, validates, and activates the security code of the tax control seals of the Special Department of the Federal Revenue Service, applied by the Brazil’s Mint, consolidating information associated with them.

Only 55.97% of legal cigarette packages had a visible official seal. However, the presence of a seal of the Special Department of the Federal Revenue Service, compatible with the image available on its website, does not guarantee its authenticity. A mobile device in the end of the retail chain would be required to verify the validity of the code entered on a certain label. Moreover, a considerable percentage of legal cigarette packages did not have a perfectly characterized seal as the Special Department of the Federal Revenue Service, depending on the degree of destruction of the package or the fact that it was removed by the consumer. These aspects limit the use of the seal to classify the legality of the product in our methodology.

On the other hand, among the Paraguayan “Gift”, none had a seal or even any indication of its presence. This fact suggests that the presence of a seal, although falsified, does not seem to be in the scope of adulteration of the network that operates the illegal cigarette market in the municipality of Rio de Janeiro, which could burden the product and compromise its competitive advantage, which is precisely its low price to the final consumer.

Limitations

One of the limitations of the study is the non-collection of household solid waste in neighborhoods of the municipality (communities) that have low SPI. However, these neighborhoods concentrate 5.5% of the total population of smokers in the municipality, which would not substantially change the results, although somewhat underestimated.

It is necessary to indicate an inverse correlation between daily cigarette consumption and the degree of physical activity: individuals who smoke 20 or more cigarettes per day (heavy smokers) tend to be more sedentary, which predisposes them to stay longer at home 4747. Lohse T, Rohrmann S, Bopp M, Faeh D. Heavy smoking is more strongly associated with general unhealthy lifestyle than obesity and underweight. PLoS One 2016; 11:e0148563.. As heavy smokers tend to consume more illegal cigarettes - due to their lower price -, to be more sedentary and predisposed to stay longer athome, the prevalence of illegal packages in household solid waste may be overestimated. On the other hand, smokers and nonsmokers have been less exposed in recent years to secondhand smoke within their own homes due to increased denormalization of tobacco use and awareness about the damage related to exposure to their smoke. In this sense, light or heavy smokers would tend to discard fewer legal or illegal packages at home.

Considering that intra-metropolitan commuting in Rio de Janeiro is more prevalent among people who receive up to five minimum wages 4848. Instituto Brasileiro de Geografia e Estatística. Reflexões sobre os deslocamentos populacionais no Brasil. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011., a portion of lower-income smokers and more likely to consume illegal cigarettes would be outside home. In this case, the prevalence of illegal packages in household solid waste may be underestimated.

Conclusions

Progress in the implementation of measures to combat the illegal market of tobacco products requires its measurement with clear methodology and replicable results, as well as evaluation of its behavior and historical trend by reliable statistics free of regulated sector interests.

The identification of the most relevant criteria for the characterization of cigarette packages as to the legality or not of the product will benefit future analyses, besides being able to support its recognition in inspection actions.

The measurement of the prevalence of illegal cigarette packages among the different PA contributes to the local dimensioning of the problem, which can direct strategies for its mitigation. The implementation of local actions, associated to fiscal, regulatory, and public security policies, including combating organized crime, aligned with the WHO-FCTC and its Protocol to eliminate illicit trade in tobacco products, will contribute to reduce the inequities generated by smoking and consequent advances in the PNCT.

Acknowledgments

The authors thank Dr. Bianca Ramalho Quintaes and her team of the Municipal Urban Cleaning Company (COMLURB) for the partnership and technical support, and Mr. Cláudio do Carmo Rodrigues for the valuable collaboration in the packages analysis. An equally special thanks to Maria Raquel Fernandes Silva, from the Tobacco Control Division, José Alencar Gomes da Silva National Institute of Cancer (INCA), for the contribution in the records of the entire process.

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Publication Dates

  • Publication in this collection
    30 Aug 2021
  • Date of issue
    2021

History

  • Received
    02 Aug 2020
  • Reviewed
    30 Oct 2020
  • Accepted
    23 Nov 2020
Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz Rio de Janeiro - RJ - Brazil
E-mail: cadernos@ensp.fiocruz.br