Brazil: balance of the National Tobacco Control Policy in the last decade and dilemmas

Abstracts

Since 2005, Brazil has been a Party of the World Health Organization Framework Convention on Tobacco Control, an international treaty whose measures are the foundation of the National Tobacco-Control Policy (NTCP), of Brazil. The results evidence a significant decrease in the prevalence of smokers and in tobacco-related morbidity and mortality. These results, however, could have been even better if there wasn’t the interference of the tobacco supply chain (TSC), controlled by transnational corporations, which has become more intense over the last 10 years. These companies made Brazil not only a repository for tobacco, but also for economic and political power capable of threatening NTCP achievements. This Essay recounts the development of NTCP and the tobacco supply chain modus operandi to hamper it, and discusses how the strengthening of policies to promote alternative crops for tobacco could shield NTCP from such interference.

Smoking; Tobacco Industry; Control and Sanitary Supervision of Tobacco-Derived Products

Abstracts

Desde 2005, o Brasil é Estado Parte da Convenção-Quadro para o controle do Tabaco da Organização Mundial da Saúde, tratado internacional cujas medidas constituem a Política Nacional de Controle do Tabaco (PNCT). Seus resultados se traduzem em significativa redução da prevalência de fumantes e da morbimortalidade tabaco-relacionada. Porém, esses resultados poderiam ter sido maiores não fosse o poder de interferência da cadeia produtiva do tabaco controlada por empresas transnacionais que tem se intensificado ao longo dos últimos 10 anos à medida que o Brasil avança na implementação da Convenção. Essas empresas tornaram o Brasil não só um celeiro de tabaco como também um celeiro de poder econômico e político capaz de colocar sob ameaça as conquistas da PNCT. Este Ensaio busca fazer uma narrativa sobre a evolução da PNCT e sobre o modus operandi da cadeia produtiva do tabaco para obstruí-la e discute como o fortalecimento de políticas de promoção de alternativas à produção de fumo poderia protegê-la desse tipo de interferência.

Hábito de Fumar; Indústria do Tabaco; Controle e Fiscalização de Produtos Derivados do Tabaco

Desde 2005, Brasil es un Estado Partícipe de la Convención-Marco para el Control del Tabaco de la Organización Mundial de la Salud, tratado internacional cuyas medidas constituyen la Política Nacional de Control del Tabaco (PNCT). Sus resultados se traducen en una significativa reducción de la prevalencia de fumadores y de la morbi-mortalidad relacionada con el tabaco. No obstante, esos resultados podrían haber sido mayores si no fuera por el poder de injerencia de la cadena productiva del tabaco, controlada por empresas multinacionales que se han intensificado a lo largo de los últimos 10 años, a medida que Brasil avanza en la implementación de la Convención. Esas empresas convirtieron a Brasil no sólo en un gran productor de tabaco, sino también en un polo de poder económico y político de este sector capaz de amenazar las conquistas de la PNCT. Este Ensayo busca estudiar la evolución de la PNCT y el modus operandi de la cadena productiva del tabaco para obstaculizarla y discute cómo el fortalecimiento de políticas de promoción de alternativas a la producción del tabaco podría protegerla de este tipo de injerencias.

Introduction

Since 2005, Brazil has been a Party of the World Health Organization WHO-FCTC Framework Convention on Tobacco Control (WHO-FCTC) ¹, an international health treaty negotiated under the auspices of the WHO ².

Why the need for an international treaty to address a public health program? Since the 1970s, successive World Health Assemblies (WHA) acknowledged transnational market strategies of tobacco corporations as the main determinants of the tobacco epidemic ³. However, only in 1999, the 52^nd WHA decided to negotiate the WHO-FCTC ^4,5.

Between October 1999 and February 2003 a complex collective negotiation process took place, permeated by clashes between health and commercial interests, since many tobacco-producing countries, including Brazil, took part in the negotiations ⁶. With this background, 192 countries elected Brazil to chair the negotiation of the Convention, an acknowledgement of its leadership in tobacco control, despite being a major tobacco-producing country.

In 2003, the WHO-FCTC final text ⁷ was approved by the 56^th WHA. It included a set of multisectorial and cooperation actions divided into two focuses: reduction of deman and supply of tobacco. WHO-FCTC text in fact acknowledged that, alone, no country could confront the transnational dynamics of the tobacco market, and that actions by the health sector alone would not be sufficient to reach the goals of the Convention ⁸.

In 2005, when Brazil ratified the WHO-FCTC, many of its measures had already been implemented, to a greater or a lesser extent. Currently, a significant reduction in the prevalence of tobacco use and mortality from tobacco-related conditions, such as cardiovascular and chronic respiratory diseases, and lung cancer has occurred. However, the challenges are still many, particularly those posed by the tobacco supply chain controlled by major transnational corporations that turned Brazil into a major producer and the largest exporter of this commodity. This fact is broadly used to advocate against the National Tobacco Control Policy (NTCP) of Brazil.

The ratification of the WHO-FCTC by Brazil entailed a long process of confrontation between the health and the tobacco productive sector. The tobacco industry had worked heavily to disseminate the idea that the Convention would forbid tobacco growing, and that the adhesion of Brazil would create a strong negative impact on the livelihood of 200,000 family-operated tobacco farms ^9,10. Only after two years of discussion (2004 and 2005) in public hearings that took place in producing areas, the Federal Senate approved the WHO-FCTC ratification in October 2005 (Legislative Decree nº 1,012), and it became effective by Presidential Decree in Janeiro 2006 ^11,12. Many studies have analyzed the historical process of the WHO-FCTC ratification in Brazil, and provided more details about the conflicts that permeated the process in that period ^13,14,15,16. The lengthy process made Brazil the 100th country to ratify the treaty, a delay that reflects tobacco industry attempts to belittle and weaken the WHO-FCTC by leaving out the country that led its entire process of negotiation.

This article analyses the evolution of the WHO-FCTC in Brazil, since its ratification in 2005, until 2015; and its main outcomes and challenges with focus on the control of the tobacco supply chain as the source of power for the tobacco industry to interfere in tobacco control policies. It also investigates the interference against tobacco-flavoring prohibition measures. To meet its goal, the text is organized taking the Convention as reference, with mention to the articles related to the issues addressed.

NTCP since WHO-FCTC ratification: governance, status and outcomes

When Brazil ratified the Convention, to a greater or lesser extent many of its measures had already been implemented in the country. Since 1989 the Ministry of Health, through the Brazilian National Cancer Institute José Alencar Gomes de Almeida (INCA), has articulated national tobacco-control actions. This initiative was based on a process of structuring and training State Health Secretariats in order to decentralize actions and to articulate partnerships with other governmental and non-governmental organizations, and led to the establishment of a solid network of governance of national tobacco-control actions ¹⁷.

With the ratification of the treaty, the NTCP has empowered, for being considered a Policy of the State. The NTCP follows the WHO-FCTC guidelines, and complies with the obligation of Brazil to adopt the treaty’s principles and regulations.

In 2003, upon completion of the negotiations, a Presidential Decree established the National Committee for the Implementation of the WHO Framework Convention on Tobacco Control (CONICQ), with the mandate to promote ratification of the Convention and to define the schedule for its effective implementation, in accordance with WHO-FCTC art. 5.2, which addresses the development of a tobacco-control coordination system nationwide. Currently, 18 sectors of the federal government have a seat at CONICQ. The Committee is chaired by the Ministry of Health, and the INCA has the Executive Secretariat office ¹⁸.

Over the 10 years after the ratification of the Convention, national tobacco-control measures were honed, expanded and new ones included. However, many of these achievements only came through after strongly confronting the obstructions posed by the tobacco industry.

Article 49 of Federal Law 12,546, of December 2011 ¹⁹, is a major achievement in the implementation of the FCTC, by addressing the measures established in article 6 (raising tobacco-product taxes and prices), article 8 (protection against passive smoking risks), and 13 (prohibition of tobacco-product advertisement, promotion and sponsorship).

Previous to that Law, the provision of WHO-FCTC article 8 was partially implemented in accordance with Federal Law 9,294, of July, 1996 ²⁰, for it admitted designated smoking areas (smoking lounges). Starting in 2007, CONICQ spared no effort to improve the federal law, in order to ban smoking in public spaces (no more smoking lounges), but was confronted by a strong opposing lobby of the tobacco industry in Congress. In 2008, some Brazilian states passed state legislation aligned with the Convention guidelines, banning smoking lounges. However, lawsuits proposed by tobacco industry-related organizations questioned the constitutionality of these laws, because they were more strict than the Federal Law 9,294/1996, in effect ^21,22, but their motivation was to prevent a cascade effect in the reduction of the number of smokers ²³.

Of note is that article 49 of Federal Law 12,546/2011 was based on an amendment to Provisional Measure 540 (PM 540), sent by the federal government to Congress in August 2011. The goal of PM 540 was to unburden some economic sectors while, in compensation, raising taxes on cigarettes ²⁴. However, the amendment made the NTCP retrogress, by withdrawing from the Brazilian Health Regulatory Agency (Anvisa) the power to regulate tobacco products. This is why, at the time, PM 540 was so strongly criticized and disputed by many health organizations and some congress representatives ^25,26,27,28.

After much discussion, the amendment was adjusted to meet the Convention guidelines, and approved in December 2011. Hence, article 49 of Federal Law 12,546/2011 banned smoking in indoor public spaces, no exceptions made. However, its implementation depended on a Presidential Decree establishing the rules for its enforcement, such as the definition of what an indoor public space was: only a fully closed space or if patios and balconies were included. Despite strong demands from society ^29,30, this Decree was approved only in May 2014, and it has been questioned by legal experts for admitting exceptions not included in the federal law ³¹. Notwithstanding, it was a major victory of public health over obstructions created by the tobacco industry, making Brazil the first megacountry to become 100% free from environmental tobacco smoke ³².

Since 2000, advertisement has been forbidden in the mass media, but allowed at points of sale (Federal Law 10,167/2000). With law, 12,546/2011, advertisement at points of sale also became forbidden, in compliance with article 13 of the WHO-FCTC. However, more and more the manufacturers are using the packs as advertisement media. Therefore, strategies are being discussed to ban displaying the packs of tobacco products at points of sale, a measure already adopted by some countries, and to standardize the packs in terms of colors and shapes, as in Australia and, soon, in many European countries ^33,34.

Regarding article 6 of the Convention, since 2007 the Internal Revenue Office (Secretaria da Receita Federal - SRF), of Brazil, had been gradually raising federal taxes on cigarettes, thus successively increasing the price of these products, which used to be among the cheapest in the world ³⁵. In 2011, Federal Law 12,546/2011 and Presidential Decree 7,555/2011 raised the federal excise tax on cigarettes, generating a tax load between 72% and 81%, and an increase in the final price of these products to the consumer; this measure is acknowledged as one of the most effective in reducing smoking. The legislation also established a minimum price policy for cigarettes ^36,37.

Regarding article 11 of the WHO-FCTC, since 2001 Brazil has regulated that public health warnings with pictures should be printed on the entire back of cigarette and other tobacco-product packs ³⁸. Now, Federal Law 12,546/2011 established that, starting in 2016, the warning “this product causes cancer” should be printed on a black rectangle covering 30% of the front of the pack ³⁹.

Smoking-cessation treatment, in compliance with WHO-FCTC article 14, had been implemented in 1,300 public health care facilities of 604 cities by 2013, attending an average of 150,000 smokers a year ⁴⁰.

In terms of tobacco-product regulation, in compliance with articles 9 and 10 of the WHO-FCTC, since 2001 the Anvisa requires the manufacturers to present a list of product components, forbids the use of expressions such as “low levels”, “light”, “ultra-light” and similar since they lead to the mistaken perception that safer cigarettes exist. In 2012, Anvisa banned the use of additives in tobacco products ⁴¹. This matter will be revisited in the chapter about the tobacco supply chain strategies to interfere in the NTCP.

The National Program for Diversification in Tobacco-Growing Areas (PNDACT), developed under the coordination of the Ministry of Agrarian Development, meets the requirements of WHO-FCTC article 17 (the development of economically feasible alternatives to tobacco farming), and follows the principles of sustainable rural development established by the National Program for Strengthening Family Farming. This program has reached some 800 cities, and 45,000 tobacco-farming families between 2006 and 2013 ^42,43,44,45.

Over the past 20 years, the prevalence of smoking in the population older than 18 years has dropped about 46% (from 34% in 1989 to 18.5% in 2008) ⁴⁶. In 2013, this rate was even lower, 14.7% ⁴⁷. This is surprising, as a decrease in the reduction rate was expected, and has occurred in many countries ^48,49. However, in the past five years, the prevalence of smoking dropped almost half the rate observed in 20 years, possibly due to a catalytic effect of WHO-FCTC national and global implementation. Other studies have supported this reduction trend ⁵⁰.

A special edition of the Lancet, published in 2011 on health in Brazil, showed that mortality from chronic noncommunicable diseases dropped 20% between 1996 and 2007, particularly due to reductions in cardiovascular (31%) and respiratory (38%) diseases; these results are attributed, in part, to smoking reduction in Brazil ⁵¹. In turn, the Atlas of Cancer Mortality, made available online by INCA ⁵², shows that world-population and age-adjusted lung cancer mortality among men dropped from 17.16 per 100,000 in 1999 to 15.54 per 100,000 in 2012. Among women, however, even though in smaller figures than men, the rate increased from 6.34 to 8.18 per 100,000 in the same period. The fact that women had started to smoke at a later age and in a smaller proportion than men, and are still under the cohort effect of this exposure may account for this phenomenon.

The tobacco supply chain and its power of interference

Brazil is currently the second largest producer and the largest exporter of tobacco, serving as a big warehouse, globally articulated and operated by the transnational corporations that develop tobacco-expansion strategies ⁵³. Of note is the fact that this warehouse is not only for crops, but it is, in fact, a warehouse of political and economic power. For this reason, one of the main challenges of the NTCP is to face the power of interference of the tobacco supply chain, which has intensified over the last 10 years, as Brazil moves forward with the implementation of the WHO-FCTC.

Presently, the three southernmost states of Brazil account for 98% of the tobacco crops. The remaining 2% are in the Northeastern region ⁵⁴.

The tobacco supply chain includes small family farms that grow tobacco, processing mills, tobacco product manufacturing facilities, distributors, exporters and retailers. According to the Brazilian Association of Tabaco Farmes (Afubra), for the 2013/2014 crop, 2.2 million people were involved in this chain, in Brazil ⁵⁵. Different tobacco transnational corporations, processing, and exporting companies are the strongest links of this chain, which is also globally articulated ⁵⁶.

The farming component of the chain integrates a system in which the tobacco company provides the farmers the inputs for their activity, and the farmers commit to selling the entire crop to the company according to a purchase and sale agreement. This dynamic allows the companies to control the chain, from growing the crop to selling the tobacco product ⁵⁷.

In this setting, mention should be made that the cycles of production and consumption of tobacco products are of a single system with articulated feedback by the same tobacco transnational corporations (Figure 1). In the consumption cycle, the teenager, the main target of these companies, is led to tobacco addiction through marketing strategies (product advertisement and promotion, attractive packs, flavors and scents in the products, strategic positioning of the products in the points of sale, low cost). In the production cycle, the main target is the small family farmer, social and economically vulnerable. Seduced by the idea that planting tobacco entails wealth and quality of life, these farmers are led to a vicious cycle of debt and economic dependency.

Figure 1
Global dynamics reflecting the power of the tobacco industry in coordinating tobacco production and use.

Tobacco growing is the main activity of most farmers, who are the weakest link of the tobacco supply chain, and also the most strategic for tobacco corporations because: (1) the cheap labor of family farming makes the costs of Brazilian tobacco-growing low, hence the power of the industry in keeping the final price of cigarettes and other tobacco products low; and (2) controlling tobacco farming is a “escape valve” for the tobacco industry, as it allows that tax increases or revenue losses from reduced demand of tobacco products are passed on to the prices they pay the farmers per kilo of tobacco ^58,59,60.

This game of self-interest increases the economic vulnerability of tobacco farmers ^{61,62,63,64,65}. This is because 85% of the Brazilian tobacco crops are exported, and that depends more on tobacco global conjuncture than the domestic scenario. In addition, until July 2015, 180 countries had ratified the WHO-FCTC, including China and Russia, the two largest tobacco-product consumers in the world, and were implementing most of its measures and guidelines. Many countries already present significant decreases in prevalence of smokers ⁶⁶, and the Global Progress Report on Implementation of the WHO Framework Convention on Tobacco Control published in October 2014 highlights that “more than two thirds of the treaty parties presented reduction in the prevalence of smoking” ⁶⁷.

The idea that tobacco growing is promising for the economy is a vision ^68,69 disconnected from a global scenario that shows signs of slowing down. Assessment of the tobacco industry by the international market monitors estimated for 2015 a significant decrease in sales volume of the four main transnational tobacco corporations, including those that coordinate the tobacco supply chain in Brazil, and a significant surplus of the global tobacco offer, causing an abrupt drop of 30% in the revenue of the main tobacco trading companies ⁷⁰. This scenario is reflected in Brazil with a 24% drop of tobacco-leaf exports in 2014 compared to 2013, and the amount “dumped” by tobacco farmers. According to data by Afubra, in 2005 this tobacco farming involved almost 200,000 family farms, whereas in 2013/2014, it involved some 162,000 family farms ⁷¹. Notwithstanding, the discourse encouraging tobacco growing is repeated like a mantra by organizations connected with the tobacco supply chain, and by Congress representatives of producing areas, who join efforts to work against tobacco-use reduction measures ^72,73,74,75. Thus, tobacco companies develop complex relationships of power and influence, and seek to strengthen themselves economically and politically. The political bias of the web of relationships lies particularly in supporting and funding candidates to city, state and federal legislative houses, strengthening the representation of legislature members who advocate the interests of the tobacco sector in producing states and, particularly, in the National Congress ^{76,77,78,79,80}.

The more Brazil has shown positive results in tobacco-use reduction, the stronger and more frequent the strategies of the tobacco industry have been, reinforcing the importance of article 5.3 of the WHO-FCTC, requiring the Parties to protect their national tobacco-control policies from undue interference from the tobacco industry and connected organizations.

In this perspective, will be analyzed an emblematic case concerning the interference against the implementation of one of the WHO-FCTC article 9 guidelines (regulation of tobacco-product contents): the prohibition by Anvisa of using additives in cigarettes and other tobacco-products.

The reaction of the tobacco supply chain against Anvisa’s prohibition of using additives in cigarettes in Brazil

Since the end of 2010, Brazil has tried to put into effect the WHO-FCTC guideline of limiting the use of additives in cigarettes and similar products, approved by the fourth session of the Conference of the Parties (COP4) in Uruguay, in 2010 ⁸¹.

This decision was based on studies that show that the additives were developed by the tobacco industry in the 1970s, in order to minimize the aversion caused by the unpleasant flavor of tobacco and throat irritation caused by the smoke, particularly in beginner smokers. Some additives sweeten the flavor of cigarettes, which is particularly attractive to adolescents; others, such as ammonia, increase the addictive capability of nicotine. Some studies have also shown that such additives enhance the toxicity potential of tobacco products ^82,83,84,85.

Notwithstanding, in Brazil there has been strong opposition articulated by the tobacco industry against this guideline, with support of legislative representatives and politicians from tobacco-producing areas. In fact, a national campaign against this measure was launched, even before the COP4 decision in favor of the guideline.

At that time, representatives of the tobacco industry and congress representatives lobbied the high echelons of government to prevent the Brazilian delegation to vote in favor of the approval of the guideline at the COP4 ^86,87,88,89. They advocated the idea that such a measure would prevent the use of burley tobacco to manufacture cigarettes, and would negatively impact the livelihood of 50,000 families who grew that type of tobacco in Brazil ⁹⁰. They stated that this type of tobacco required sugar to be added, in order to mask its unpleasant flavor and throat irritation caused by the smoke. They even pressured the Brazilian government to join other countries in questioning the Canadian government before the World Trade Organization’s Committee on Technical Barriers to Trade, about the additives ban imposed by that country ⁹¹.

During 2010, CONICQ was committed to correcting the misinformation disseminated by the tobacco industry about the measure. To that end, it made an analysis of the scenario that supported the Brazilian delegation stand at COP4 ^92,93. Hence, Brazil not only maintained its position to support the approval of the guidelines at the COP4 meeting, but also, in November 2010, Anvisa organized a public consultation on a measure to ban additives ^94,95. The tobacco supply chain reaction was strong: federal, state and city legislators connected to tobacco producing applied pressures against this initiative, and a number of public hearings were held in the southern, tobacco-producing states, to expand the opposition against Anvisa ^{96,97,98,99,100}.

A federal congressman presented a Legislative Decree to withhold the Anvisa public consultation (CP 112) ¹⁰¹. This congressman’s campaign was funded by a tobacco company that operates in his state, Rio Grande do Sul ¹⁰².

In addition to organizing political pressure against Anvisa, Afubra has coordinated a strategy to delay the compilation and assessment of inputs to the public consultation by Anvisa. Taking advantage of the lack of information and vulnerability of tobacco farmers, Afubra was able to mobilize 200,000 people against the measures proposed ¹⁰³. To that end, Afubra organized the logistics for collecting the inputs and sending them to Anvisa. Most of the inputs were limited to the message “I am against”. By doing that, the analysis of the inputs by Anvisa was delayed by almost 6 months - which was openly celebrated by Afubra ¹⁰⁴.

In addition to this interference on a nationwide scope, the announcement of Anvisa’s public consultation about the ban of additives also prompted an international reaction by some tobacco-producing countries that questioned Brazil at the WTO’s Committee on Technical Barriers to Trade. According to the report of the Committee’s formal meeting, “Producers and exporters of Burley and Oriental varieties of tobacco perceive the ban on additives to be a de facto prohibition on ‘blended’ tobacco products (conventionally produced by blending these varieties of tobacco with a number of additives) in the Brazilian market. About 15 members said that this regulation was more trade restrictive than necessary to achieve Brazil’s objective. This was particularly important for some countries, including African and least-developed countries (Zambia, Tanzania, Dominican Republic, Mozambique, Kenya), which depend on the sale of Burley and Oriental tobacco for national revenue...” ¹⁰⁵.

This reaction shows the transnational reach and power of multinational tobacco corporations which, by controlling the tobacco supply chain, can interfere in tobacco-control policies of other countries, even non producers, through free-trade international agreements.

Despite the strong movement against the measure, in March 2012, Anvisa published the Collegiate Board Resolution (RDC) 14, banning the sales of tobacco products with any flavoring or scenting additives. The tobacco industry, however, proposed a number of law suits. The most important one was proposed by the National Industry Confederation (CNI), that presented a Direct Unconstitutionality Suit (ADI 4874) questioning the power of Anvisa to regulate tobacco products, hence the ban of additives. In September 2013, the Brazilian Supreme Court granted a temporary injunction suspending the measure, which is still in effect at the submission of this article ¹⁰⁶.

Worthy of mention is that the ADI also placed at stake the role of Anvisa in regulating the trading of products and inputs that are hazardous to health. In an interview, the director-president of Anvisa explained the threat the ADI posed in questioning Anvisa’s legitimacy in regulating health-related products: “the CNI, to meet the demand of an industry sector - cigarette manufacturers - challenged the legislation that created Anvisa. If their arguments are accepted by the Brazilian Supreme Court, the segments of drugs, food and medical products will fall into a regulatory limbo, in the midst of extreme legal instability. It is the industry of disease, of the cigarette, preventing the health industry to operate” ¹⁰⁷.

In December 2013, Anvisa established a working group with local and international experts on this subject, in order to assess the additives used in the tobacco products listed in Anvisa’s Normative Instruction 6/2013. In August 2014, the working group final report recommended Anvisa’s Collegiate Board Resolution be revised to include sugar among the banned additives; it had originally been excluded in the list of banned additives due to the strong lobby of the tobacco industry ^108,109.

Until the time this essay was written, the ADI had not been judged, and the additives banning is on hold, meaning that cigarettes with additives can be sold in Brazil.

This sequence of facts shows the interference capability of the tobacco supply chain, and its power to supersede scientific evidence and recommendations by health institutions to maintain the profitability of their business.

Final considerations

Notwithstanding the advances in tobacco control, the situation of major tobacco producers still poses a great challenge for public health in Brazil. In addition to the social responsibility of developing policy of alternatives to a tobacco-growing to safeguard hundreds of thousands of farmers from an expected global reduction in tobacco demand, the NTCP also faces more and more intense obstructionist strategies of the tobacco supply chain against the necessary adjustments, particularly those of regulatory nature.

The tobacco supply chain works with misinformation, i.e., that tobacco growing is still a great opportunity for Brazilian foreign trade, and that tobacco-control measures adopted nationwide hamper this dynamic. Concurrently, they disqualify PNDACT capability to provide “alternatives as profitable as tobacco”.

The organization power of the tobacco supply chain helps in electing and defeating congressional candidates from the producing areas. This is one of the reasons why the claims of the tobacco industry, despite being fallacious, politically intimidate all those who speak against their interests ^110,111,112.

Over the last decades, the tobacco supply chain has expanded its ability to reach federal and state levels of government, and, at the very least, has been able to slow decision-making by officials and congress representatives on measures to strengthen the NTCP, including PNDACT.

In this setting, it is essential to understand that, thanks to the economic and political interaction promoted by the tobacco supply chain, major tobacco corporations gain power and political influence.

Hence, the implementation of article 17 of the WHO-FCTC (economically viable alternatives to tobacco growing), which, in Brazil, is conducted by the PNDACT, must be strengthened and seen as a mechanism for the implementation of article 5.3 of the WHO-FCTC, since reducing the number of farmers that depend on tobacco will also limit the political power of major transnational tobacco corporations to interfere with demand-reduction measures.

Acknowledgments

To the Brazilian National Cancer Institute José Alencar Gomes da Silva, Ministry of Health, Brazil, and to the representations of the Federal Government at the National Committee for the Implementation of the WHO Framework Convention on Tobacco Control (CONICQ).

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• ¹⁵ Sogocio MPSC. O Brasil adverte: fumar é prejudicial à saúde. Análise do processo de ratificação da Convenção-Quadro para o Controle do Tabaco [Dissertação de Mestrado]. Brasília: Instituto Rio Branco; 2008.
• ¹⁶ Mengel AA, Diesel V. Globalização, Convenção-Quadro para o controle do tabaco e as disputas pelos rumos dos territórios fumicultores. Revista IdeAS Interfaces em Desenvolvimento, Agricultura e Sociedade 2009; 3:226-55. http://r1.ufrrj.br/cpda/ideas/ojs/index.php/ideas/article/view/40 (acessado em 24/Ago/2015).
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• ¹⁷ Cavalcante TM. O controle do tabagismo no Brasil. Rev Psiquiatr Clín (São Paulo) 2005; 32:283-300.
• ¹⁸ Instituto Nacional de Câncer José de Alencar Gomes da Silva. Observatório da Política Nacional de Controle do Tabaco. CONICQ. A Comissão. http://www2.inca.gov.br/wps/wcm/connect/observatorio_controle_tabaco/site/home/conicq/comissao (acessado em 24/Ago/2015).
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• ¹⁹ Presidência da República. Lei nº 12.546, de 14 de dezembro de 2011. Diário Oficial da União 2011; 15 dez.
• ²⁰ Presidência da República. Lei nº 9.294, de 15 de julho de 1996. Dispõe sobre as restrições ao uso e à propaganda de produtos fumígeros, bebidas alcoólicas, medicamentos, terapias e defensivos agrícolas, nos termos do § 4° do art. 220 da Constituição Federal. Diário Oficial da União 1996; 16 jul.
• ²¹ Lei antifumo é considerada inconstitucional pela Justiça. Extra 2009. http://extra.globo.com/noticias/rio/lei-antifumo-considerada-inconstitucional-pela-justica-344045.html (acessado em 24/Ago/2015).
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• ²² Organização Panamericana de Saúde; Instituto Nacional de Câncer. Respira Brasil: as legislações de ambientes livres de fumo das cinco regiões do Brasil. http://actbr.org.br/uploads/conteudo/767_Respira_Brasil.pdf (acessado em 24/Ago/2015).
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• ²³ Instituto Nacional de Câncer. Tabagismo passivo. A importância de uma legislação que gere ambientes 100% livres de fumaça de tabaco. Nota técnica. http://www2.inca.gov.br/wps/wcm/connect/3b5a1c004eb68a5ea168b3f11fae00ee/Nota+T%C3%A9cnica+Ambientes+Livres.pdf?MOD=AJPERES&CACHEID=3b5a1c004eb68a5ea168b3f11fae00ee (acessado em 24/Ago/2015).
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• ²⁴ Olhar Direto. Relator da MP que aumenta imposto do cigarro propõe liberar fumo em bar, 2011 Relator da MP que aumenta imposto do cigarro propõe liberar fumo em bar, 2011 http://www.olhardireto.com.br/noticias/exibir.asp?id=207167 (acessado em 24/Ago/2015).
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• ²⁵ Aliança de Controle do Tabaco. Irresponsabilidade social. ACTBr Boletim 2011; 76. http://www.actbr.org.br/comunicacao/boletim-act-76#irre_social (acessado em 24/Ago/2015).
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• ²⁶ Governo estuda liberação do fumo em bares do país. Jornal do Brasil 2011. http://www.jb.com.br/ciencia-e-tecnologia/noticias/2011/09/23/governo-estuda-liberacao-do-fumo-em-bares-do-pais/ (acessado em 24/Ago/2015).
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• ²⁷ Portal GTerra. Volta dos fumódromos em restaurantes em discussão, 2011. http://www.gterra.com.br/empresarial/volta-dos-fumodromos-em-restaurantes-em-discussao-45936.html (acessado em 24/Ago/2015).
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• ²⁸ Emenda contraria leis antitabaco e propõe fumódromo disfarçado. Deputado defende abertura de bares específicos para quem fuma. Entidades que são contra o cigarro consideram proposta um retrocesso. Gazeta do Povo 2011. http://www.gazetadopovo.com.br/vida-e-cidadania/emenda-contraria-leis-antitabaco-e-propoe-fumodromo-disfarcado-9pcryddqaf8i0jc9kat5patzi (acessado em 24/Ago/2015).
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• ²⁹ Câmara dos Deputados. Deputados e especialistas pedem regulamentação imediata da Lei Antifumo. Lei proíbe fumo em ambientes coletivos fechados em todo o país, mas falta de regulamentação pelo Executivo faz com que não seja fiscalizada, 2013 http://www2.camara.leg.br/camaranoticias/noticias/SAUDE/459307-DEPUTADOS-E-ESPECIALISTAS-PEDEM-REGULAMENTACAO-IMEDIATA-DA-LEI-ANTIFUMO.html (acessado em 24/Ago/2015).
• ³⁰ Unidade de Pesquisa Álcool e Drogas. Regulamentação da lei antifumo está emperrada há sete meses, 2012. http://www.uniad.org.br/interatividade/noticias/item/15135-regulamenta%C3%A7%C3%A3o-da-lei-antifumo-est%C3%A1-emperrada-h%C3%A1-sete-meses (acessado em 24/Ago/2015).
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• ³¹ Vianna CGF, Vedovato LR, Barata D. Apontamentos sobre o Decreto 8.262/14 à luz do controle do tabagismo e da Convenção-Quadro para o Controle do Tabaco. Cad Ibero Am Direito Sanit (Impr.) 2014; 3:149-60.
• ³² PR Newswire - a Cision Company. Brazil to become world's largest smoke-free country, 2011. http://www.prnewswire.com/news-releases/brazil-to-become-worlds-largest-smoke-free-country-135659733.html (acessado em 24/Ago/2015).
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• ³³ Instituto Nacional de Câncer José Alencar Gomes da Silva. Notas técnicas para controle do tabagismo: Embalagem padronizada de produtos de tabaco. http://www2.inca.gov.br/wps/wcm/connect/be366e8047362496ada1af7c4f0415f8/Nota+tecnica_embalagens+padronizadas.pdf?MOD=AJPERES&CACHEID=be366e8047362496ada1af7c4f0415f8 (acessado em 24/Ago/2015).
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• ³⁴ Canadian Cancer Society. Advertências sanitárias nas embalagens de cigarros, relatório situacional internacional, 2014. http://global.tobaccofreekids.org/files/pdfs/pt/WL_status_report_pt.pdf (acessado em 24/Ago/2015).
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• ³⁸ Instituto Nacional de Câncer. Brasil: advertências sanitárias nos produtos de tabaco 2009. http://www.coppt.pt/attachments/069_brasil_advertencias_sanitarias_nos_produtos_de_tabaco2009b.pdf (acessado em 24/Ago/2015).
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• ³⁹ Agência Nacional de Vigilância Sanitária. Consulta Pública nº 17, de 5 de março de 2015. Proposta de RDC para regulamentação de advertência sanitária que ocupará trinta por cento da parte inferior da face frontal das embalagens de produtos fumígenos derivados do tabaco, em cumprimento à Lei 12.564/2011 e ao Decreto 8.262/2014. http://portal.anvisa.gov.br/wps/content/anvisa+portal/anvisa/regulacao+sanitaria/assuntos+de+interesse/consultas+publicas/assuntos+de+interesse/consultas+publicas+encerradas/2015/2015030617 (acessado em 24/Ago/2015).
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• ⁴⁰ Comissão Nacional para Implementação da Convenção-Quadro para o Controle do Tabaco, Instituto Nacional de Câncer José Alencar Gomes da Silva. Política Nacional de Controle do Tabaco: relatório de gestão e progresso 2013-2014. http://www2.inca.gov.br/wps/wcm/connect/7605fc004fe6c76ebbf3ff76651c600b/14-Relat%C3%B3rio+de+Gest%C3%A3o+e+Progresso+2013-2014.pdf?MOD=AJPERES&CACHEID=7605fc004fe6c76ebbf3ff76651c600b (acessado em 14/Fev/2017).
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• ⁵⁹ Instituto Nacional de Câncer José Alencar Gomes da Silva. Notas técnicas para o controle do tabagismo: a importância e a urgência da diversificação de produção em áreas que produzem tabaco no Brasil. http://www2.inca.gov.br/wps/wcm/connect/67a02b804430b74b8f33bf2537792882/Nota+t%C3%A9cnica+-+Diversifica%C3%A7%C3%A3o+Produ%C3%A7%C3%A3o+Tabaco+-+FINAL.pdf?MOD=AJPERES&CACHEID=67a02b804430b74b8f33bf2537792882 (acessado em 24/Ago/2015).
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• ⁷⁴ Na bagagem, a defesa do tabaco brasileiro. Gazeta do Sul 2014. http://www.grupogaz.com.br/gazetadosul/noticia/444960-na_bagagem_a_defesa_do_tabaco_brasileiro/edicao:2014-10-13.html (acessado em 24/Ago/2015).
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• ⁷⁵ AMPROTABACO: entidade que defende municípios produtores de tabaco empossa nova diretoria. Rádio Difusora do Xisto 2015. http://www.difusoradoxisto.com.br/noticias/geral/315-amprotabaco-entidade-que-defende-municipios-produtores-de-tabaco-empossa-nova-diretoria.html (acessado em 24/Ago/2015).
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• ⁷⁸ Fumo ajudou a eleger 13 congressistas. Folha de S. Paulo 2008. https://outrapolitica.wordpress.com/2008/09/18/fumo-ajudou-a-eleger-13-congressistas/ (acessado em 24/Ago/2015).
• ⁷⁹ Deputado que apoia fumódromo recebeu doação da indústria. Folha de S. Paulo 2008. http://www1.folha.uol.com.br/fsp/cotidian/ff1809200819.htm (acessado em 24/Ago/2015).
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• ⁸² World Health Organization. WHO Study Group on Tobacco Product Regulation (TobReg). http://www.who.int/tobacco/global_interaction/tobreg/en/ (acessado em 24/Ago/2015).
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• ⁸³ Talhout R, Opperhuizen A, van Amsterdan JG. Sugars as tobacco ingredient: Effects on mainstream smoke composition. Food Chem Toxicol 2006; 44:1789-98.
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• ⁸⁶ Parlamentares a favor da indústria de fumo e contra aditivos em cigarros. Correio do Estado 2010. http://www.correiodoestado.com.br/noticias/parlamentares-a-favor-da-industria-de-fumo-e-contra-aditivos_83761/ (acessado em 24/Ago/2015).
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• ⁸⁷ Deputado Federal Luiz Carlos HEINZE. Heinze solicita audiência com grupo de ministros que discutem posição do Brasil sobre Convenção-Quadro Heinze solicita audiência com grupo de ministros que discutem posição do Brasil sobre Convenção-Quadro http://www.deputadoheinze.com.br/index.php/component/acymailing/archive/view/listid-4-passarinheiros/mailid-50-heinze-solicita-audiencia-com-grupo-de-ministros-que-discutem-posicao-do-brasil-sobre-convencao-quadro (acessado em 24/Ago/2015).
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• ⁸⁸ Deputado Federal Luiz Carlos HEINZE. Comissão de Agricultura apela a Lula para que Brasil reveja posição sobre Convenção-Quadro, 2010. http://www.deputadoheinze.com.br/index.php/noticias/931-comissao-de-agricultura-apela-a-lula-para-que-brasil-reveja-posicao-sobre-convencao-quadro (acessado em 24/Ago/2015).
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• ⁸⁹ Afubra e federações pressionam por posição favorável do Brasil no Uruguai, 2010. http://www.paginarural.com.br/noticia/142139/afubra-e-federacoes-pressionam-por-posicao-favoravel-do-brasil-no-uruguai (acessado em 24/Ago/2015).
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• ⁹⁰ Fumo tipo Burley na corda bamba. Produtores temem nova resolução da Convenção-Quadro, que pode desestimular o cultivo da variedade. Correio do Povo 2010. http://www.correiodopovo.com.br/Impresso/?Ano=115&Numero=263&Caderno=11&Noticia=156329 (acessado em 24/Ago/2015).
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• ⁹¹ World Trade Organization. Technical barriers to trade - tobacco and alcohol again among members' trade concerns. Canada - Bill C-32 Amendment to the "Tobacco Act" (previously raised). http://www.wto.org/english/news_e/news10_e/tbt_23jun10_e.htm (acessado em 24/Ago/2015).
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• ⁹⁴ Agência Nacional de Vigilância Sanitária. Consulta Pública nº 112, de 29 de novembro de 2010. http://portal.anvisa.gov.br/wps/wcm/connect/5c95c700486d1e499941992bd5b3ccf0/CP+112_ADITIVOS_DOU+30-11-10.pdf?MOD=AJPERES (acessado em 24/Ago/2015).
  » Consulta Pública nº 112, de 29 de novembro de 2010.» http://portal.anvisa.gov.br/wps/wcm/connect/5c95c700486d1e499941992bd5b3ccf0/CP+112_ADITIVOS_DOU+30-11-10.pdf?MOD=AJPERES
• ⁹⁵ Agência Nacional de Vigilância Sanitária. Consulta Pública nº 117, de 27 de dezembro de 2010. http://portal.anvisa.gov.br/wps/wcm/connect/f674f08047458b00949dd43fbc4c6735/CP+N%C2%BA+117+GPDTA.pdf?MOD=AJPERES (acessado em 24/Ago/2015).
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• ⁹⁶ Câmara dos Deputados. Notas taquigráficas de Audiência Publica da Comissão de Agricultura da Câmara dos Deputados, 2010. Assunto: Discussão sobre a situação dos trabalhadores e produtores da variedade de fumo Burley no Brasil. http://www2.camara.leg.br/atividade-legislativa/comissoes/comissoes-permanentes/capadr/documentos/notas-taquigraficas/notas-taquigraficas-2010/audiencia-publica-da-comissao-01-12-2010-tema-discussao-sobre-a-situacao-dos-trabalhadores-e-produtores-da-variedade-de-fumo-burley-no-brasil/view (acessado em 24/Ago/2015).
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• ⁹⁷ Estados e setor fumo vão a Brasília contra a ANVISA. Gazeta do Sul 2011 Gazeta do Sul 2011 http://www.gaz.com.br/gazetadosul/noticia/268092-insatisfacao_vai_ser_levada_a_brasilia.html (acessado em 24/Ago/2015).
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• ⁹⁸ Deputado diz que propostas da Anvisa podem inviabilizar plantio de tabaco. Em Questão 2010. http://cguemquestao.blogspot.com/2011/03/deputado-diz-que-propostas-da-anvisa.html (acessado em 24/Ago/2015).
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• ¹⁰¹ Deputado Luiz Carlos HEINZE. Heinze quer sustar consulta da Anvisa que pode acabar com fumicultura brasileira, 2010. http://www.deputadoheinze.com.br/index.php/noticias/968-heinze-quer-sustar-consulta-da-anvisa-que-pode-acabar-com-fumicultura-brasileira (acessado em 24/Ago/2015).
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• ¹⁰² Luiz Carlos Heinze Financiadores de Campanha. Congresso em Foco 2006.
• ¹⁰³ Associação Brasileira de Fumicultores do Brasil. Mais de 200 mil formulários devem chegar à Anvisa, 2011. http://www.afubra.com.br/blog/?p=266 (acessado em 24/Ago/2015).
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• ¹⁰⁴ Agência Brasil. Grande número de contribuições atrasa consulta pública da Anvisa que proíbe aromatizantes em cigarros, 2011. http://agenciabrasil.ebc.com.br/noticia/2011-04-04/grande-numero-de-contribuicoes-atrasa-consulta-publica-da-anvisa-que-proibe-aromatizantes-em-cigarros (acessado em 24/Ago/2015).
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• ¹⁰⁵ World Trade Organization. Technical barriers to trade: formal meeting. Members concerned about public health. http://www.wto.org/english/news_e/news11_e/tbt_24mar11_e.htm (acessado em 24/Ago/2015).
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• ¹⁰⁶ Supremo Tribunal Federal. Ação Direta de Inconstitucionalidade nº 4.874. http://redir.stf.jus.br/estfvisualizadorpub/jsp/consultarprocessoeletronico/ConsultarProcessoEletronico.jsf?seqobjetoincidente=4328586 (acessado em 24/Ago/2015).
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• ¹¹⁰ Campaign for Tobacco-Free Kids, Action on Smoking and Health. Trust us: we're the tobacco industry. Tobacco industry lobbying, 2001. http://www.ash.org.uk/files/documents/ASH_135.pdf (acessado em 24/Ago/2015).
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• ¹¹¹ Monardi F, Glantz SA. Are tobacco industry campaign contributions influencing state legi slative behavior? Am J Public Health 1998; 88:918-23.
• ¹¹² Glantz SA, Begay ME. Tobacco industry campaign contributions are affecting tobacco control policymaking in California. JAMA 1994; 272:1176-82.

Publication Dates

• Publication in this collection
  2017

History

• Received
  25 Aug 2015
• Reviewed
  08 Apr 2016
• Accepted
  02 May 2016