Tobacco control in Brazil : the achievements and challenges of a successful policy

This Supplement of CSP was organized in collaboration with the Center for Studies on Tobacco and Health, National School of Public Health, Oswaldo Cruz Foundation (CETAB/ ENSP/Fiocruz). It has an unprecedented focus, shedding light on and systematically organizing current knowledge on the magnitude of smoking as a public health issue and on best practices, and obstacles to tobacco control policy implementation in Brazil, a country regarded worldwide as a success story. Smoking is one of the leading avoidable causes of early death and health inequality in the world. An estimated 7.2 million persons worldwide, including 156,200 Brazilians, die every year from diseases associated with active and passive smoking, and these deaths are concentrated in the poorest and most vulnerable populations 1. The (still underestimated) total annual cost of smoking in Brazil, is nearly BRL 57 billion, 39.3 billion of which due to medical care and treatment costs and 17.5 billion due to lost productivity 2. According to the Brazilian National Health Survey in 2013, 22 million Brazilian adults (15% of the population aged 18 years or older) were smokers 3. Tobacco production and consumption have devastating consequences for health, the environment, and the economy, but a long and victorious negotiation process headed by the World Health Organization (WHO) led to one of the most solid strategies and instruments for equitable health protection: the WHO Framework Convention on Tobacco Control (WHO-FCTC), the first and only global public health treaty to this day. Approved in 2003 by the 56th World Health Assembly, the WHO-FCTC came into effect in February 2005 following ratification by 40 countries, including Brazil. Consisting of 38 articles and a series of effective measures backed by current scientific evidence for curtailing the consumption of tobacco products and its consequences, the WHO-FCTC serves as the framework and pillar for the success of smoking control policies. Due to the treaty’s huge importance, four articles in this Supplement analyze the WHOFCTC’s relevance for tobacco control policy in Brazil, highlighting the government’s leading role in the treaty’s negotiations, the obstacles faced by ratification, and the role and conflicts of the institutions involved in the policy’s implementation. The authors discuss the fact that Brazil is a leading producer and exporter of tobacco leaves and analyze how tobacco farmers are used by the tobacco industry to manipulate the opinions of politicians Tobacco control in Brazil: the achievements and challenges of a successful policy

This Supplement of CSP was organized in collaboration with the Center for Studies on Tobacco and Health, National School of Public Health, Oswaldo Cruz Foundation (CETAB/ ENSP/Fiocruz).It has an unprecedented focus, shedding light on and systematically organizing current knowledge on the magnitude of smoking as a public health issue and on best practices, and obstacles to tobacco control policy implementation in Brazil, a country regarded worldwide as a success story.
Smoking is one of the leading avoidable causes of early death and health inequality in the world.An estimated 7.2 million persons worldwide, including 156,200 Brazilians, die every year from diseases associated with active and passive smoking, and these deaths are concentrated in the poorest and most vulnerable populations 1 .The (still underestimated) total annual cost of smoking in Brazil, is nearly BRL 57 billion, 39.3 billion of which due to medical care and treatment costs and 17.5 billion due to lost productivity 2 .According to the Brazilian National Health Survey in 2013, 22 million Brazilian adults (15% of the population aged 18 years or older) were smokers 3 .
Tobacco production and consumption have devastating consequences for health, the environment, and the economy, but a long and victorious negotiation process headed by the World Health Organization (WHO) led to one of the most solid strategies and instruments for equitable health protection: the WHO Framework Convention on Tobacco Control (WHO-FCTC), the first and only global public health treaty to this day.Approved in 2003 by the 56th World Health Assembly, the WHO-FCTC came into effect in February 2005 following ratification by 40 countries, including Brazil.
Consisting of 38 articles and a series of effective measures backed by current scientific evidence for curtailing the consumption of tobacco products and its consequences, the WHO-FCTC serves as the framework and pillar for the success of smoking control policies.Due to the treaty's huge importance, four articles in this Supplement analyze the WHO-FCTC's relevance for tobacco control policy in Brazil, highlighting the government's leading role in the treaty's negotiations, the obstacles faced by ratification, and the role and conflicts of the institutions involved in the policy's implementation.The authors discuss the fact that Brazil is a leading producer and exporter of tobacco leaves and analyze how tobacco farmers are used by the tobacco industry to manipulate the opinions of politicians and the population in the country's southern region in favor of the industry's interests.From another angle, one of the articles analyzes the perceptions of women farmers concerning the tobacco growing process.
Reflection on tobacco control policies necessarily puts the issue of globalization and the impact of transnational corporations -including the alcohol and food industries and others -as an important social determinant of health into perspective.In Brazil and elsewhere, the greatest obstacle to a tobacco-free world is the action by a legal and economically powerful industry.In this sense, the policy backed by the WHO-FCTC involves a range of measures whose objectives are to resist the industry's attacks, because otherwise all efforts to curb smoking will be insufficient.The need to protect tobacco control policies from interference by the tobacco industry is written into Article 5.3 of the WHO-FCTC.Two articles in the Supplement focus specifically on this issue: one addresses the importance of the Fiocruz Observatory on Tobacco Industry Strategies as a way of strengthening tobacco control in Brazil and Latin America as a whole, and the other discusses the industry's interference during the implementation of warning labels on cigarette packs and cartons.Still on the topic of globalization processes, another article analyzes Brazil's tobacco control policy vis-à-vis economic policies, and the Debate section discusses the limits and criteria for establishing public-private partnerships in the field of health promotion, aimed at protecting public interests from those of large corporations.Due to their current relevance, the United Nations's 2030 Agenda for Sustainable Development Goals, or Agenda 2030, which the Brazilian government joined in 2015, merit special attention here, adding to the WHO-FCTC in strengthening integrated measures to deal with major health problems.Agenda 2030, which sets clear targets for the reduction of chronic non-communicable diseases and implementation of the WHO-FCTC, reinforces the indivisibility of economic, social, and environmental development and the need to overcome poverty as a means to promoting development and fostering a more just society.The production and consumption of tobacco products relate to various objectives on the Agenda 2030, especially those pertaining to the reduction of poverty and hunger, since smoking is a leading cause of health inequality in the world 4 .In Brazil, the percentage of smokers among individuals with primarylevel schooling or less is more than double that of university graduates.The relationship between smoking and infectious diseases, often overlooked, but reviewed in the Agenda's 2030 documents, is one of the themes in an article in this special edition.
Any discussion of tobacco control policy worldwide and in Brazil should emphasize that although smoking rates are still alarmingly high, considerable progress has been made.The legal framework created by the WHO-FCTC has been the main pillar and driving strategy for progress with the control measures.Even before Brazil ratified the treaty, the country had established government policies coordinated by the National Cancer Institute and later by the National Commission for Implementation of the Framework Convention on Tobacco Control (CONICQ), backed decisively by organized civil society.Outstanding measures have included the ban on cigarette advertising in all types of media, health warnings with images on cigarette packs, and tax and price increases.Two articles in the special edition describe these interventions.The first analyzes ten years of experience with the policy as a whole, its progress and results, and the second addresses data that reinforce the impact of the smoking ban in closed public environments.The efficacy of these measures is reflected in the relative reduction of nearly 56% and 59% in the proportion of tobacco use in men and women aged 18 years and older, respectively, from 1989 to 2013, and by the trend in the smoking prevalence estimates obtained through telephone surveys conducted in eight consecutive years in Brazil's state capitals, which was analyzed in one of the articles in this issue.Despite the progress, major challenges remain regarding the implementation of plain cigarette packs, the maintenance of price and tax policies, and resistance to the industry's influence on opinion-makers, legislators, and parts of the Executive branch.Another challenge is defining measures for dealing with indirect advertising, a theme analyzed in one article, and the new age of tobacco industry technological innovations, with new products that are particularly appealing to young people, such as water pipes, electronic cigarettes, flavored tobacco products, and filters with menthol capsules, as discussed in four articles in this Supplement.
The Global Burden of Disease Study 2015, recently published in The Lancet 5 , cited Brazil as one of the countries with the greatest decline in smoking prevalence and most comprehensive tobacco control policy.This Supplement, featuring articles by various authors who have been protagonists in this long process, is a celebration of this successful and innovative policy that has prevented thousands of deaths in our country.

Tobacco control in Brazil: the achievements and challenges of a successful policy
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