The decision-making process in Brazil ’ s ratification of the World Health Organization Framework Convention on Tobacco Control

Tobacco consumption is a leading cause of various types of cancer and other tobacco-related diseases. In 2003, the World Health Assembly adopted the World Health Organization Framework Convention on Tobacco Control (WHO-FCTC), which aims to protect citizens from the health, social, environmental, and economic consequences of tobacco consumption and exposure to tobacco smoke. The Convention was to be ratified by the Member States of the WHO; in Brazil’s case, ratification involved the National Congress, which held public hearings in the country’s leading tobacco growing communities (municipalities). The current study analyzes this decision-making process according to the different interests, positions, and stakeholders. In methodological terms, this is a qualitative study based on document research, drawing primarily on the shorthand notes from the public hearings. We analyze the interests and arguments for and against ratification. The article shows that although preceded by intense debates, the final decision in favor of ratification was made by a limited group of government stakeholders, characterizing a decision-making process similar to a funnel. Tobacco; Health Policy; Policy Making Correspondence A. Pereira Neto Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz. Rua Leopoldo Bulhões 1480, Rio de Janeiro, RJ 21041-210, Brasil. andrepereiraneto@gmail.com 1 Instituto Nacional de Câncer José Alencar Gomes da Silva, Rio de Janeiro, Brasil. 2 Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. 3 Instituto de Estudos em Saúde Coletiva, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil. ARTIGO ARTICLE doi: 10.1590/0102-311X00126115 Cad. Saúde Pública 2017; 33 Sup 3:e00126115 This article is published in Open Access under the Creative Commons Attribution license, which allows use, distribution, and reproduction in any medium, without restrictions, as long as the original work is correctly cited.


Introduction
Tobacco consumption is considered an important cause of different types of cancer and is identified as the leading cause of avoidable deaths in the world 1 .A recent study by the World Health Organization (WHO) shows the social, economic, political, and environmental losses caused by smoking in every society 2 .Tobacco farming involves thousands of farm workers on family smallholdings, subject to technological packages supplied by powerful transnational companies, enmeshed in a globalized market, harming the farmers' health and often using child labor 3 .
Brazil is the world's second leading producer and leading exporter of tobacco leaves.Initially, tobacco production in Brazil occupied small areas, mostly concentrated in the Recôncavo region of Bahia, Northeast Brazil.Tobacco became an export product with the development of arable land in the South, using European labor.In 1917, the Brazilian Tobacco Corporation was founded in the city of Santa Cruz do Sul, Rio Grande do Sul State, having originated from the British American Tobacco company.It was the first step in turning the city into the national hub of the tobacco industry.In 1920, the company's name was changed to Companhia Brasileira de Fumo em Folha [Brazilian Tobacco Leaf Company], and in 1955 it was taken over by Souza Cruz.Brazil's tobacco leaf production is currently concentrated in the southern states of the country, as follows: Rio Grande do Sul (50%), Santa Catarina (28.8%), and Paraná (17.5%).Through the so-called "integrated tobacco production system", transnational companies began offering tobacco growers a guaranteed market for their crop, plus technical assistance and high-yield inputs such as seeds, pesticides, and fertilizers.This has created a system of dependency between small farmers and transnational companies, encompassing all the way from classification criteria for tobacco leaf quality to setting sale prices for the crop 4 .
In the late 20th century, the WHO took an official stance on tobacco consumption.After assessing countless studies, the WHO proposed that Member States adopt measures aimed to reduce such consumption 4 .On June 16, 2003, the first international treaty negotiated under the auspices of the WHO was approved unanimously 5 : the Framework Convention on Tobacco Control (WHO-FCTC).This document included a wide range of measures to protect present and future generations from the health, social, environmental, and economic consequences of tobacco consumption and exposure to tobacco smoke.It was decided that the Convention would only enter into force when the fortieth country joined the treaty.
In Brazil, the decision-making process in the ratification of the WHO-FCTC began with the debate over a bill of law in 2004 6 , which reproduced the Convention's wording in full.From December 2004 to October 2005, the bill was debated in public hearings in Brazil's five leading tobaccogrowing municipalities.The hearings convened tobacco industry representatives, farmers, and proponents of the WHO-FCTC, in addition to national and regional political leaders with different ideological and partisan identities 4 .In October 2005, the National Senate passed a legislative decree 7 that ratified and incorporated, in full, the wording of the Framework Convention, signed by Brazil on June 16, 2003, with the WHO.
The current article analyzes the conflicting interests and positions for and against ratification in the public hearings.The aim was to identify the main stakeholders in this decision-making process8, which culminated with the ratification of the WHO-FCTC.

Decision-making process: theoretical and methodological framework
This article presents an analysis of the decision-making process 8 that led to ratification of the WHO-FCTC.For this, we drew on part of the political science literature that addresses the theme.Authors generally emphasize that such analyses should take into account the "public arenas" 9 , stakeholders, and especially the intermediation of interests throughout the process 10 .
Numerous factors can affect the decision-making process.One such factor is the overall historical context, while others are more specific and can affect the flow of the decision-making process, interactions between stakeholders, and the public policy's approval and even its reach 11 .Other important factors include the nature of the issue targeted by the policy decision and the concentration or diffu-Cad.Saúde Pública 2017; 33 Sup 3:e00126115 sion of its costs and benefits.The breadth of benefits may limit or facilitate the decision-making in these "public arenas" 9 .
Some authors see a tendency to close off these arenas and to concentrate the decision-making power in a narrow group.Knoke et al. 12 developed an image in which they associate this process with a "funneling" 12 of the policy's stakeholders.The mouth of the funnel draws a wide range of individuals or mobilized groups.In this wide part, the stakeholders and interest groups are able to view the issues at stake more clearly.They establish their preferences and choose which side to take, based on the definition of the alternatives that appear during the decision-making process.The next step in the "funneling" 12 is where the "peak" associations concentrate.Typical "peak" organizations have a vast and rich constituency that gives the leaders ample freedom to choose between the available options.These stakeholders are few in number but highly visible and inevitably involved in many struggles in the public policy field.Finally, the funnel's "stem" features a small group consisting of those that make the final decisions in the relevant institutional "public arenas" 9 -ministries, regulatory agencies, and/ or the legislative branch.Virtually all these institutional stakeholders participate in the policy's final production phase, since a collective decision is not possible without definitive action by them; hence, they mobilize in measures for and against the policy, collaborating with the "peak" associations and key interest groups in favor of the policy's result 12 .
The "funneling" 12 metaphor implies a series of initial activities ranging from broad audiences to final actions, where the latter are taken by a small number of decision-makers.However, most real policy events do not fit such a sequential scenario.It is more common for institutional stakeholders such as government ministries or regulatory agencies to initiate policy proposals, and they are the ones that react to events initiated by pressure groups and the peak associations' lobby.Despite the chaos in the heat of the policy struggle, the conceptual simplicity of the "funnel" helps elucidate a persistent pattern: as a policy proposal moves towards actual resolution, the subset of stakeholders with sufficient power to affect the final decision usually shrinks.In short, the "funnel" of mobilization captures the exclusionary tendency of the decision-making process, and only in rare instances does mass participation have an impact 12 .
The current article presents a qualitative study based on document research, drawing primarily on the public hearings' shorthand notes 13 .We examine the role of organized political forces, the socalled "pressure groups" that comprise the policy flow and adopt positions of conflict or consensus in a given chain of the "public arena" 9 .They also allow the policymakers to perform a safer assessment of the forces and tendencies involved, as well as the risks and benefits in the adoption of a given proposal.

Paths to approval
Brazil's ratification of the WHO-FCTC took the form of Legislative Bill 602 in 2004 6 .In May that year the bill was approved by the Chamber of Deputies (lower house), which then referred it to the National Senate.

First public hearing
The National Senate held the first public hearing to debate the bill on September 15, 2004.According to the Senate's shorthand notes, the hearing lasted five and a half hours.Opponents of ratification argued that there had not been a broad debate between Congress and society on issues pertaining to the decrease in tobacco consumption and the measures' repercussions for small tobacco farmers.They questioned whether crop diversification (called "reconversion" by the tobacco industry) would be implemented satisfactorily.Heinsi Gralow, then-president of the Brazilian Tobacco Farmers' Association (Afubra), expressed these arguments: "We want to know where, how, how much money, and where the funds will come from to save 226,650 [tobacco farming] families in Brazil, not only in the South.We can't forget the Northeast -Bahia, Alagoas, Paraíba, Rio Grande do Norte, and Pernambuco -which have tobacco growers for cigars and aromatics" 13 .
Senator Fernando Bezerra (Brazilian Labour Party -Rio Grande do Norte State, PTB-RN), rapporteur at the first hearing, said the following: Cad. Saúde Pública 2017; 33 Sup 3:e00126115 "…I have worked hard reviewing the matter and reached the conclusion, in a statement by me, in principle, in favor [of ratification]..., because two hundred thousand people die of cancer in Brazil" 13 .
Despite this statement, the rapporteur apologized to the audience and said he could not stay to participate in the rest of the debate 13 .
There was apparently no head-on opposition to the treaty's ratification in this public hearing, despite the speeches both for and against.The issue apparently focused on whether or not to enforce "reconversion" 14 .
The members of Congress that were coordinating the ratification process managed to have the debate held in public hearings outside of the National Congress.On the occasion, it was decided that the next hearings would take place in five municipalities with small tobacco farmers, namely Santa Cruz do Sul (Rio Grande do Sul), Irati (Paraná), Florianópolis (Santa Catarina), Camaquã (Rio Grande do Sul), and Cruz das Almas (Bahia).
Our detailed analysis of each public hearing provided new food for thought, unveiling the arguments for and against ratification.All the hearings, held outside the National Senate, drew a large media presence and were broadcast live, nationwide, by the Senate's TV channel.

Second public hearing
The second public hearing took place on December 6, 2004, in Rio Grande do Sul, the state that accounts for 52.3% of Brazil's tobacco crop.The Rio Pardo Valley is the area of Brazil with the largest cluster of large tobacco companies 15 and includes the city of Santa Cruz do Sul, where this hearing took place.
The key arguments for ratification emphasized the problem of addiction caused by the consumption of tobacco products.Part of the statement by then-director of the National Cancer Institute José Alencar Gomes da Silva (INCA), José Gomes Temporão, points in this direction: "…We have to prepare now, not for what's going to happen in the next five or ten years, when nothing is going to change from the practical point of view; we need to prepare for what's going to happen with your grandchildren and great-grandchildren, for what's going to happen here in twenty, thirty, or forty years…" 13 .
The groups that spoke against ratification cited the risk of unemployment and the fact that it limited citizens' individual freedom to grow whatever crop they considered most profitable on their own land 13 .
This hearing included participation by government and business leaders.On the occasion, Caio Rocha, president of the Rio Grande do Sul State Institute for Technical Assistance and Rural Extension (EMATER-RS), representing the State Governor, highlighted the importance of tobacco farming by contributing to the reduction of greenhouse gases 3 .This new argument against ratification, presented by a government authority, reveals the complex power relations and interests at play.
Opponents of ratification thus insisted on emphasizing the economic losses that would befall the tobacco growing towns and tobacco farmers, while proposing to postpone the process as an alternative 13 .The position was defended by then-president of the Tobacco Industry Union (SINDIFUMO), Cláudio Henn, who stated: "…For the record, we are not against the Framework Convention.(…) we just don't want it to be done hastily.Thanks to Your Honor's position, it has been postponed…" 13 .In addition to the speakers, the audience voiced other positions against ratification 13 .

Third public hearing
The third public hearing was held in Irati, Paraná State, on August 19, 2005 13 .This hearing drew nearly five thousand people and was shown on a big screen outside the venue.During the hearing, the defenders of ratification from the public health area took a defensive stance, arguing that approval of the Framework Convention would not interfere (as opponents claimed) with tobacco farmers' livelihood.Part of the speech by then-president of the Department of Rural Socioeconomic Studies (DESER), Marcos Rochinski, illustrates this position: "...In our opinion, there is no basis to the rumor that the banks will be prevented from financing the tobacco crop, and neither does the Convention propose the elimination of tobacco farming.The wording does not men-Cad.Saúde Pública 2017; 33 Sup 3:e00126115 tion prohibiting countries or tobacco growers from growing tobacco, nor does it set any deadlines for enforcing these measures" 13 .
In addition to the arguments on the harm to the population's health, a policy proposal was needed to develop alternative farm crops.In this sense, issues pertaining to the yield of alternative crops and measures for diversification now occupied the center of the discussions in the public hearings.Government funding for crop diversification was apparently not forthcoming.The speech by Almedo Dettenborn of the Association of Municipalities of the Rio Pardo Valley (AMVARP) illustrates this position: "...I have tried to implement incentives for swine and poultry production here, but have not succeeded.I wish the subsidies -the funds from the Framework Convention, coming from the world -would change our economic profile.Then I would be the first to applaud the Convention..." 13 .

Forth public hearing
The forth public hearing was held in Florianópolis, Santa Catarina State, on August 26, 2005 "...I look out over this audience, small farmers with calloused hands, certain that tobacco gives them a good living, just as tomatoes do where I come from.Growing tomatoes may even require more pesticides, and more hazardous ones [applause].Of course, many may claim that tobacco leads to misfortune, but as I was saying this morning to my friends from Itaiópolis: people only smoke if they want to [applause]..." 13 .
The argument by State Representative Reno Caramori (PFL-SC) emphasizes the issue of individual freedom to choose whether to smoke or not.However, the latest edition of The Tobacco Atlas 16 by the American Cancer Society (2015) shows that tobacco cultivation involves the use of chemical pesticides and fertilizers that create serious problems for the environment and farmers.
In this hearing, defenders of ratification publicly denounced the involvement of the Brazilian Tobacco Farmers' Association (Afubra) with the International Tobacco Growers' Association (ITGA), financed by the tobacco industry.The exposé came from Paula Jones of Rede Tabaco Zero (Zero Tobacco Network): "...The main opponents of the treaty's ratification in Brazil are Afubra and some allied organizations.But who does Afubra really represent?Does it really represent you, the small family farmers, who are out there every day planting, or does it represent the multinational tobacco corporations?I guarantee you, and I can prove it, that it defends the interests of the big multinational tobacco companies..." 13 .
While Afubra had the support of Big Tobacco, the Zero Tobacco Network was backed by the Pan-American Health Organization (PAHO) and Brazilian Health Regulatory Agency (Anvisa) and INCA.Zero Tobacco is a nongovernmental organization that convenes social groups, medical associations, scientific communities, and activists to take action against tobacco consumption 13 .International institutions for and against ratification also showed conflicting interests and views of the Convention.
During the same hearing, Senator Jorge Bornhausen (PFL-SC) expressed his solidarity for the small tobacco farmers: "...We're thinking about those that die, and we have to think about those that live, and under what conditions they farm (...) a crop, that's a family crop, that takes advantage of a small farm property, that has credit, technical assistance, and a buyer" 13 .
The arguments took shape as the hearings proceeded.Defenders of ratification emphasized the importance of alternatives to tobacco for the farmers and warned of tobacco-related diseases.The opponents associated ratification with deteriorating living conditions for thousands of farmers, since the widely touted "reconversion" stood little chance of becoming a tangible reality.In addition, they claimed, measures in the Convention to curtail tobacco consumption would violate individual freedom.

Fifth public hearing
The fifth public hearing was held on September 23, 2005, in Camaquã, Rio Grande do Sul State.
Defenders of WHO-FCTC ratification by the Brazilian government insisted that their critics were being untruthful by claiming that ratification would mean the eradication of tobacco farming.Érico Feltrin, from the Chief of Staff's Office (representing the Office of the President of Brazil), challenged the audience to find any mention in the treaty of eradicating tobacco farming 13 .The audience, consisting of tobacco farmers, felt otherwise.For them, if tobacco consumption decreased, production would slow down as a consequence.
The presence of a representative from the Chief of Staff's Office at the hearing did not prevent the Governor of Rio Grande do Sul, Germano Rigotto (Brazilian Democratic Movement Party-Rio Grande do Sul State, PMDB-RS), from speaking against ratification: "This international agreement by the WHO has been joined by several countries, but the first issue we need to raise is that it's easy to join when there aren't two million four hundred thousand people involved in tobacco production" 13 .
This time, members of the Federal and State Executive branches voiced their differences publicly.The Governor of the State of Rio Grande do Sul was opposed to the representative from the Chief of Staff's Office of the Brazilian President.This was one more situation of disagreement that might have resulted in a government standstill or the inclusion of new topics on the agenda 10 .
The hearing in Camaquã drew an estimated ten thousand participants.Defenders of ratification considered it the most difficult hearing, since the State Governor himself opened the proceedings with a public stance against ratification.His position managed to draw numerous State and National Representatives, city council members, and mayors from different political parties and regions of Rio Grande do Sul.
Regional interests weighed against ratification.The constituencies pressured for non-ratification of the WHO-FCTC.National Representatives, Senators, and Governors from the government's coalition could not vote against their constituencies' interests 17 .This tendency became even more explicit in the fifth hearing.Opponents of ratification had changed their position.Rather than postponing the decision, they now proposed that Brazil abstain from the ratification, thus serving the tobacco farmers' demands.The speech by the President of the Rio Grande do Sul State Federation of Agriculture, Carlos Rivaci Esperotto, illustrates this position: "...The most intelligent position, and the one we believe in, (...) is to remain silent.As Your Honor says, silence is the intelligent way" 13 .

Sixth public hearing
The sixth and final public hearing took place in Cruz das Almas, Bahia State, on October 11, 2005.This was the only hearing on ratification of the WHO-FCTC held in Northeast Brazil, a region with low tobacco production, now mainly tobacco leaf for cigars and cigarillos, when compared to the tobacco crop in the South.Public participation in this hearing was smaller than in the previous ones 13 .Shorthand records show 300 people attending.The audience breakdown was also different, mostly consisting of university students, tobacco growers' representatives, unions, and local politicians 13 .
The fact that other countries had already ratified the Convention was widely cited by defenders of ratification.The representative from the Ministry of Health provided an update on the signatories to the WHO-FCTC elsewhere in the world, saying that "of the eleven countries to which we export tobacco, ten have already ratified, including China" 13 .The rapporteur for the Committee on Agriculture, Senator Heráclito Fortes (PFL-PI), then immediately requested that the Ministry of Health's representative provide the committee with a document that attested to China's ratification, which he did that same day.Given approval of the Convention by the world's largest tobacco-producing country, Fortes then took a position in favor of ratification, drafting a statement to that effect in his report 13

"Funneling" in the decision-making process
The day after the sixth hearing, a meeting was held in the National Senate in Brasilia with rapporteur Senator Heráclito Fortes, the representative from the Chief of Staff's Office, and the representative from the Ministry of Health.The purpose of the meeting was to negotiate an agreement to guarantee safeguards for the tobacco chain's weak link: the tobacco farmers, small landholders, traditional family farmers.
Studies by the Ministry of Agrarian Development 18 analyze the potential of strategies and policies for agricultural diversification in rural areas with asymmetries and local specificities.Initiatives that prioritize traditional knowledge of the environment and farm workers' health point to difficulties in consolidating such measures, which assume the adoption of broader public policies, changes in the market structure, and consumer education in order to strengthen family-based agroecology 19 .
Many of the institutions and stakeholders for and against approval of the WHO-FCTC attended the first hearing.The two sides had mobilized their constituencies in different ways.They aimed to

Table 1
Summary of the arguments for and against ratification of the World Health Organization Framework Convention on Tobacco Control during six public show their own political strength and mobilize public opinion in favor of their respective positions.However, despite all the debate, the decision in favor of ratification was made by a more limited group of government stakeholders.This was not an isolated fact, since the concentration of decision-making power in a narrow group is a social phenomenon that is found in other studies analyzing the decisionmaking process 12,20 .Therefore, in order to better explain this process, some authors have drawn an analogy to a funnel 12 .The analogy assumes a process that unfolds over a certain length of time, involves different audiences, and can be grasped in actual measures, while not following a Cartesian order.
Since the narratives analyzed here suggest a tense atmosphere in the towns where the WHO-FCTC hearings were held in Brazil, the simplicity of the funnel analogy helps perceive what many authors consider a persistent pattern 12 , which can be seen in the current study.

Final remarks
The article discusses a highly important topic and addresses a political process that has received little attention, namely the negotiations leading up to ratification of the WHO-FCTC by Brazil.This qualitative study was based on the shorthand notes from the public hearings held by the National Senate in different municipalities -all leading tobacco growing communities in Brazil.Although preceded by intense debates, the final decision in favor of ratification was made by a more limited group of government stakeholders.This decision-making process was thus similar to a "funnel".
In this study, the "public arenas" 9 were the public hearings held precisely in the country's largest tobacco growing areas.The tobacco industry lobby clearly intended to pressure Senators to vote against ratification of the WHO-FCTC by Brazil.An example can be seen in the story published in Gazeta do Sul on the eve of the public hearing in Santa Cruz do Sul, on December 6, 2004.According to the newspaper, the city, dependent on tobacco production, was living a "decisive moment" 21 .
"The economy of Santa Cruz in the Rio Pardo Valley and that of many municipalities in the States of Santa Catarina and Paraná will experience one of the most important moments in their history on Monday.Senators will participate in a public hearing at the University of Santa Cruz do Sul (UNISC) to discuss whether Brazil should join the Framework Convention on Tobacco Control.… The meeting will take place in the UNISC Auditorium, where farmers, industry members, and leaders will try to convince the Senators not to ratify the Framework Convention.A total of 810 persons from various sectors will be accredited for the hearing" 22 .
The article's discussion clearly reveals the stakeholders involved and their respective interests.On the one side, the Federal government and its institutions, accompanied by nongovernmental organizations related to cancer and the fight against smoking.On the other, local interests of small tobacco farmers, expressed in the words of those who aimed to speak for the constituencies of the Governors and members of Congress from different parties in the tobacco growing states 17 .Joining them were regional and national tobacco growers' associations, linked to international tobacco institutions 19 .This clearly showed the complex power relations and interests at stake at the time.
The interactions between the arguments proposed in this "public arena" 9 could be observed throughout the process.Ratification was justified on grounds of the harm to health caused by tobacco consumption.Meanwhile, opposition to the WHO-FCTC reacted by claiming the principle of individual freedom.The tobacco farmers' leaders also denounced the losses that thousands of tobaccofarming families were bound to suffer from the elimination of tobacco growing.Defenders of the WHO-FCTC argued that the crop substitution policy known as "reconversion" would guarantee the families' survival and offset the possible social and economic losses.Critics voiced their doubts as to the capacity of "reconversion" to generate the promised benefits.
Ten years after ratification, Brazil is still one of the world's leading tobacco producers and exporters 16 .The Program to Support Crop Diversification in Areas with Tobacco Cultivation appears not to have fully reached its objectives 23 .However, a study published by Deser in March 2015 highlights a 24% drop in tobacco leaf exports in 2014 when compared to 2013 22 .
The national debate on ratification of the WHO-FCTC had been sparked by a decision made in another "public arena" 9 , namely the WHO Assembly.The problem for the Brazilian Federal Government was to find a way to legitimize ratification.The public hearings held in tobacco-growing Cad.Saúde Pública 2017; 33 Sup 3:e00126115 municipalities aimed to hinder the decision, which was finally made by a limited group.How does one explain this "funneling" 12 ?
Two hypotheses appear possible.One involves the cost of tobacco-related diseases for the country's Brazilian Unified National Health System (SUS).According to a recent study 24 , in 2005 some 35% of hospitalizations in men and 27% in women in the SUS were attributed to smoking, involving diseases of the respiratory and circulatory systems and cancer.The decision made by "funneling" 12 must have been made to relieve this financial burden.One should not underestimate the amplitude of benefits deriving from the reduction of tobacco consumption and production as an element that contributed to the decision.The second explanation is less measurable, but equally significant.It relates to another decision-making process: approval of the WHO-FCTC in the WHO forum.Brazil played a leading role in that "public arena" 9 .One sign of this leadership is the fact that Brazilian Ambassador Luiz Felipe Seixas Correa was elected unanimously to chair the Intergovernmental Negotiating Body (INB) of the Convention.The Convention was negotiated over the course of four years (1999-2003), and throughout this period representatives of the Brazilian government played a decisive role 25 .Brazil was also the second nation to sign the document, so the country would have been demoralized internationally if it had failed to ratify the Convention on its own territory.
The current study has limitations that deserve to be mentioned.One is the fact that the research was based almost exclusively on shorthand notes, a kind of writing developed to be as fast as speech.Other studies could be done using audiovisual information sources, since the hearings were broadcast on television.The reasons leading to the "funneling" 12 could also be verified by a careful analysis of the political context in the first Lula Administration, particularly the inherent challenges in the enforcement of the policy for social protection 26 .At any rate, the study contributes to our understanding of this important moment in the history of public health in Brazil.
tobacco-related cancer mortality in Brazil.Fernando Bezerra -relator e Senador (incidence of tobacco-related diseases.Dr. José Gomes Temporão -Director of the National Cancer Institute (INCA) Caio Rocha -representative of the Rio Grande do Sul State Company for Technical Assistance and Rural Extension (EMATER-RS) Cláudio Heinz -Tobacco Industry Union (SINDIFUMO) should abstain -not approve -the Convention.Érico Feltrin -representative of the Chief of Staff's Office -Office of the President of Brazil Germano Rigotto -Governor (Rio Grande do Sul) Carlos Rivaci Esperotto -President of the State Federation of Agriculture (Rio Grande do Sul) Cruz das Almas (Bahia State) Oct 11, 2005 For -China had already signed ratification.Heráclito Fortes -Rapporteur and Senator (Piauí) Cad.Saúde Pública 2017; 33 Sup 3:e00126115 Contributors E. C. Rangel contributed in the research and writing of the original text.A. Pereira Neto contributed in a orientation and final revision.T. M. Cavalcante, E. A. Oliveira and V. L. Costa e Silva collaborated in the final revision.All authors have approved the final version for publication.Cad.Saúde Pública 2017; 33 Sup 3:e00126115 Tabaco; Política de la Salud; Formulación de Políticas Submitted on 04/Aug/2015 Final version resubmitted on 02/Jun/2016 Approved on 05/Apr/2017 . The clash between defenders and opponents of ratification was even more polarized, with different positions even among representatives of the State government itself.The State Health Secretary, representing the State Governor, spoke in favor of ratification, while the Chairman of the State Commission on Agriculture and Rural Policy took the opposite position.The principle of freedom of choice was reiterated by the opponents of ratification.State Representative Reno Caramori (Liberal Front Party -Santa Catarina State, PFL-SC), Chairman of the State Commission on Agriculture and Rural Policy, stated his view as follows:

Table 1
summarizes the main arguments for and against ratification in each of the six public hearings, specifying who voiced each argument.