Acessibilidade / Reportar erro

Noncompliance with the law prohibiting the sale of cigarettes to minors in Brazil: an inconvenient truth

ABSTRACT

Objective:

To draw up an up-to-date scenario of compliance with the law prohibiting the sale of cigarettes to minors.

Methods:

We used data about youth access to cigarette purchase that were obtained through a nationwide survey conducted in 2015 among students aged 13-17 years. We estimated simple proportions of attempts to buy cigarettes, success of attempts, purchase of cigarettes on a regular basis, and purchase of cigarettes on a regular basis in a store or bar. All estimates were stratified by gender, age group, and Brazilian macro-region. Crude absolute difference and adjusted absolute difference in the proportion of smokers in each category by variable of interest were analyzed by a generalized linear model with binomial distribution and identity link function.

Results:

Approximately 7 in every 10 adolescent smokers attempted to buy cigarettes at least once in the 30 days prior to the survey. Of those, approximately 9 in every 10 were successful, and individuals aged 16-17 years (vs. those aged 13-15 years) were less often prevented from buying cigarettes (adjusted absolute difference, 8.1%; p ≤ 0.05). Approximately 45% of all smokers aged 13-17 years in Brazil reported buying their own cigarettes on a regular basis without being prevented from doing so, and, of those, 80% reported buying them in a store or bar (vs. from a street vendor).

Conclusions:

Our findings raise an important public health concern and may contribute to supporting educational and surveillance measures to enforce compliance with existing anti-tobacco laws in Brazil, which have been disregarded.

Keywords:
Smoking/epidemiology; Smoking/legislation & jurisprudence; Adolescent behavior; Public health

RESUMO

Objetivo:

Fornecer um cenário atualizado do cumprimento da lei que proíbe a venda de cigarros para menores de 18 anos de idade.

Métodos:

Foram utilizados dados de acesso à compra de cigarros obtidos por meio de uma pesquisa de âmbito nacional, realizada em 2015, entre jovens escolares de 13 a 17 anos. Foram estimadas as proporções simples de tentativa de comprar cigarros; sucesso dessa tentativa; compra regular de cigarros; e compra regular de cigarros em lojas ou botequins. Todas as estimativas foram estratificadas por sexo, faixa etária e macrorregiões brasileiras. Para avaliar as diferenças absolutas, brutas e ajustadas, das proporções das categorias consideradas em relação às variáveis analisadas, foi utilizado um modelo linear generalizado com distribuição binomial e função de ligação identidade.

Resultados:

Aproximadamente 7 em cada 10 fumantes adolescentes tentaram comprar cigarros pelo menos em uma ocasião nos 30 dias anteriores à pesquisa. Desses, aproximadamente 9 em cada 10 obtiveram sucesso, sendo que jovens entre 16-17 anos (vs. 13-15 anos) foram menos impedidos de comprar cigarros (diferença absoluta ajustada = 8,1%; p ≤ 0,05). Aproximadamente 45% de todos os fumantes brasileiros entre 13 e 17 anos de idade referiram ter comprado regularmente os seus próprios cigarros sem serem impedidos, e, desses, 80% relataram tê-los comprado em lojas/botequins (vs. vendedores ambulantes).

Conclusões:

Nossos achados trazem um importante alerta de saúde pública e podem contribuir para apoiar ações educativas e de fiscalização no sentido de reforçar o cumprimento das leis antitabaco já existentes no Brasil, que vêm sendo desrespeitadas.

Descritores:
Fumar/epidemiologia; Fumar/legislação & jurisprudência; Comportamento do adolescente; Saúde pública

INTRODUCTION

Brazil has achieved great advances in the fight against the tobacco epidemic in recent years because of the implementation of a series of legislative and educational measures based on the World Health Organization Framework Convention on Tobacco Control.11 World Health Organization [homepage on the Internet]. Geneva: World Health Organization [cited 2017 Oct 16]. WHO Framework Convention on Tobacco Control 2003. Available from: http://www.who.int/fctc/text_download/en/index.html
http://www.who.int/fctc/text_download/en...

2 Szklo AS, de Almeida LM, Figueiredo VC, Autran M, Malta D, Caixeta R, et al. A snapshot of the striking decrease in cigarette smoking prevalence in Brazil between 1989 and 2008. Prev Med. 2012;54(2):162-7. https://doi.org/10.1016/j.ypmed.2011.12.005
https://doi.org/10.1016/j.ypmed.2011.12....

3 GBD 2015 Tobacco 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(10082):1885-1906. https://doi.org/10.1016/S0140-6736(17)30819-X
https://doi.org/10.1016/S0140-6736(17)30...
-44 Szklo AS, de Souza MC, Szklo M, de Almeida LM. Smokers in Brazil: who are they? Tob Control. 2016;25(5):564-70. https://doi.org/10.1136/tobaccocontrol-2015-052324
https://doi.org/10.1136/tobaccocontrol-2...

The reduction in the proportion of smokers reflects not only increased smoking cessation but also a likely decrease in smoking initiation among adolescents and young adults.44 Szklo AS, de Souza MC, Szklo M, de Almeida LM. Smokers in Brazil: who are they? Tob Control. 2016;25(5):564-70. https://doi.org/10.1136/tobaccocontrol-2015-052324
https://doi.org/10.1136/tobaccocontrol-2...
) In fact, Brazilian national data from recent household surveys have shown a reduction in the proportion of smokers aged 18 to 24 years, which decreased from 13.6% to 10.6% from 2008 to 2013, as well as a reduction in the proportion of cigarette use among adolescents aged 14 to 17 years, which decreased from 6.2% to 3.4% from 2006 to 2012.44 Szklo AS, de Souza MC, Szklo M, de Almeida LM. Smokers in Brazil: who are they? Tob Control. 2016;25(5):564-70. https://doi.org/10.1136/tobaccocontrol-2015-052324
https://doi.org/10.1136/tobaccocontrol-2...
,55 Laranjeira R, Madruga CS, Pinsky I, Caetano R, Mitsuhiro SS. Segundo Levantamento Nacional de Álcool e Drogas: Relatório 2012. São Paulo: Instituto Nacional de Ciência e Tecnologia para Políticas Públicas de Álcool e Outras Drogas, UNIFESP; 2014.

Given that the mean age at initiation of regular cigarette smoking in Brazil is around 16 years,66 Instituto Brasileiro de Geografia e Estatística (IBGE) [homepage on the Internet]. Rio de Janeiro: IBGE; [cited 2017 Oct 16]. Pesquisa Nacional de Saúde 2013--Percepção do estado de saúde, estilos de vida e doenças crônicas Brasil, Grandes Regiões e Unidades da Federação. Available from: http://www.ibge.gov.br/home/estatistica/populacao/pns/2013/default.shtm
http://www.ibge.gov.br/home/estatistica/...
it is of fundamental importance that compliance with the law prohibiting the sale of cigarettes to minors be periodically assessed.77 Ministério Público do Paraná [homepage on the Internet]. Curitiba: o Ministério [cited 2017 Oct 16]. Estatuto da Criança e do Adolescente. Lei nº 8.069, de 13 de julho de 1990, e legislação correlata. 9th ed. Brasília : Câmara dos Deputados; 2012. [Adobe Acrobat document, 207 p.]. Available from: http://www.crianca.mppr.mp.br/arquivos/File/publi/camara/estatuto_crianca_adolescente_9ed.pdf,88 Brasil. Câmara dos Deputados [homepage on the Internet]. Brasília: a Câmara [cited 2017 Oct 16]. Lei Nº 10.702, de 14 de julho de 2003 - Publicação Original [about 3 screens]. Available from: http://www2.camara.leg.br/legin/fed/lei/2003/lei-10702-14-julho-2003-487461-publicacaooriginal-1-pl.html
http://www2.camara.leg.br/legin/fed/lei/...
) It has been observed, for example, that, despite the reduction in the proportion of adolescent smokers that occurred in Brazil between 2006 and 2012,55 Laranjeira R, Madruga CS, Pinsky I, Caetano R, Mitsuhiro SS. Segundo Levantamento Nacional de Álcool e Drogas: Relatório 2012. São Paulo: Instituto Nacional de Ciência e Tecnologia para Políticas Públicas de Álcool e Outras Drogas, UNIFESP; 2014. surveys conducted among students aged 13 to 15 years in several Brazilian cities between 2002 and 2009 indicated that compliance with the law prohibiting the sale of cigarettes to children and adolescents was pretty far from ideal.99 Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). A situação do tabagismo no Brasil: dados dos inquéritos do Sistema Internacional de Vigilância, da Organização Mundial da Saúde, realizados no Brasil, entre 2002 e 2009. Rio de Janeiro: INCA; 2011.) In fact, among the adolescent smokers who had tried to buy cigarettes in the 30 days prior to the surveys, the proportion of those who reported that they had not been prevented from buying cigarettes ranged from 51.0% to 91.6%. This suggests that the proportions of adolescent smokers in Brazil could have been further reduced. In addition, in 2012 and 2015, comparative national data on the proportion of cigarette consumption among students aged 13 to 15 years signaled a reversal of the decrease in smoking initiation among youth (5.1% vs. 5.6%).1010 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2012. Rio de Janeiro: IBGE, 2013.,1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016.

The objective of the present study was, therefore, to draw up an up-to-date scenario of compliance/noncompliance with the law prohibiting the sale of cigarettes to minors. To that end, we used data about youth access to cigarette purchase that were obtained through a nationwide survey conducted in 2015 among students aged 13 to 17 years.1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016.) This study may contribute not only to the understanding of the course of the smoking epidemic in Brazil but may also provide grounds for action, if necessary, toward the effective implementation of this law.

METHODS

We used data from the Pesquisa Nacional de Saúde do Escolar (PeNSE, Brazilian National School-Based Adolescent Health Survey), conducted in 2015, to assess compliance with the law prohibiting the sale of cigarettes to minors in Brazil.1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016.

The PeNSE is a survey of students that was first conducted in 2009 and occurs every 3 years in Brazil. Important innovations were introduced into the 2015 edition of the PeNSE.One of the most significant was that data were derived from a sample that included sixth to ninth graders and tenth to twelfth graders at public and private schools nationwide. Details regarding the cluster sampling procedure can be obtained elsewhere.1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016.) The indicators used in the present study concern the 13- to 17-year age group, totaling 10,926 questionnaires.

Although the cigarette consumption-related themes investigated in 2015 are the same as those of the previous editions of the survey, in that year, two new questions regarding youth access to cigarettes were also included: “In the past 30 days, did anybody refuse to sell you cigarettes (at any time) because of your age?”-the response choices were as follows: “I did not try to buy cigarettes in the past 30 days” OR “Yes, someone refused to sell me cigarettes because of my age” OR “No, my age did not keep me from buying cigarettes”; and “In the past 30 days, how did you usually get your own cigarettes?”-the response choices were as follows: “I bought them in a store or bar” OR “I bought them from a street vendor” OR “I gave someone else money to buy them for me” OR “I borrowed them from someone else” OR “An older person gave them to me” OR “I got them some other way”.

Data analysis

The analysis of the variables regarding youth access to cigarettes was restricted to the adolescents who reported having smoked cigarettes in the past 30 days (n = 688).The adolescent smokers were separated into two age groups (13- to 15-year olds vs. 16- to 17-year olds) in order to assess the impact that the individual’s physical aspect, related to growth and hormonal maturity, has on the attempts to buy cigarettes and, subsequently, on the success (or failure) of those attempts.

We estimated simple proportions of the following variables: “attempts to buy”; “success of attempts”; “purchase on a regular basis”; and “purchase on a regular basis in a store or bar.” All estimates were stratified by gender, age group, and Brazilian macro-region. To that end, we created a dichotomous variable called “attempts to buy”, classified as follows: (1) a combination of individuals who were prevented from buying cigarettes sometime in the 30 days prior to the completion of the questionnaire and those who were not prevented from doing so; and (0) individuals who did not attempt to buy cigarettes during that period.

We also created another dichotomous variable called “success of attempts”, which was classified as follows: (1) individuals who were not prevented from buying cigarettes in the 30 days prior to the survey; and (0) individuals who were prevented from buying cigarettes during that period.

In addition, for the adolescent smokers who reported having been able to buy cigarettes sometime in the 30 days prior to the survey, we created a dichotomous variable called “purchase on a regular basis”, described as follows: (1) individuals who reported having bought cigarettes usually from a store, bar, or street vendor during that period; and (0) individuals who reported having gotten cigarettes through means other than a purchase during that period.

Finally, for the adolescent smokers who were not prevented from buying cigarettes in the 30 days prior to the survey, we created a dichotomous variable called “purchase on a regular basis in a store or bar”, as follows: (1) individuals who bought cigarettes in a store or bar during that period; and (0) individuals who bought cigarettes on a regular basis from a street vendor during that period.

Crude absolute difference and adjusted absolute difference in the proportion of smokers in each category by gender, age group, and Brazilian macro-region were analyzed by a generalized linear model with binomial distribution and identity link function.1212 Wacholder S. Binomial regression in GLIM: estimating risk ratio and risk differences. Am J Epidemiol. 1986;123(1):174-84. https://doi.org/10.1093/oxfordjournals.aje.a114212
https://doi.org/10.1093/oxfordjournals.a...
) In this model, “attempts to buy” (OR “success of attempts” OR “purchase on a regular basis” or “purchase in a store or bar”) was used as a dependent variable, whereas gender, age group, and Brazilian macro-region were used as independent variables. Confidence intervals for adjusted absolute differences obtained from the regression model were calculated on the basis of a type I error of 5%. Additive interactions among independent variables were assessed by inclusion of corresponding interaction terms. The choice of an additive model, including for assessing interactions, was based on the importance of the results from the standpoint of prevention of youth access to cigarettes.1313 Szklo M, Nieto FJ. Epidemiology: beyond the basics. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2014.

Variables were processed and data were analyzed using STATA 12.0 (StataCorp LP, College Station, TX, USA).1414 StataCorp. Stata Statistical Software. Release 12.0. College Station, Texas: StataCorp; 2011.) The STATA svy command was used in order to handle cluster sampling appropriately and allow introduction of expansion fractions in the analyses.

The 2015 PeNSE1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016. was approved by the Brazilian National Health Council-Comissão Nacional de Ética em Pesquisa (CONEP, Brazilian National Research Ethics Committee; no. 1.006.467 of 03/30/2015).

RESULTS

Among the approximately 810,000 adolescent smokers who reported having smoked cigarettes in the past 30 days prior to the survey, there were higher proportions of 13- to 15-year-olds (vs. 16- to 17-year-olds), males, and Southeastern students (Table 1).In 2015, the proportion of smokers among students aged 13 to 17 years in Brazil was estimated to be 6.6% (the proportions of smokers among 13- to 15-year-olds and among 16- to 17-year-olds were estimated to be 5.4% and 8.4%, respectively).

Table 1
Distribution of the individuals who reported having smoked in the 30 days prior to the survey, by age group, gender, and Brazilian macro-region.

Approximately 7 in every 10 smokers aged 13 to 17 years tried to buy cigarettes at least once in the 30 days prior to the survey; this proportion was significantly lower among girls (adjusted absolute difference, −9.5%; p ≤ 0.05; Table 2).

Table 2
Crude absolute difference (AD) and adjusted AD in the proportion of smokers who tried to buy cigarettes sometime in the 30 days prior to the survey, by age group, gender, and Brazilian macro-region.

Of the adolescent smokers who tried to buy cigarettes sometime in the past 30 days, approximately 9 in every 10 were successful (Table 3).We also found that the adolescents aged 16 to 17 years were less often prevented from buying cigarettes than were the younger ones (adjusted absolute difference, 8.1%; p ≤ 0.05).In addition, when compared with the adolescent smokers attending schools in the Southeast, South, or Central-West, those attending schools in the Northeast reported a higher proportion of success in purchasing cigarettes.

Table 3
Crude absolute difference (AD) and adjusted AD in the proportion of smokers who were not prevented from buying cigarettes at any time in the 30 days prior to the survey, by age group, gender, and Brazilian macro-region, among the smokers who tried to buy cigarettes sometime in the 30 days prior to the survey.

Of the adolescent smokers who reported having been able to buy cigarettes at least once in the 30 days prior to the survey, approximately 7 in every 10 said that they did it regularly, that is, they usually got their own cigarettes by buying them directly from a store, bar, or street vendor. We found that the proportion of this behavior was considerably higher among the smokers aged 16 to 17 years than among those aged 13 to 15 years (adjusted absolute difference, 24.5%; p ≤ 0.05).In addition, the adolescent smokers attending schools in the Northeast apparently had the lowest proportion of “purchase on a regular basis” (Table 4).

Table 4
Crude absolute difference (AD) and adjusted AD in the proportion of smokers who usually bought cigarettes from a store, bar, or street vendor in the 30 days prior to the survey,a by age group, gender, and Brazilian macro-region, among the smokers who were not prevented from buying cigarettes at any time in the 30 days prior to the survey.

Among the adolescents whose most common mode of cigarette acquisition in the 30 days prior to the survey was direct purchase, approximately 8 in every 10 reported having bought cigarettes in a store or bar (vs. from a street vendor).The smokers aged 16 to 17 years (in comparison with those aged 13 to 15 years) and the adolescent smokers attending schools in the Southeast, South, or Central-West of Brazil (in comparison with those attending schools in the Northeast) reported having bought cigarettes on a regular basis and more often in a store or bar than from a street vendor (Table 5).

Table 5
Crude absolute difference (AD) and adjusted AD in the proportion of smokers who usually bought cigarettes from a store or bar in the 30 days prior to the survey,a by age group, gender, and Brazilian macro-region, among the smokers who were not prevented from buying cigarettes at any time in the 30 days prior to the survey and who purchased cigarettes on a regular basis in those 30 days.

DISCUSSION

The results presented here paint a dismal picture of the effectiveness of the implementation of the law prohibiting the sale of tobacco products to minors in Brazil. Approximately 7 in every 10 adolescent smokers felt motivated to try at least once to break this law. Even worse, the vast majority of those who chose to venture into this illegal behavior were rewarded by encountering no great resistance from retailers and/or street vendors to them purchasing cigarettes; to make matters further worse, a substantial proportion of those same adolescents reported buying cigarettes on a regular basis. As expected, the closer adolescents were to adulthood (age 16-17 years), the greater the likelihood of them not being prevented from buying cigarettes because of their age and, consequently, of them doing so more regularly and in licensed places, such as stores or bars. When we applied specific proportions of each of these factors listed above, we found that approximately 45% of all adolescent smokers aged 13 to 17 years in Brazil reported buying their own cigarettes on a regular basis without being prevented from doing so.

Recent comparative data from a study of Brazilian students aged 12 to 17 years conducted between 2013 and 20141515 Figueiredo VC, Szklo AS, Costa LC, Kuschnir MC, da Silva TL, Bloch KV, et al. ERICA: smoking prevalence in Brazilian adolescents. Rev Saude Publica. 2016;50 Suppl 1:12s. https://doi.org/10.1590/s01518-8787.2016050006741
https://doi.org/10.1590/s01518-8787.2016...
and from the 2015 PeNSE1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016. suggest a trend toward an increase in the proportion of adolescent smokers (5.7% and 6.6%, respectively).It is worth noting that the proportion of adolescent smokers reflects the sum of the effectiveness of a series of tobacco control policies aimed at reducing smoking initiation that are currently in effect in Brazil. For example, it is likely that the new structure of tobacco product taxation implemented in 2012 has contributed enormously to discouraging adolescents from starting smoking.1616 Brasil. Ministério da Fazenda [homepage on the Internet]. Brasília: o Ministério [cited 2017 Oct 16]. Tributação IPI Cigarros--MP 540/2011--Decreto 7.555/2011. [Adobe Acrobat document, 8p.]. Available from: http://www.fazenda.gov.br/noticias/2011/agosto/Tributacao_IPI_Cigarros_MP_e_DECRETO_Imprensa.pdf
http://www.fazenda.gov.br/noticias/2011/...
,1717 Levy D, de Almeida LM, Szklo A. The Brazil SimSmoke 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(11):e1001336. https://doi.org/10.1371/journal.pmed.1001336
https://doi.org/10.1371/journal.pmed.100...
) In addition, the regulation that prohibited smoking in enclosed collective areas as of late 20141818 Brasil. Presidência da República. Ministério da Casa Civil. Brasília: a Presidência [cited 2017 Oct 16]. Decreto Nº 8.262, de 31 de maio de 2014 [about 4 screens]. Available from: http://www.planalto.gov.br/ccivil_03/_Ato2011-2014/2014/Decreto/D8262.htm
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may have contributed to a further reduction in the social acceptability of smoking in bars and nightclubs, which are places where many youth start smoking. However, low compliance with the law prohibiting youth access to tobacco products may be undermining the effects of the Brazilian national tobacco control policy measures on the prevention of smoking initiation by adolescents.

Although cigarette packs contain a warning about legislation prohibiting the sale of cigarettes to minors, data from the PeNSE1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016. indicate that there is a great deal of irresponsibility on the part of retailers and that compliance with the law is poorly enforced by the responsible agencies. This situation is aggravated by the widespread availability of points of sale,1919 Souza Cruz [homepage on the Internet]. Rio de Janeiro: Souza Cruz [cited 2017 Oct 16]. Vendedores da Souza Cruz atendem diretamente cerca de 300 mil varejos em todo o país [about 2 screens]. Available from: http://www.souzacruz.com.br/group/sites/SOU_AG6LVH.nsf/vwPagesWebLive/DOAGCK8J?opendocument
http://www.souzacruz.com.br/group/sites/...
by the tobacco industry point-of-sale marketing strategies for placement of cigarette packs always next to candy, and by the suspension of the Brazilian National Health Oversight Agency resolution that, in 2012, prohibited the addition of sweet flavors to cigarettes.2020 Brasil. Ministério da Saúde. Agência Nacional de Vigilância Sanitária (ANVISA) [homepage on the Internet]. Brasília: o Ministério [cited 2017 Oct 16]. Resolução da Diretoria Colegiada - RDC Nº 14, de 15 de março de 2012. Publicação Original [Adobe Acrobat document, 6p.]. Available from: http://www2.inca.gov.br/wps/wcm/connect/a054848041f466a297cdd739cf5dede3/RDC_14_2012_COMP.pdf?MOD=AJPERES&CACHEID=a054848041f466a297cdd739cf5dede3
http://www2.inca.gov.br/wps/wcm/connect/...
) In addition, there has been an exponential growth in the availability of contraband tobacco products, which are sold at very low prices in stores, in bars, and mainly by street vendors.2121 Iglesias RM, Szklo AS, Souza MC, de Almeida LM. Estimating the size of illicit tobacco consumption in Brazil: findings from the global adult tobacco survey. Tob Control. 2017;26(1):53-59. https://doi.org/10.1136/tobaccocontrol-2015-052465
https://doi.org/10.1136/tobaccocontrol-2...

It is of note that the PeNSE1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016. questions related to youth access to cigarettes also address another practice that is in violation of current laws, that is, the sale of single cigarettes. In fact, Law no. 7212/2010 establishes that, in Brazil, cigarettes must be sold, as well as displayed for sale, only in packs of 20 units.2222 Brasil. Presidência da República. Ministério da Casa Civil. Brasília: a Presidência [cited 2017 Oct 16]. Decreto Nº 7.212, de 15 de junho de 2010. Publicação Original. Available from: http://www.planalto.gov.br/ccivil_03/_ato2007-2010/2010/decreto/d7212.htm
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) Buying a single cigarette, even if at a higher per-unit price, but still at a lower price than that of a whole pack, with no health warning attached,2323 Brasil. Presidência da República. Ministério da Casa Civil. Brasília: a Presidência [cited 2017 Oct 16]. Lei Nº 9.294, de 15 de julho de 1996. Publicação Original. Available from: http://www.planalto.gov.br/ccivil_03/leis/L9294.htm
http://www.planalto.gov.br/ccivil_03/lei...
facilitates smoking initiation and cigarette use on a regular basis. Surveys among ninth graders (aged 13-15 years) conducted in several Brazilian cities between 2002 and 2009 indicated that, in fact, buying single cigarettes is a widespread practice in Brazil, with rates reaching above 90% in some cities.99 Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). A situação do tabagismo no Brasil: dados dos inquéritos do Sistema Internacional de Vigilância, da Organização Mundial da Saúde, realizados no Brasil, entre 2002 e 2009. Rio de Janeiro: INCA; 2011.

Because the effect of tobacco use is cumulative, our findings raise an important public health concern, since smoking is a risk factor that has a major impact on the burden of chronic non-communicable diseases.2424 Bauer UE, Briss PA, Goodman RA, Bowman BA. Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA. Lancet. 2014;384(9937):45-52. https://doi.org/10.1016/S0140-6736(14)60648-6
https://doi.org/10.1016/S0140-6736(14)60...
) In fact, a recent study indicated that, in 2015, approximately 156,000 people died from diseases directly related to smoking in Brazil.2525 Pinto M, Bardach A, Palacios A, Biz AN, Alcaraz A, Rodríguez B, et al. Carga de doença atribuível ao uso do tabaco no Brasil e potencial impacto do aumento de preços por meio de impostos [monograph on the Internet]. Buenos Aires: Instituto de Efectividad Clínica y Sanitaria; 2017 [cited 2018 Jan 16]. Available from: www.iecs.org.ar/tabaco) Another nationwide study found that, in 2013, there were approximately 280,000 “all-cause deaths” directly or indirectly attributable to smoking in Brazil2626 Szklo AS, Iglesias RM, de Souza MC, Szklo M, Cavalcante TM, de Almeida LM. Understanding the relationship between sales of legal cigarettes and deaths: A case-study in Brazil. Prev Med. 2017;94:55-59. https://doi.org/10.1016/j.ypmed.2016.11.008
https://doi.org/10.1016/j.ypmed.2016.11....
; in addition, that study showed that the cumulative risk of mortality from COPD or lung cancer in Brazil, both for men and women, is more than 20 times higher in smokers than in nonsmokers.2626 Szklo AS, Iglesias RM, de Souza MC, Szklo M, Cavalcante TM, de Almeida LM. Understanding the relationship between sales of legal cigarettes and deaths: A case-study in Brazil. Prev Med. 2017;94:55-59. https://doi.org/10.1016/j.ypmed.2016.11.008
https://doi.org/10.1016/j.ypmed.2016.11....

The limitations of the present study lie in the fact that the cross-sectional nature of the PeNSE1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016. prevents us from establishing any temporal or causal relationship between findings. However, even if cigarette experimentation was not stimulated by violation of the law prohibiting the sale of cigarettes to minors, the data suggest that noncompliance with this law is important for the maintenance of this health-harmful behavior in nearly half of the adolescent smokers in Brazil. In addition, the study is subject to information bias because all information was self-reported by the participants. However, given that questionnaires were self-administered and anonymity was ensured,1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016. at least the influence of parents and/or interviewers on the responses may have been minimized.

The two major questions analyzed in our study were related only to the sale of cigarettes to minors. It is known, however, that there are other tobacco products, such as water pipes, that are very commonly used among adolescents,2727 Szklo AS, Sampaio MM, Fernandes EM, Almeida LM. Smoking of non-cigarette tobacco products by students in three Brazilian cities: should we be worried? [Article in Portuguese]. Cad Saude Publica. 2011;27(11):2271-5. https://doi.org/10.1590/S0102-311X2011001100020
https://doi.org/10.1590/S0102-311X201100...
all of which should be subject to the same restrictions as cigarettes.77 Ministério Público do Paraná [homepage on the Internet]. Curitiba: o Ministério [cited 2017 Oct 16]. Estatuto da Criança e do Adolescente. Lei nº 8.069, de 13 de julho de 1990, e legislação correlata. 9th ed. Brasília : Câmara dos Deputados; 2012. [Adobe Acrobat document, 207 p.]. Available from: http://www.crianca.mppr.mp.br/arquivos/File/publi/camara/estatuto_crianca_adolescente_9ed.pdf,88 Brasil. Câmara dos Deputados [homepage on the Internet]. Brasília: a Câmara [cited 2017 Oct 16]. Lei Nº 10.702, de 14 de julho de 2003 - Publicação Original [about 3 screens]. Available from: http://www2.camara.leg.br/legin/fed/lei/2003/lei-10702-14-julho-2003-487461-publicacaooriginal-1-pl.html
http://www2.camara.leg.br/legin/fed/lei/...
) According to data from the PeNSE,1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016. the proportions of youth aged 13 to 17 years who reported being smokers and using tobacco products other than cigarettes concomitantly or exclusively were 3% and 4%, respectively. For those youth, unfortunately, we have no information about attempts to buy these other tobacco products nor about the success of attempts and means of acquisition.

Regarding generalization of the findings to all adolescents in Brazil, it should be borne in mind that the PeNSE1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016. was conducted on individuals attending school and that elementary and middle schooling is widely available in the country, thereby reducing potential losses.2828 Instituto Brasileiro de Geografia e Estatística (IBGE) [homepage on the Internet]. Rio de Janeiro: IBGE [cited 2017 Oct 16]. Pesquisa Nacional por Amostra de Domicílios: Síntese de Indicadores 2013, 2nd edition. Available from: http://www.ibge.gov.br/home/estatistica/populacao/trabalhoerendimento/pnad2013/default_sintese.shtm
http://www.ibge.gov.br/home/estatistica/...
) However, the fact that adolescent smokers are likely to have higher rates of school absenteeism than do adolescent nonsmokers cannot be left out.2929 Levy DE, Winickoff JP, Rigotti NA. School absenteeism among children living with smokers. Pediatrics. 2011;128(4):650-6. https://doi.org/10.1542/peds.2011-1067
https://doi.org/10.1542/peds.2011-1067...

Our findings may contribute to supporting compliance with existing laws in Brazil that are aimed at reducing smoking initiation and therefore, in the future, may also contribute to reducing cigarette smoking-related morbidity and mortality. The scenario described in the present study indicates the need to stimulate federal, state, and municipal powers to take educational and surveillance measures, including through joint efforts with retail trade bodies and with unions representing the newsstand sector and other commercial sectors. Therefore, it would also be important to motivate agencies such as the Public Prosecutor’s Office to negotiate a conduct adjustment term with the tobacco companies supplying the vast network of retailers nationwide,1919 Souza Cruz [homepage on the Internet]. Rio de Janeiro: Souza Cruz [cited 2017 Oct 16]. Vendedores da Souza Cruz atendem diretamente cerca de 300 mil varejos em todo o país [about 2 screens]. Available from: http://www.souzacruz.com.br/group/sites/SOU_AG6LVH.nsf/vwPagesWebLive/DOAGCK8J?opendocument
http://www.souzacruz.com.br/group/sites/...
in which the companies agree to take shared responsibility for enforcing the law prohibiting the sale of tobacco products to minors.77 Ministério Público do Paraná [homepage on the Internet]. Curitiba: o Ministério [cited 2017 Oct 16]. Estatuto da Criança e do Adolescente. Lei nº 8.069, de 13 de julho de 1990, e legislação correlata. 9th ed. Brasília : Câmara dos Deputados; 2012. [Adobe Acrobat document, 207 p.]. Available from: http://www.crianca.mppr.mp.br/arquivos/File/publi/camara/estatuto_crianca_adolescente_9ed.pdf,88 Brasil. Câmara dos Deputados [homepage on the Internet]. Brasília: a Câmara [cited 2017 Oct 16]. Lei Nº 10.702, de 14 de julho de 2003 - Publicação Original [about 3 screens]. Available from: http://www2.camara.leg.br/legin/fed/lei/2003/lei-10702-14-julho-2003-487461-publicacaooriginal-1-pl.html
http://www2.camara.leg.br/legin/fed/lei/...
) At the same time, it would also be important to mobilize members of the House of Representatives and the Senate to propose and pass a federal law restricting the sale of tobacco products to licensed tobacco stores.

The information presented in this study may also help leverage the implementation of other measures to combat smoking, such as a ban on cigarettes with additives2020 Brasil. Ministério da Saúde. Agência Nacional de Vigilância Sanitária (ANVISA) [homepage on the Internet]. Brasília: o Ministério [cited 2017 Oct 16]. Resolução da Diretoria Colegiada - RDC Nº 14, de 15 de março de 2012. Publicação Original [Adobe Acrobat document, 6p.]. Available from: http://www2.inca.gov.br/wps/wcm/connect/a054848041f466a297cdd739cf5dede3/RDC_14_2012_COMP.pdf?MOD=AJPERES&CACHEID=a054848041f466a297cdd739cf5dede3
http://www2.inca.gov.br/wps/wcm/connect/...
and approval of the protocol to eliminate illicit trade in tobacco products3030 WHO Framework Convention on Tobacco Control [homepage on the Internet]. Geneva: World Health Organization; c2017 [cited 2017 Jan 2]. Protocol to Eliminate Illicit Trade in Tobacco Products. Available from: http://www.who.int/fctc/protocol/en/
http://www.who.int/fctc/protocol/en...
; such measures would prevent cigarettes from being available to adolescents in stores and through street vendors

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  • 1
    Study carried out at the Instituto Nacional de Câncer José de Alencar Gomes da Silva - INCA - Rio de Janeiro (RJ) Brasil.
  • Financial support:

    None.

Publication Dates

  • Publication in this collection
    08 Oct 2018
  • Date of issue
    Set-Oct 2018

History

  • Received
    25 Oct 2017
  • Accepted
    28 Jan 2018
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