Impact of the Covid-19 pandemic on the Service and Care for Smokers in the SUS

: During the Covid-19 pandemic, the smoker treatment service was impacted. This article evaluated the impact of the pandemic on the service in the SUS. This is an ecological descriptive observational study using the National Tobacco Control Program (PNCT) database for the years 2019, 2020 and 2021, from five states (PA, PB, GO, RJ and RS) for the second four months. Relative differences were estimated in the number of units that offered the service and in the number of consultations for clinical evaluation, first and fourth sessions. For the years 2019 and 2020, there was a percentage difference of -51.9% in the number of units that offered the service in all states studied. For the years 2019 and 2021, the relative difference for the health units was -20.96% and, for the clinical evaluation, the first and fourth sessions were: -54.19%, -55.07% and -61 .31%, respectively. These differences were greater for the capitals when compared to the other municipalities. Despite the negative impact, especially in the first year of the pandemic, the study showed that the services did not interrupt their activities and showed some recovery in 2021. It was also important to note that smokers, despite the recommendations, did not stop seeking treatment.


Introduction
Smoking, according to the World Health Organization (WHO), has been recognized as a pandemic since 1999.For this reason, in 2003, WHO, together with its member countries, prepared the Framework Convention on Tobacco Control, the first international public health treaty, bringing intersectoral measures that must be implemented for effective tobacco control, among them, the provision of smoking cessation services, in its article 14 (PONTES, 2020).
In Brazil, actions to restrain this pandemic have been adopted since 1989, through the creation of the National Tobacco Control Program (PNCT), which aims to reduce the prevalence of smokers in Brazil and the consequent morbidity and mortality from tobacco-related diseases (INCA, 2022).One of the main strategies of the PNCT is the organization and articulation of the Service and Care for Smokers in the SUS, implemented throughout the national territory.
In 2020, the world was faced with a new pandemic of a virus -SARS-Cov-2 -, which started in China and quickly spread across all continents.According to Daumas (2020), Brazil was hit by the Covid-19 pandemic on March 20, 2020, and this, as it is a new disease, brought many challenges for the population, for government officials and especially for the health system.The country had to adopt a series of socio-educational measures that collaborated with the control of the Covid-19 pandemic, which was added to the smoking pandemic (INCA, 2022).
Due to the high degree of transmissibility, some measures of social distancing, social isolation, lockdown of establishments and reorganization of health services were taken.Some health facilities were closed, while others redirected services exclusively to patients infected with SARS-Cov-2.There was reallocation of health professionals in the system itself and restriction in the "portfolio of health services" offered to the population, among them the service and care for smokers.
Since Brazil has continental dimensions and a population heterogeneously spread across the territory, the pandemic did not reach all states in the same way in the same period (CAVALCANTE et al., 2020).This article presents an analysis of the impact of the measures taken to control Covid-19 in the year before the pandemic (2019) and in the two subsequent years on the Service and Care for Smokers in the Unified Health System (SUS) in a sample of five states from the main Brazilian geographic regions.

Methodology
An ecological descriptive observational study was carried out (LIMA, 2003), a method that allows studying a group of people, defining a geographic space and comparing data.This method enables the generation of new hypotheses and is indicated for evaluating the effectiveness of an intervention.It uses secondary level sources, being therefore considered low cost and fast execution.
The study had, as the focus of analysis, the basic health units (UBS) and the assistance to smokers in the SUS.The variables selected for the survey were the number of UBS that offered care during the study period, the number of consultations carried out for the clinical evaluation of the smoker and the number of consultations carried out in the first and fourth structured consultations.The variable "health units" reflects the offer of treatment for smokers.The variable "clinical evaluation" reflects the demand for care and the others reflect the adherence of the smoker to the cessation program (first and fourth structured consultations), in the second four months, for the years 2019, 2020 and 2021, by selected federation units, location (capital and other municipalities) and state.

Secondary data source
The source of information was the database of the Service and Care for Smokers in the SUS, which is under the responsibility of the Division of Smoking of the Coordination of Prevention and Surveillance of the National Cancer Institute.This database is fed by health units (basic and specialized care) that provide care to smokers.Completion takes place at the local (municipal) level and are consolidated by the state Health secretariats through a standardized form from the National Cancer Institute.

Sample selection
From the PNCT database of the 27 states, the completeness of the information referring to the years 2019, 2020 and 2021 was assessed.As there were interruptions during the pandemic period in several locations, only 12 states were able to send the complete data for analysis.Among them, five states representing the five Brazilian geographic regions were chosen: Pará (PA), representing the North Region; Paraíba (PB), in the Northeast; Goiás (GO), in the Midwest; Rio de Janeiro (RJ), the Southeast and Rio Grande do Sul (RS), the South Region.

Data analysis
For data analysis, a database was built in Excel and the percentage changes in the number of consultations between the periods of 2019 and 2020, and 2019 and 2021 were calculated.From there, tables were prepared for a better visualization of this information.In order to analyze possible differences within the territory of the states, an analysis was also carried out by location: capital x other municipalities.

Results
The results obtained in this study are presented below, with the number of UBS that offered the treatment, number of consultations referring to the clinical evaluation, number of consultations referring to the first and fourth structured session, for the years 2019, 2020 and 2021, and the relative differences for the periods 2019-2020 and 2019-2021, by location (state, capital and other municipalities), recorded in the second quarter of each year.

The impact of the COVID-19 pandemic
In Table 1, we can observe the impact of the Covid-19 pandemic on the provision of treatment for smokers in the Service and Care for Smokers in the SUS, between the years 2019 and 2021, considering the five selected states.Between 2019 and 2020, there was a significant reduction in the number of units that offered the service, which varied, between states, from -29.32% (GO) to -85.04% (PB).As for the years 2019 and 2021, this relative difference attenuated, with variations from -19.69% (PB) to -47.27% (PA).It is worth mentioning that, in the state of Goiás, there was an increase of 13.09% in the number of units that offered the service at the end of 2021.
Regarding the capitals, there was a significant variation between the states, from -32.99% (RS) to -100% (GO) for the years 2019 and 2020.As for the years 2019 and 2021, it is observed that the state of Pará returns to the threshold of 2019, with a positive balance in the service offer; the state of Paraíba significantly reduces the difference between 2019 and 2020 (from -85.71% to -14.29%); while Goiás remains without offering the service in the capital (-100%).In Rio Grande do Sul, however, there is an increase in the relative difference between the years 2019 and 2021, when compared to the previous period (-32.99% to -44.33%).In the other | Page 5 of 15 municipalities of the states, the relative difference in service provision for the years 2019 and 2020 ranged from -25.82% (GO) to -85.02% (PB).For the years 2019 and 2021, this relative difference becomes positive for the state of Goiás (18.68%) and varied, among the other states, from -3.00% (RJ) to -49.38% (PA).(Table 1).

Clinical evaluation consultations carried out
The clinical evaluation consultation is the moment when the smoker patient enters the service.In this consultation, an assessment of your health situation and the entire planning of your treatment is made, and it is possible to refer you to a group or individual approach.It can be said that it is the gateway to the Service and Care for Smokers in the SUS.
According to Table 2, the relative differences in the number of visits between the states ranged from -65.43% (RS) to -86.95% (PB), for the years 2019 and 2020, and from -42.10% (RS) to -62.64% (RJ), for the years 2019 and 2021.These differences will show a greater variation for the state capitals, from -66.90% (RS) to -100% (GO) for the years 2019 to 2020, and from -27.62% (RS) to -100% (GO) for the years 2019 and 2021.For the other municipalities, the relative differences showed a pattern similar to that observed for the states.

First structured session of the Service and Care for Smokers in the SUS
The patient's attendance at the first session at the Service and Care for the Person Who Smokes in the SUS makes his participation in the program effective, which begins with four structured sessions.Among the states, for the years 2019 and 2020, the relative differences ranged from -64.84% (RS) to -87.99% (PB).Between 2019 and 2021, the relative differences show a smaller variation, from -46.56% (RS) to -61.32% (RJ), as shown in Table 3.

Fourth structured session of the Service and Care for Smokers in the SUS
The consultation referring to the fourth structured session of the Service and Care for Smokers in the SUS concludes an important first stage of the program, when the meetings are weekly.The next two meetings will be fortnightly, and the others will be monthly, until completing a year of follow-up.
The relative differences for the years 2019 and 2020 showed a variation from -69.96% (GO) to -86.94% (PB).For the years 2019 and 2021, these differences will vary from -52.18% (PB) to -66.74% in RJ.The scenario in the capitals continues to be influenced by the total suspension of services offered in the state of Goiás.For the years 2019 and 2020, the relative differences ranged from -76.14% (PA) to -100% (GO), while for the years 2019 and 2021, this variation was from -56.78% (PB) to -100% (GO).Once again, the variation pattern of the other municipalities follows the pattern of the states (Table 4).

Discussion
The Service and Care for Smokers in the SUS in Brazil is oriented based on the cognitive-behavioral approach, and should be offered to any citizen without restriction (BRASIL, 2020).It aims at the complete cessation of nicotine use in up to 12 months of treatment, which can be extended according to the patient's needs.According to the Clinical Protocol of Therapeutic Guidelines, the treatment must be divided into four weekly sessions, two fortnightly and ten monthly sessions, and may occur individually or in groups (10 to 15 patients).The Service and Care for Smokers in the SUS provides for the use of medication for those who need such support (BRASIL, 2020).
GM Ordinance No. 2,436, of September 21, 2017, determined that primary health care is the citizen's gateway to the service and care for smokers in the SUS, being responsible for about 90% of the visits to patients who seek the service to stop smoking (BRASIL/MS, 2017).
In the clinical evaluation consultation, it is possible to identify pulmonary functional alterations, the existence of diseases related to smoking, possible contraindications and drug interactions during the pharmacological treatment of dependence.At that time, the smoker's profile, their degree of nicotine dependence and their motivation to quit smoking are also evaluated.Based on this information, an individualized treatment plan is defined for each patient, taking into account the information provided (BRASIL, 2020).
The Covid-19 pandemic hit Brazil in March 2020, causing a series of social problems, especially related to health issues.The transmission of the SARS-CoV-2 virus, with a high rate of transmissibility, via the respiratory route, led to the adoption of different health and socio-educational measures, with the aim of controlling the pandemic.The following stand out: social isolation, social distancing, use of masks and rescheduling/cancellation of elective health services (AQUINO et al., 2020).
Therefore, several health services were dismantled due to the rules of social distancing and relocation of health professionals to other more urgent sectors.This fact was confirmed in the report "Third Round of the Global Pulse Survey on Continuity of Essential Health Services During the Covid-19 Pandemic", by WHO, released in February 2022.The third round of the survey, concerning the continuity of vital health services during Covid-19, found that continued interruptions in health services were reported in more than 90% of the countries surveyed (WHO, 2022).
The first death confirmed in Brazil by Covid-19 occurred in São Paulo, a state with a high population density, with a large flow of international travelers, on March 12, 2020 (VERDÉLIO, 2020).Community transmission throughout the national territory was declared on March 20, 2020, with measures to isolate cases | Page 9 of 15 and contacts and social distancing from the general population being recommended as the main strategies to slow the expansion of Covid-19 (DAUMAS, 2020).
In the initial period, there was no movement coordinated by the Federal Government in Brazil to control the pandemic.On April 16, 2020, the Federal Supreme Court delegated to the states, through Direct Action of Unconstitutionality (ADI) 6341, autonomy in carrying out measures to deal with the pandemic (STF, 2020).
The first states to take measures to control the pandemic in Brazil were Rio de Janeiro, São Paulo and the Federal District, which adopted measures such as: closing schools, isolation measures, quarantine, restrictive measures for population movement, restrictions on the type of commercial establishments that could remain open, opening hours, among others (BUENO, 2021).
Important regional differences between the Federative Units showed how the pandemic reached the states at different times and with different impacts (CAVALCANTE et al., 2020).There was an imbalance between municipalities and states in relation to the supply of health actions and services.This can be exemplified by the crisis presented and reported in the media, about the situation in the state of Amazonas, which suffered seriously from the difficulty of being able to meet the population's need with basic equipment such as oxygen cylinders (FIOCRUZ, 2021).
Aspects related to the official norms to be established by each state and municipality, as well as the installed capacity to respond to the pandemic, influenced the data presented here (DC RJ, 2020; DC RS, 2020; DC GO, 2020; DC PA, 2020).
On the one hand, in all states studied, there was a significant reduction in the provision of care for smokers in health units.Many professionals who worked in the treatment of smokers were shifted to care for cases of Covid-19, while others, because they belonged to groups considered at risk, were removed from work.On the other hand, the population was instructed to seek health units only in case of need or to obtain medication for continuous use.This set of factors had repercussions on both supply and demand for care at health units (BVS, 2020).
The final effect, however, was heterogeneous in the states studied.In terms of service provision, Goiás drew attention due to the divergence of norms adopted in the capital and other municipalities.While in the former, services were fully suspended, in the case of municipalities, not only was the relative reduction the lowest among the states for the years 2019 and 2020, but it was reversed for the years 2019 and 2021, with an increase in the number of units offering treatment for smokers.In the | Page 10 of 15 capital of Pará, there was also a small increase in the offer for the year 2021; and in Rio de Janeiro, there was a recovery in service provision outside the capital, which almost reached the same number of units as in 2019, with a recovery of around 97% (300 UBS in 2019, to 291 UBS in 2021).A possible explanation for this fact is that, during the pandemic, a new distance training strategy was offered for health professionals to assist smokers.In 2020 and 2021, 8,963 health professionals were trained by the National Tobacco Control Program coordinated by the National Cancer Institute, of the Ministry of Health (INCA, 2022).As the restrictions were relaxed and the health units were able to partially return to their activities, such increase in training may have stimulated a greater offer of the service in some places.
It is also worth noting that the impact on the provision of Service and Care for Smokers will be greater in 2021, compared to 2020, in the capital of the state of Rio Grande do Sul.As the pandemic did not initially reach the Brazilian states homogeneously, but gradually reached the territory, it is possible that the effect on health services was greater in the second year, in some places.Through the interactive panel of CONASS, it is possible to verify that in RS the number of cases practically tripled in the year 2021, with 452,920 cases in 2020 and 1,054,197 in 2021.The number of deaths also had a significant increase, being 8,934 in 2020and 27,510 in 2021(CONASS, 2022)).
The number of consultations for clinical evaluations is directly related to the offer of new vacancies for smokers, while the structured sessions may be reflecting the continuity of care that was being provided by the units and the need to obtain medications that were in use.In the case of clinical evaluations, for the year 2020, except for the state of Rio Grande do Sul, the number of consultations was equivalent to a quarter of the number of consultations carried out in the previous year.In the following year, this number was equivalent to half of that observed in 2019.In all these cases, the impact seems to have been greater in the capitals, when compared to the other municipalities.It is possible that a greater concentration of people in the capitals has led both local authorities to implement stricter rules and the population, even without vaccine protection, has avoided seeking treatment.
It is worth mentioning that, apart from the capital of Goiás, where services were interrupted, in other places, despite population recommendations to avoid health units except in cases of great need, and the recommendation to interrupt services considered elective, care for smokers continued, which demonstrates the importance of this demand for health services.One factor that could explain this demand is that there was a lot of publicity in the media about the relationship between Covid-19 and smoking.Another factor that may have contributed is the demand for drugs used in the treatment, although supply to the units has been discontinued over the last few years, due to the supply of raw materials on the international market.
For Patton (1997), there are three primary objectives for carrying out program evaluation: making judgments; facilitate their development; and contribute to knowledge.In view of this perspective, this assessment of the impact of the pandemic on the actions of the PNCT will significantly contribute to the elaboration of criteria that can collaborate with the resumption of the service, not only reaching the number of services offers and attendances in 2019, but also, increasingly, contributing to the network expansion.

Study limitations
This study had some important limitations, such as the restriction of the analysis to five states representing the country's geographic macro-regions.This limitation was due to the difficulty of the states, during the pandemic, in receiving data from the municipalities, compiling them and sending the complete consolidated databases to the National Cancer Institute.
However, despite some specific situations, in general, the behavior of the data is similar over the period in these states, which allows us to assume that there is a downward trend in the number of units providing care and in the number of clinical evaluations and sessions.

Conclusion
This article evaluated the impact of the pandemic on the smoking cessation program in the SUS, measuring the effects of the pandemic on the Service and Care for Smokers in the SUS, in five selected states, for the first two years of the pandemic.Based on this study, it is possible to measure the effort that the National Tobacco Control Program will now have to make to recover the same capacity as in the pre-pandemic period.The impact was greater in state capitals than in other municipalities.By the end of 2021, the supply of health services for smoking cessation was reduced to half of that observed in 2019.However, the supply and demand for treatment were not interrupted in most of the locations studied.

Table 2 .
Number of consultations carried out regarding the clinical evaluation in the Service and Care for Smokers in the SUS, in the second quarter, according to the location, considering the five states, in the years 2019, 2020 and 2021

Table 3 .
Number of consultations carried out regarding the first session in the Service and Care for Smokers in the SUS, in the second quarter, according to location, considering the five states, in the years 2019, 2020 and 2021

Table 4 .
Number of consultations carried out regarding the fourth session in the Service and Care for Smokers in the SUS, in the second quarter, according to location, considering the five states, in the years 2019, 2020 and 2021 Source: Databank from Programa Nacional de Controle do Tabagismo, DITAB-INCA.