Organizational models for the sustainability of the National Tobacco Control Program: a pilot proposal to be adopted nationally

: Introduction: The consumption of tobacco products, from planting to consumption, is responsible for serious health problems, representing a cycle of diseases, poverty and deaths worldwide. This serious public health problem led Brazil to develop, from the 1980s onwards, a set of tobacco control measures, constituting a policy with legislative, economic, communication and educational actions, which has as its foundation the National Program for Control of Tobacco. Tobacco (PNCT). Objective: This article is an experience report that is part of a national study carried out between 2020 and 2022, and describes actions through technical visits to tobacco control coordination offices in five states. Method: The states were selected according to criteria established by Ditab/INCA, which coordinates the network of the State Program for Tobacco Control (PECT) in the 26 States and Federative Unit of the country. Thus, a State of each region was chosen: Tocantins (North), Paraíba (Northeast), Goiás (Midwest), Rio de Janeiro (Southeast) and Paraná (South). Results: Practices were developed to enhance, improve and add technical, political, communication actions, among others, in order to give sustainability to the State Program and, more broadly, the PNCT.

Tobacco use is responsible for serious health problems, illness, death and impoverishment worldwide.The damage constitutes a veritable epidemic, to which 8 million deaths per year are attributed, both through direct and passive use of the products.It is estimated that about 1.1 billion people use some form of tobacco, and of this total, almost 80% live in low-and middle-income countries, such as Brazil (WHO, 2019).
Brazil has been developing tobacco control measures since the 1980s.Several actions make up a structured policy through specific programs, such as the National Tobacco Control Program (PNCT), which aims to reduce the prevalence of smokers and the consequent morbidity and mortality related to the consumption of tobacco products.Strategic actions are aimed at preventing initiation, encouraging smoking cessation and protecting the population from exposure to environmental tobacco smoke, stimulating the improvement of legislation.The work is carried out in a decentralized manner, through the State and Municipal Health Secretariats, forming a network throughout the national territory (CAMPOS, 2015).
To expand actions and improve the work, a structured and consistent plan is needed to sensitize state and municipal Health secretaries to support the implementation of financial, political and technical sustainability mechanisms.
Considering the continental dimensions of the country, its regional and cultural differences, network of partnerships and local interface, which define the basis of the actions of the work carried out, it is indispensable to promote and establish specific actions in loco, to promote and guarantee means of sustainability for the maintenance and improvement of the activities developed in the states.It is essential to identify priorities, ensuring the sustainability of the work already carried out regionally (CAMPOS, 2015;CAMPOS et al., 2021).
The PNCT, in Brazil, faces permanent challenges, such as: launching new products with health risks (electronic cigarettes, for example), non-compliance with legislation (sponsorship of events), dissemination of misleading advertising about its tobacco products, strategies that compromise public health, in addition to the focus of seduction aimed at children and adolescents (BERTONI; SZKLO, 2021).
In Brazil, the PNCT is a model for other countries.Despite the budget constraint, the work has been carried out effectively, ensuring national and international recognition.The result of this is the reduction in prevalence from 34% (1989) to 12% (2019) (PNS 2019).This article contains a proposal for an organizational model that aims to improve the National Tobacco Control Program network in the States and the Federal District, strengthening evidence-based recommendations on tobacco control policies, through the promotion of actions for the sustainability of the PNCT. 1

Method
This article is part of a national study in five states in each of the country's regions, carried out between 2020 and 2022.In the first stage of this project, selection criteria for states were defined, such as: one state per region; state coordination of the PNCT being within the state Health Secretariat; state coordination that has a team for division of tasks and participation of the state coordination in technical visits (2018/2019).The states of Tocantins (North Region), Paraíba (Northeast Region), Goiás (Center-West Region), Rio de Janeiro (Southeast Region) and Paraná (South Region) were selected.
Next, we carried out a survey constituting the panorama with information on the sociodemographic and epidemiological scenario of the states of Goiás (GO), Paraíba (PB), Paraná (PR), Rio de Janeiro (RJ) and Tocantins (TO), so as to subsidize the role of state coordination/technical reference of the State Program for Tobacco Control to promote sustainability actions.
The comprehensive national study with diverse actions that motivated this article was carried out by the Tobacco Control Division (DITAB), of the

Context of the project
The results of the study come from technical visits carried out in person with state managers from GO, PB, PR, RJ and TO to understand the organization and provision of services by the PNCT.Field work took place between April and November 2022.All meetings were systematized in a technical report and made available to the states in full.We identified that the five states develop, at the local level, with the participation of their municipalities, tobacco control actions aimed at preventing the initiation of tobacco use, smoking cessation with assistance to the population in the health units of the Unified Health System (SUS) in the three levels of care, concentrated in about 90% in primary care.Also, their establishments reproduce the guidelines of the legislation regarding tobacco-free environments that prohibit the use of tobacco products indoors.
Although the differences and distinct forms of socio-spatial insertion of the state secretariats are recognized, in this study, it is interesting to emphasize the similarities regarding the organization, challenges and strategies adopted to favor the sustainability of the PNCT in locations characterized by population sparseness and long distances.The investigation is guided by the following question: what are the challenges faced by state and municipal management to guarantee the PNCT?
For the analysis of the material, we triangulated information in order to explore and recognize the ways of organization, strategies and local challenges to organize and facilitate the population's access to the PNCT services.To treat the results, we carried out thematic analysis of the technical reports and in-depth reading of the field material (MINAYO, 1998).The material was categorized into three dimensions of analysis: context; the organization of the PNCT in the SUS and challenges for ensuring sustainability.For a better understanding of the political-technical-scientific dimension of the project, we created this infographic, which gives a dimension of the actions developed in the states (Figure 1).

Technical axis
A questionnaire / inventory was developed for the selected states to help understand and analyze the strengths and weaknesses of each state, and thus make it possible to structure proposals for actions that are compatible and adjusted to regional scenarios.
This inventory was divided into five parts for better study, understanding and mapping of relationships and interactions, for a geopolitical analysis of each State Coordination, covering issues related to: (i) Health Secretariat, (ii) Municipal Coordinations of the PNCT, (iii) Partnership Network, (iv) Political Articulations, (v) Sustainability of Actions and (vi) Tobacco Industry Interference.
Based on the adaptation of the Swot Matrix planning model, the team responsible for the activities in the states can develop an analysis of the responses from the five state coordination offices to prepare preliminary proposals for actions: Formalization of the State Tobacco Control Program (PECT): upon formalization of the program in the state, establish goals to also carry out the formalization of the program in the municipality -Municipal Program for Tobacco Control (PMCT).This proposal aims to avoid the high turnover of professionals in the municipality, which demands efforts from the states to train technicians.
Communication: make up a network of messages, agile through the formation of a group of messages for interaction and support with the municipal coordinators, sharing problems, solutions and actions carried out.This network has the potential to encourage greater advances by municipalities.
Formation/Training: carry out technical training by INCA with the Visas and Procons, aiming at approximation and interaction of these areas with the state coordinator of the PNCT, as well as future training in the state; a webinar with a technical group from INCA linked to topics and proposals for sustainability and Tax Reform, aligning knowledge.
Management Support / Management Instruments: possibility of promoting access to the Pluriannual Plan (PPA), an instrument used by the public administration that places the guidelines, objectives and goals that are intended to be achieved in the period of validity of the Plan, in each program in a regionalized manner.It aims to clarify the administration, application of public and private resources, when applicable, for situations involving partnerships.It is important to point out that the PPA is valid for four years, and the bill for its approval must be formulated in the first year of the elected government's term, and sent for consideration by the

Sustainability axis
During the term of the project, two online workshops were held for the network of state coordinators of the PNCT, entitled: With the Covid-19 pandemic, SUS gained prominence in the mainstream media, with televised or written news about the Brazilian health system, even by those who until recently would have been able to claim that they had never used the SUS, ignoring the principles of its actions based on universality, comprehensiveness and equity.
Still in the midst of this media highlight, we also cite the references made to the representative bodies of municipal Health secretaries: National Council of Health Secretaries (CONASS), National Council of Municipal Health Secretaries (CONASEMS) and State Councils of Municipal Health Secretaries (COSEMS).
As for their genesis, we can say that these entities originated from the need to create mechanisms for agreement between the managing bodies of the SUS, in the various negotiation forums and in the three spheres of government.These entities are important spaces for political articulation and formation of federative agreements between health managers.For these reasons, we believe that approaching these partners is strategic, to favor and strengthen the actions of the National Tobacco Control Policy in the three entities of the federation.
Also within the scope of sustainability, training was held for technical groups on tobacco control in the states.Two matrices were developed to guide the activities.The first was inspired by a SWOT (it is an abbreviation of the English words strengths, weaknesses, opportunities and threats).The function of this tool was to evaluate the internal and external environments of the institutions and partners invited to compose the tobacco control working group in the states.
After analyzing the matrices, completed in the first technical visit, actions and strategies for the working group were listed.To support the state in identifying priorities, a GUT matrix was used in a second technical visit, which is an easy-touse and simple-to-understand tool that helps in the prioritization process, allowing the analysis of problems and internal situations of the group according to Severity, Urgency and Trend.

Political axis
During the term of the project, we participated in the XXXVI National Congress of Municipal Health Secretariats (2021).This is the largest congress on health policies in Brazil and in this edition it had more than six thousand participants, including technicians and health managers from municipalities, states and the federal government.Participation took place with the creation of a PNCT booth and a workshop with representatives of the states and municipalities selected for the pilot project.On the same occasion, we produced a short video about the activities at the congress.
During the technical visits, we included in the schedule the agenda of meetings with the COSEMS of each state, aiming to bring the institution closer to the municipal interests of the National Tobacco Control Program.An attempt was made to strengthen state coordinators as technical references for the municipalities in all matters involving the PNCT, in addition to discussing possible sustainability strategies at the municipal level of a technical, political and financial nature.
It is important to contextualize that, in April 2022, we started technical visits with integration and sustainability actions between the various areas of the state government for a full implementation of the FCTC.The first states were Rio de Janeiro (April 15, 2022) and Tocantins (April 25-29).In May, technical visits were carried out in the state of Paraná (from 23 to 27 May), in the state of Goiás (from 6 to 10 June) and in the state of Paraíba (from 27 June to 1 July).In November, the second round of technical visits took place in the states of Tocantins (November 7th to 9th), Goiás (November 10th to 11th) and Paraíba (November 14th to 17th).
The technical visits carried out in the states included internal actions in the state health secretariats and related areas, in addition to meetings with external partners from civil society, SUS management collegiate bodies, technical visits with health professionals in municipalities indicated by the state, with a focus and discussion on action for the treatment of smoking, meetings with Sanitary Surveillance, Procon, and representatives of institutions indicated by the state to compose the formation / strengthening of the technical group for tobacco control in the states.At the end of each technical visit, a base report was produced for the diagnosis of the activities carried out.

Communication axis
During the project, a dissemination platform (website or social networks) of the results of the study was not created, as this was not one of the focuses of the project.However, the technical visits to the five Brazilian states selected for the sustainability project generated a lot of spontaneous media in local and national news channels (Graph 2 and Table 2).| Page 12 of 15 visits to the states, which caused a two-month delay in carrying out the technical visits.This had a direct impact on the execution of the block of actions in the Legislative Assemblies in each State, which aimed at training teams from state coordinations to seek and act in partnership with state legislators in strengthening and improving tobacco control.In 2022, in view of the national elections in the country, it was necessary to suspend this activity.
Despite the support for the project by the coordination of smoking in Rio de Janeiro, the state chose to postpone the implementation of actions until 2023, with technical support from DITAB / INCA.

Final considerations
This project had great technical-political potential for all the institutions involved, with social relevance.Knowledge and dissemination of the specificities and needs of states and municipalities will contribute to the strengthening of local responses and the formulation of public policies in the SUS.
An increase in exchange between universities and services is also expected; the preparation of publications aimed at a wide audience; the consolidation and expansion of a network of national partners to combat tobacco.
This work does not end with this pilot project, as its experience and satisfactory results made it possible to reproduce, in the 26 states and the federal district, recommendations aimed at guaranteeing the sustainability of the PNCT in different axes.

Scientific axis
Adopt a questionnaire/inventory instrument to measure municipal structures, as well as point out weaknesses and strengths, guiding tobacco control actions in the state.Raise awareness and establish partnerships with universities in the state to promote studies and research with lines of action focused on the local reality.Publish research and articles on the actions developed by the PECT.

Technical axis
Establish an intersectoral agenda of virtual or face-to-face meetings with possible organizations that have an agenda compatible with tobacco control, to raise awareness of their work in the area.Create an interface with state non-governmental organizations working in public health for a possible partnership in tobacco control actions.Form a Working Group on Tobacco Control, with representations from State Secretariats, universities, Visas, Procons, the Parquet, NGOs, COSEMS, etc., to cross-cut specific issues, as well as plan and enhance tobacco control actions.

Communication axis
Form up to three groups of quick messages, WhatsApp, to obtain agility and capillarity of tobacco control communication (eg: 1-group of municipal coordinators/point of reference; 2 -tobacco control working group; and 3-group of partners) Searching for new communication partnerships, in addition to the Health Secretariat, such as newspapers, magazines and social networks, to guide articles on CT, on electronic devices.These communication vehicles alert society about the damage to health, establish empathy and create social acceptance of possible tobacco control actions that will be developed in the state.

Sustainability axis
Seek interaction with the Planning Secretariat to find out about the possibilities of obtaining resources from the Pluriannual Plan (PPA).Seek an interface with the Treasury Secrtariat to study and prospect possibilities for earmarking resources from the Tax on Circulation of Goods and Services (ICMS) or other state funds/taxes.Disseminate in meetings of managers and other state forums information on the role of tobacco control actions as a means of promoting the population's health and reducing impacts on the costs of the public health system.

Figure 1 .
Figure 1.Dimensions of the project Improvement of the National Tobacco Control Policy in Brazil, [Aprimoramento da Política Nacional de Controle do Tabaco no Brasil], 2020-2022 'Concepts and Sources of Financing in the State Health Secretariats aiming at the Sustainability of the PNCT' and 'The Importance of Establishing Partnerships with the State Legislative Power to Strengthen Tobacco Control Actions'.| Page 9 of 15

Graph 2 .
Number of news, interviews and posts made in the states in the journal of technical visits in 2022 Source:The authors.Chart 2. Number of news, interviews and posts made in the states in the journal of technical visits epidemiological scenario of the Covid-19 pandemic in Brazil, it was difficult to maintain the initial work schedule planned for carrying out technical Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 33, e33SP104, 2023 Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 33, e33SP104, 2023| Page 13 of 15 2

Brazil 211,755,692 R$ 1,438,67 5,570 23.8 0.60 6.62 Source: IBGE, 2012.
State Legislative Assembly; propose the creation of a State Commission for Tobacco Control with members from different state secretariats, to transversalize the actions, support and enhance the set as a block.Actions in the State Legislative Assembly: technically enable the manager to incorporate political actions that translate into tobacco control laws in the Legislative Assembly of his/her state.Create / Strengthen key partnerships for PECT: hold virtual meetings and technical visits, with technical proposals for partnerships with bodies that can be key partners for strengthening the PECT, such as: Public Ministry, Federal Police, Municipal | Page 7 of 15 continue... and State Surveillance, Universities, Medical Societies, Media, Non-Governmental Organizations and collegiate bodies of SUS management.To ensure the continuity of activities, during the project, continuous meetings were held with the state coordinations for the development of actions, products, discussions of ongoing activities, validation of proposals, agreement on the schedule of technical visits and other actions demanded by the states or by INCA.Below, we present the number of meetings held (Chart 1 and Graph 1): Number of monthly virtual meetings with the state coordinations of the states selected to participate in the 2021-2022 project Physis: Revista de Saúde Coletiva, Rio de Janeiro, v. 33, e33SP104, 2023 | Page 8 of 15 Graph 1. Number of monthly virtual meetings with the state coordinations of the states selected to participate in the 2021-2022 project Source: The authors.