History of the ‘INCA Smoke-Free Program’ and its Developments within the National Tobacco Control Program: Advances and Challenges of the Care Approach

INTRODUCTION

"Don't forget to give me toothpicks and a cigarette to scare away mosquitoes¹."

Thus sang Noel Rosa in his famous composition, Conversa de Botequim¹ (Pub Talk), a partnership with Vadico, in which the customer makes several requests to the waiter in a bohemian setting, associated with freedom. The year was 1935 and, almost 100 years after the creation of this iconic lyric, cigarettes have lost that old-time glamor but remain one of the main avoidable causes of cancer in Brazil and worldwide, being responsible for approximately 22% of deaths by this disease, according to the World Health Organization (WHO)².

In Brazil, around 12% of all deaths recorded in the national territory are tied to tobacco abuse, resulting in a total cost of around 153 billion Reais. This value encompasses not only expenses with medical assistance, but also loss of productivity and care associated with smoking. Of this total, the several types of cancer related to tobacco abuse account for about 10 billion Reais³. Such a scenario is set in a country that, over the years, has consolidated itself as the world's leading exporter of tobacco leaves, as well as an international reference for combating smoking. This paradox highlights the importance of effective public policies and comprehensive assistance for smokers⁴.

DEVELOPMENT

THE HISTORY OF NICOTINE ADDICTION TREATMENT AT INCA

The first efforts to control smoking within the National Cancer Institute (INCA), according to Portes⁴, began in 1997, with the creation of the cigarette-free program Programa INCA Livre do Cigarro (PIL), established by Ordinance MS N. 30, of February 18, 1997. This normative determined that the use of smoke-generating tobacco products in the institution was limited to specifically designated spaces – the smoking areas – and a commission was instituted to supervise the program. This innovative project had a double purpose: to facilitate the creation of smoke-free environments within the Institute and offer support for treating nicotine addiction, acknowledging that tobacco smoking is not merely a habit, but an actual addiction⁴.

In its initial phase, PIL focused on treating INCA employees who presented a nicotine addiction. It is noteworthy that 70% of the team who wished to quit smoking presented a high or extremely high degree of addiction. This reality explained the persistence in smoking, even among health professionals aware of the damage caused by tobacco and its repercussions on their professional activities. The program was key in establishing smoke-free hospital environments, serving as a model for the implementation of similar policies in other health institutions at the time⁵.

From 1999 onwards, the program's activities, which initially took place in a location away from the Hospital do Câncer I (HCI), were transferred to the hospital unit, facilitating access. Thus, the Study Center for the Treatment of Nicotine Addiction was inaugurated in 2000, focused, at first, on treating the Institute's employees and their families, and later developing an important clinical trial with patients from the population⁶.

In 2001, a survey conducted in collaboration with the HCI Social Services identified that patients also sought support in overcoming their nicotine addiction, which led to the inauguration, in September 2002, of a room specially dedicated to the treatment of smokers⁵.

The success of the program, demonstrated by a 67.4% abstinence rate after six months, motivated its extension also to include patients’ families. From January 1, 2000, through March 3, 2011, 1,391 people were assisted, of which 903 were diagnosed with cancer⁵. The accumulated knowledge was compiled in important scientific publications, consolidating INCA's experience in the treatment of nicotine addiction. In this evolutionary process, INCA's Study Center for the Treatment of Nicotine Addiction continues to effectively assist, aligned with national guidelines for the treatment of nicotine addiction.

FROM AN INTERNAL MODEL TO THE IMPLEMENTATION OF A NATIONAL PROGRAM

The approach adopted by the Study Center for the Treatment of Nicotine Addiction is founded on the model implemented by INCA/Ministry of Health for the National Program of Tobacco Use Control (PNCT), made official through Ordinance GM/MS N. 502, of June 1, 2023⁷, which established compromises in the three federation levels to approach the program within the National Health System (SUS).

In this context, the treatment model developed and tested at INCA received specific adaptations to assist people in oncology treatment with a high addiction degree, resulting in significant protocol modifications: increase in the number of weekly sessions; personalized individual consultations; emphasis on the benefits of tobacco cessation, even in the face of disease manifestations associated with its use; active search supported by administrative data from the institute; inclusion of relatives in the process; intersectoral collaboration for patient follow-up; medication support for most of the assisted, and integration with the treatment of underlying conditions.

This work, developed internally at INCA, has been fundamental for the constant improvement of the Clinical Protocol and Therapeutic Guidelines for the Treatment of Smoking (PCDT, in the Portuguese acronym)⁸. These guidelines advocate for an integrated approach that combines behavioral counseling with pharmacotherapy, applied both in individual consultations and in groups. A meticulous initial clinical evaluation determines the need for medication, as well as nicotine patches and chewing gum, in addition to bupropion, available for free on SUS. The assistance also includes psychological and interdisciplinary support, essential for minimizing the physical and emotional impacts of cessation.

Moreover, it is important to highlight a fundamental element of the treatment at INCA, which is the maintenance group, designed for patients who were able to cease the use of tobacco. This group helps identify factors that trigger abuse and formulate strategies to deal with abstinence. In this context, the maintenance group, currently conducted by a psychologist, is a crucial therapeutic approach in the treatment process and follow-up of members, aiming to avoid relapses, strengthen motivation to abstain, and provide continuous emotional support.

It is worth mentioning that the group also works as a safe space for exchanging experiences among participants, representing a valuable opportunity to cultivate a feeling of belonging and solidarity, which becomes essential for continuing the process of tobacco cessation. Moreover, the treatment also addresses themes related to coping with cancer, managing physical and emotional symptoms, and creating strategies to deal with stress, understanding that tobacco cessation is a dynamic and non-linear journey that requires follow-up, especially for oncological patients, whose vulnerability is increased by treatment requirements and the emotional impact of the disease.

FROM LOCAL EXPERIENCE TO NATIONAL TRAINING

The accumulated experience in the treatment of nicotine addiction at INCA grounds one of the main pillars of the institute's initiative: training health professionals across the national territory. This activity has significantly broadened the reach of the PNCT, enabling the institute's successful model to be replicated and adapted to the diverse realities of the country.

In 2020-2021, online professional training resources were implemented, replacing the in-person resources due to the COVID-19 pandemic. This initiative resulted in the training of 22,431 health professionals, encompassing the Middle West, Northeast, North, Southeast, and South Regions, during the 2020-2024 period⁹. The impact of these initiatives is reflected in the growing number of smokers who receive treatment via SUS, currently estimated at around 200 thousand individuals a year⁹.

In this sense, the work developed internally at the Institute, with the treatment provided to oncological patients, employees, and their relatives, functions as a lab for the continuous improvement of methodologies applied at a national scale. The adaptations, challenges, and solutions found in the daily assistance provided by INCA are systematized and incorporated into the training sessions, enriching the national program and strengthening its impact in the different Regions of the country.

CONCLUSION

INCA, with its history of leadership and innovation, remains an essential pillar in the journey towards smoking control in Brazil, acting as an articulator of the PNCT and engaging states, municipalities, and non-governmental organizations. The successful experience of the nicotine addiction treatment at the Institute, initiated with the PIL, evolved into a more comprehensive program that currently benefits smokers in the whole national territory through SUS.

The synergy between services offered internally at INCA and the dissemination of knowledge and technical competency to the public network reveals how well-structured local initiatives can evolve into meaningful public policies. The continuous exchange between daily clinical practice at the Institute and national guidelines for combating smoking enables constant adjustments and improvements, culminating in a more solid program aligned with the demands of the Brazilian population.

However, new challenges, like electronic smoking devices, inequalities in accessing treatment, and new strategies of the tobacco industry, require innovative and continuous responses. By integrating international experiences and strengthening national initiatives, it is possible to advance even further in reducing the impacts of smoking.

• FUNDING SOURCES
  None.

DATA AVAILABILITY STATEMENT

All the contents associated with the article are included in the manuscript.

References

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• ² Instituto de Efetividade Clínica e Sanitária, Palacios A, Pinto M, et al. A importância de aumentar os impostos do tabaco no Brasil [Internet]. Buenos Aires: Instituto de Efetividade Clínica e Sanitária; [2020]. [acesso 2025 jan 25]. Disponível em https://actbr.org.br/uploads/arquivos/IECS-2021.pdf Acesso em: 18 fev 2025.
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• ³ Instituto de Efetividade Clínica e Sanitária, Pinto M, Bardach A, et al. O tabagismo no Brasil: morte, doença e política de preços e impostos. Buenos Aires: Instituto de Efetividade Clínica e Sanitária; [2024]. [acesso 2025 jan 25]. Disponível em https://tabaco.iecs.org.ar/wp-content/uploads/2024/05/20TABAQUISMO-BRASIL.pdf
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• ⁷ Ministério da Saúde (BR), Gabinete da Ministra. Portaria GM/MS nº 502, de 1º de junho de 2023. Institui o Programa Nacional de Controle do Tabagismo (PNCT) no âmbito do Sistema Único de Saúde [Internet]. Diário Oficial da União, Brasília, DF. 2023 jun 13 [acesso 2024 dez 18]; Edição 110; Seção 1:60. Disponível em: https://ninho.inca.gov.br/jspui/bitstream/123456789/14185/1/Portaria%20n.%20502-23.pdf
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Edited by

• Scientific-editor:
  Anke Bergmann. Orcid iD: https://orcid.org/0000-0002-1972-8777

Publication Dates

• Publication in this collection
  04 Aug 2025
• Date of issue
  2025

History

• Received
  10 Apr 2025
• Accepted
  12 June 2025