Trends in Prevalence of Cigarette Smoking in Brazil: 2006–2019

Abstract

Objectives. To analyze trends in cigarette smoking among Brazilian adults from 2006 to 2019.

Methods. We performed a time-series analysis based on data from the Surveillance of Risk and Protective Factors for Chronic Diseases Telephone Survey (n = 730 309). We calculated the annual prevalence of current cigarette smokers, heavy smokers, and passive smokers in the workplace and investigated linear trends using Prais–Winsten regression, for the entire period and for the past 5 years. We performed the analyses for the total population and according to the sociodemographic characteristics.

Results. The prevalence of cigarette smoking, heavy smoking, and passive smoking in the workplace declined, respectively, an average of 3.99% per year, 5.65% per year, and 6.55% per year from 2006 to 2019. We observed this reduction regardless of gender, age, educational level, and geographic region. The magnitude of reduction in the prevalence of current cigarette smoking decreased in the past 5 years, while the magnitude of the change in heavy smoking increased.

Conclusions. The prevalence of cigarette smoking decreased in the time period studied. The smaller magnitude of reduction for current cigarette smoking in the most recent years might indicate a fatigue with the current policy scenario.

In the most recent decades, tobacco smoking has been highlighted as one of the main behavioral risk factors for noncommunicable chronic diseases (NCDs), the leading causes of death worldwide.¹ According to the World Health Organization (WHO), the global prevalence of tobacco smoking (including cigarettes and any other smoked tobacco product, such as pipes, cigars, cigarillos, bidis, kreteks, and water-pipe tobacco) decreased from 24% in 2005 to 19% in 2017.² However, it is still estimated that 10% of total global deaths (8 million deaths per year) will be related to smoking by 2030.³ Thus, to assist in the prevention of avoidable deaths from NCDs and to reduce the health threat of tobacco use and exposure, the global target is a relative reduction of 30% in the prevalence of tobacco use in individuals aged 15 years or older by 2025 (with 2010 levels as baseline),² as well as encouraging the implementation of the WHO Framework Convention on Tobacco Control (FCTC) in all parties to the treaty.⁴

Several governments have already engaged in reducing the prevalence of tobacco use in the population through monitoring, educational, and regulatory measures.^5,6 In Brazil, between 1989 and 2003, cigarette smoking among adults was reduced by an average of 2.5% per year, from 34.8% to 22.4%.⁷ A modest reduction in the mean number of cigarettes smoked was also observed, from 14.9 cigarettes per day to 12.6 cigarettes per day. Both downward trends were greater among men, younger age groups, and those with higher socioeconomic status.⁷ This downward trend has been continuously monitored since Brazil signed the FCTC in 2005.⁸

However, based on data from the Brazilian Health Information System, the disease and economic burden associated with smoking is still high in the country. In 2015, smoking was responsible for 156 337 deaths, 4.2 million potential years of life lost, 229 071 acute myocardial infarctions, 59 509 strokes, and 77 500 cancer diagnoses.⁹ Besides that, about BRL 57 billion (US $10.6 billion) were spent on direct health costs and indirect costs attributable to loss of productivity by premature death and disability.⁹ In this context, the present study aims to analyze the trends and sociodemographic distribution of cigarette smoking over a 14-year period in a representative sample of the adult population from Brazilian state capitals and the Federal District.

METHODS

We performed a time series analysis based on data from the Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (Vigitel; Surveillance of Risk and Protective Factors for Chronic Diseases Telephone Survey), conducted by the Ministry of Health, from 2006 to 2019 (730 309 participants). Vigitel investigates risk and protective factors for NCDs among the adult population (aged ≥ 18 years) in the 26 Brazilian state capitals and the Federal District, which represents approximately a fifth of total Brazilian adults, through telephone interviews conducted annually since 2006.

A minimum sample size of approximately 2000 adults in each city per year was established to estimate the frequency of each factor with a 95% confidence interval (CI) and a maximum error of 2 percentage points. The Vigitel sampling process is performed in 2 stages. In the first one, 5000 landlines are randomly selected in each city from landline telephone catalogs (made available annually by the main telephone companies in Brazil). These numbers are then organized into replicates (or subsamples) with 200 landlines (reproducing the same proportion of lines by postal code of the original catalog). This division is performed because of the difficulty in estimating the proportion of active residential numbers in the catalogs. Nonresidential numbers, out-of-service numbers, and numbers that do not answer to any attempt of contact (6 attempts are performed on different days and hours, including weekends and holidays) are considered ineligible. Once the eligibility of the landline is established, at the second stage, 1 adult among the residents of each household is selected (simple random sample) and invited to participate.¹⁰

Weighting factors are estimated, allowing the representation of the total adult population of each city. The weight is composed of 2 factors. The first one aims to deal with unequal sampling probability of households with more than 1 landline and more than 1 resident, while the second compares the distribution of the population interviewed through Vigitel with that predicted for the entire population in each study site and year (according to gender, age, and educational level) based on official predictions.¹⁰ More details on the sampling process used in Vigitel can be obtained from the annual reports of the system.¹⁰

Data Collection and Organization

Regarding data collection, a computer-assisted telephone interviewing method was used, allowing the immediate identification of invalid responses and the automatic pass-through of not-applicable questions ensuring the continuous feeding of the database, in addition to the provision of the total time duration of the each interview (about 12 minutes). Vigitel’s core questionnaire involves questions on sociodemographic characteristics, cigarette smoking, self-reported weight and height, food consumption, physical activity, alcoholic beverage consumption, self-rated health status, self-reported cancer screening tests in women, and self-reported morbidity.

Three questions concerning cigarette smoking were used in the present investigation: “Do you currently smoke?” (“Yes, every day”; “Yes, but not daily”; or “No”); “How many cigarettes do you smoke per day?”; and “Does a co-worker usually smoke in the same environment where you work?” (“Yes” or “No”; only for those referring to have worked in the 3 months before the interview). We calculated 3 dichotomous indicators to identify respectively the prevalence of (1) current cigarette smoking (regardless of the number of cigarettes and frequency and duration of the cigarette smoking habit), (2) heavy smoking (individuals who smoked 20 or more cigarettes per day), and (3) passive smoking (secondhand smoking) in the workplace. Information regarding passive cigarette smoking has been available since 2009, whereas the other smoking-related indicators have been available for the entire study period.

We included a set of 4 sociodemographic variables in the analysis: gender (male or female), age groups (18–24, 25–34, 35–44, 45–54, 55–64, or ≥ 65 years), educational level (0–8, 9–11, or ≥ 12 years) and geographic region (northern, northeastern, midwestern, southeastern, or southern).

Data Analysis

Initially, we described the population distribution for each year according to gender, age group, education level, and geographic region. Next, we estimated the annual prevalence of each indicator (current cigarette smokers, heavy smokers, and passive smokers in the workplace). We conducted all analyses for the total population of each indicator and according to sociodemographic characteristics (gender, age groups, education level, and geographic region).

We employed Prais–Winsten regression models to investigate time trends in the prevalence of cigarette smoking. This model is based on linear regression analysis and aims to correct the effect of serial autocorrelation, which is recommended in time-trend studies.¹¹ The dependent variables were the prevalence of the indicators related to cigarette smoking in each given year and the independent variable was the year of data collection. In these analyses, the regression coefficient indicates the average annual relative variation (percentage). These models allowed establishing the cigarette smoking prevalence trends as stable (P > .05), declining (P < .05 shown as a negative regression coefficient), or ascending (P < .05 shown as a positive regression coefficient).¹¹ We performed this analysis for the entire study period, from 2006 to 2019, and for the most recent period, from 2015 to 2019. This most recent period was delimited considering the publication of the last decrees related to tobacco control measures in Brazil.¹²

We illustrated the time trend in the prevalence of cigarette-use indicators (current cigarette smokers, heavy smokers, and passive smokers in the workplace) for the total population in trend graphs.

We performed data analysis with Stata statistical software version 14 (StataCorp LP, College Station, TX) and the survey module, which takes into consideration the complex survey design.

RESULTS

The population was composed mostly of women, young adults (aged 25–44 years), individuals with lower educational level (0–11 years), and those residing in the southeastern and northeastern regions of the country. Between 2006 and 2019, there was a measurable change in population age and educational level. The percentage of individuals aged 18 to 44 years decreased, whereas the percentage of people aged 45 years or older increased from 15.8% to 17.9% (age 45–54 years), from 10.0% to 13.1% (age 55–64 years), and from 9.4% to 11.4% (age ≥ 65 years). Similarly, the percentage of individuals with between 0 and 8 years of formal education decreased from 45.5% to 28.8%, while the percentage of those with 12 years and more of formal education increased from 21.2% to 32.8%. The percentage of people residing in the most developed regions of the country decreased in the studied period (from 8.4% to 8.0% in the southern region and from 45.9% to 44.6% in the southeastern region; Table 1).

TABLE 1—

Distribution (%) of the Adult Population (Aged ≥ 18 Years) by Gender, Age, Educational Level, and Geographic Region: 26 Brazilian State Capitals and the Federal District, 2006–2019

	Distribution of the Adult Population, %
Variables	2006	2007	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	Annual Variation, %a (2006–2019)	Annual Variation, %a (2015–2019)
Gender
Male	46.1	46.2	46.1	46.1	46.1	46.1	46.1	46.1	46.1	46.0	46.0	46.0	46.0	46.0	−0.02**	−0.03**
Female	53.9	53.8	53.9	53.9	53.9	53.9	53.9	53.9	53.9	54.0	54.0	54.0	54.0	54.0	0.02**	0.03**
Age, y
18–24	18.9	18.2	17.9	17.5	17.1	16.7	16.4	15.9	15.6	15.2	14.8	14.5	14.1	13.8	−2.36**	−2.46**
25–34	25.4	25.4	25.4	25.4	25.4	25.4	25.2	25.3	25.3	25.2	25.2	25.2	25.1	25.0	−0.11**	−0.21**
35–44	20.6	20.5	20.4	20.2	20.1	20.0	19.9	19.7	19.6	19.4	19.3	19.1	19.0	18.8	−0.70**	−0.77**
45–54	15.8	15.9	16.1	16.3	16.4	16.6	16.8	16.9	17.1	17.3	17.4	17.6	17.7	17.9	0.97**	0.90**
55–64	10.0	10.2	10.4	10.7	10.9	11.1	11.4	11.6	11.8	12.1	12.3	12.6	12.8	13.1	2.10**	2.02**
≥ 65	9.4	9.8	9.8	9.9	10.1	10.2	10.4	10.5	10.6	10.8	10.9	11.1	11.2	11.4	1.36**	1.30**
Educational level, y
0–8	45.5	45.0	43.7	42.0	40.6	38.8	36.8	36.6	35.9	34.6	32.5	30.8	30.2	28.8	−3.53**	−4.38*
9–11	33.3	35.1	34.7	35.8	35.8	36.7	38.5	37.5	38.1	38.1	35.9	37.3	38.0	38.4	0.85*	0.95
≥ 12	21.2	19.8	21.6	22.2	23.5	24.5	24.7	25.9	25.9	27.3	31.6	31.9	31.8	32.8	3.88**	3.34
Geographic region
Northern	9.7	9.3	9.4	9.4	9.8	9.8	9.9	10.0	10.0	10.1	10.2	10.2	10.3	10.4	0.74**	0.64**
Northeastern	25.5	24.2	25.4	25.5	25.0	25.1	25.1	25.1	25.1	25.1	25.2	25.2	25.2	25.2	0.05	0.08**
Midwestern	10.5	11.1	11.1	11.2	11.2	11.3	11.4	11.4	11.5	11.5	11.6	11.6	11.7	11.7	0.59**	0.48**
Southeastern	45.9	46.6	45.6	45.4	45.8	45.6	45.5	45.4	45.3	45.1	45.0	44.9	44.8	44.6	−0.25**	−0.28**
Southern	8.4	8.7	8.5	8.5	8.2	8.2	8.1	8.1	8.1	8.1	8.1	8.1	8.0	8.0	−0.48*	−0.20**
Total no.	52 796	55 824	54 353	54 367	54 339	54 144	45 448	52 929	40 853	54 174	53 210	53 034	52 395	52 443

Source. Vigitel: Surveillance of Risk and Protective Factors for Chronic Diseases Telephone Survey.

^aCorresponding to the coefficient evaluated through Prais–Winsten regression (expressed in percentage per year).

^*P < .05; **P < .001.

Cigarette smoking prevalence showed a significant reduction of 3.99% per year, ranging from 15.7% in 2006 to 9.8% in 2019. This trend was observed in all groups, regardless of gender, age group, educational level, and geographic region. The average reduction was greater among women (–4.56% per year; P < .001), in the group aged 45 to 54 years (–5.98% per year; P < .001), in those with higher educational level (≥ 12 years; –4.87% per year; P < .001) and in individuals who lived in the less-developed regions (northern: −6.92% per year; P < .001 and northeastern: −6.61% per year; P < .001). The magnitude of reduction was lower in the recent period (from 2015 to 2019) when compared with the entire study period (2.72% per year vs 3.99% per year). This magnitude of reduction was greater only for women (5.20% per year) and individuals aged 65 years or older (7.14% per year) in the recent period (Table 2).

TABLE 2—

Prevalence of Current Cigarette Smokers by Gender, Age, Educational Level, and Geographic Region: 26 Brazilian State Capitals and the Federal District, 2006–2019

	Prevalence of Current Cigarette Smokers, %
Variables	2006	2007	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	Annual Variation, %a (2006–2019)	Annual Variation, %a (2015–2019)
Gender
Male	19.5	19.5	18.0	17.5	16.8	16.5	15.5	14.4	12.8	12.8	12.7	13.2	12.1	12.3	−3.87**	−1.45
Female	12.4	12.3	12.0	11.5	11.7	10.7	9.2	8.6	9.0	8.3	8.0	7.5	6.9	7.7	−4.56**	−5.20*
Age, y
18–24	12.1	13.5	11.4	10.9	10.9	8.8	8.5	7.1	7.8	7.2	7.4	8.5	6.7	7.9	−4.56*	−0.02
25–34	14.0	14.6	13.8	14.5	14.2	13.2	11.7	12.1	11.9	10.5	9.7	9.6	9.4	9.2	−3.78**	−2.80*
35–44	18.7	17.4	16.5	14.8	15.1	13.9	12.9	11.2	9.9	10.4	10.0	11.7	9.1	9.7	−5.44**	−2.49
45–54	22.8	21.5	19.6	18.9	18.0	18.6	16.0	15.1	13.2	12.7	12.6	11.2	11.1	10.9	−5.98**	−4.68*
55–64	15.0	15.8	17.2	16.7	16.7	15.9	15.0	13.6	12.5	12.8	13.5	11.6	12.3	13.6	−1.73	−0.15
≥ 65	9.6	8.4	9.3	8.4	8.1	9.0	7.6	6.9	8.1	8.2	7.7	7.3	6.1	7.8	−2.08**	−7.14*
Educational level, y
0–8	19.3	18.7	18.9	18.1	18.1	18.2	16.3	15.0	14.1	14.4	14.3	13.2	13.0	13.8	−3.10**	−2.00
9–11	13.8	13.6	12.0	11.9	12.2	10.7	10.0	10.3	10.3	9.0	9.4	9.9	8.8	9.5	−3.27**	−0.06
≥ 12	10.8	12.2	10.8	10.8	10.0	9.7	9.1	7.4	6.8	7.2	6.9	7.4	6.2	6.7	−4.87**	−2.68
Geographic region
Northern	15.0	14.9	13.3	12.3	12.2	11.5	9.3	8.1	7.9	8.2	6.7	7.8	6.3	6.7	−6.92**	−4.21*
Northeastern	13.1	12.8	10.6	11.5	10.3	9.3	8.9	7.4	7.6	6.4	6.6	5.9	5.9	6.3	−6.61**	−2.21
Midwestern	14.7	14.3	13.9	13.7	13.4	10.9	10.6	10.9	10.1	10.1	10.6	10.6	8.7	10.5	−3.43**	−3.10
Southeastern	16.8	16.9	17.1	15.4	16.2	15.8	14.4	13.6	12.7	12.7	12.2	12.2	11.4	11.9	−3.33**	−2.55**
Southern	19.1	18.8	17.6	20.0	17.1	17.8	14.8	14.6	14.5	12.9	13.4	13.9	12.5	12.5	−3.76**	−1.36
Total	15.7	15.6	14.8	14.3	14.1	13.4	12.1	11.3	10.8	10.4	10.2	10.1	9.3	9.8	–3.99**	–2.72*

Source. Vigitel: Surveillance of Risk and Protective Factors for Chronic Diseases Telephone Survey.

^aCorresponding to the coefficient evaluated through Prais–Winsten regression (expressed in percentage per year).

^*P < .05; **P < .001.

We observed a similar scenario for heavy cigarette smoking. In general, the prevalence of adults who reported smoking 20 cigarettes or more per day decreased from 4.6% in 2006 to 2.3% in 2019. The average reduction was greater among women (–6.00% per year; P < .001), individuals aged 45 to 54 years (–8.50% per year; P < .001), those with higher educational level (≥ 12 years; –6.91% per year; P < .001), and those who lived in the less-developed regions (northern: −9.72% per year; P < .001 and northeastern: −8.00% per year; P < .001). However, in this case, the reduction was greater in the most recent period (2015–2019; –7.49% per year; P < .05) than in the entire study period (–5.65% per year; P < .001; Table 3).

TABLE 3—

Prevalence of Adults (Aged ≥ 18 Years) Who Smoked 20 or More Cigarettes Per Day by Gender, Age, Educational Level, and Geographic Region: 26 Brazilian State Capitals and the Federal District, 2006–2019

	Prevalence of Adults (Aged ≥ 18 y) Who Smoke 20 or More Cigarettes Per Day, %
Variables	2006	2007	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	Annual Variation, %a (2006–2019)	Annual Variation, (%)a (2015–2019)
Gender
Male	6.3	6.4	6.2	5.4	5.4	5.2	5.5	4.5	4.1	4.2	4.0	3.8	3.4	3.2	−5.22**	−7.36*
Female	3.2	3.3	3.2	3.1	3.4	3.0	2.8	2.4	2.1	2.2	1.8	1.6	1.6	1.5	−6.00**	−8.01*
Age, y
18–24	2.2	2.7	1.9	1.8	2.3	1.8	1.8	1.8	1.0	1.6	1.6	1.4	1.2	1.1	−5.40**	−10.65*
25–34	3.0	3.6	3.5	3.0	3.5	2.9	3.2	2.7	3.0	2.9	2.2	1.9	2.0	1.8	−4.51**	−10.99*
35–44	5.7	5.3	5.1	5.3	4.5	3.8	4.6	3.3	2.7	3.6	3.1	3.0	2.7	1.6	−7.00**	−12.43*
45–54	9.4	8.1	7.3	6.8	6.9	7.0	5.7	5.5	5.0	3.6	3.6	3.5	3.2	3.0	−8.50**	−4.98*
55–64	5.7	6.6	7.4	6.4	7.1	5.8	7.0	4.6	4.2	4.3	4.4	4.0	3.7	4.3	−4.64*	−3.79
≥ 65	2.5	2.6	3.9	1.9	2.3	3.8	2.9	2.6	2.4	2.7	2.3	2.3	1.9	2.6	−2.06*	−5.87
Educational level, y
0–8	5.9	6.1	6.8	6.0	5.8	6.1	6.2	4.9	4.1	5.1	4.3	3.6	3.3	3.6	−4.75**	−10.24
9–11	3.8	3.8	2.9	3.0	3.6	2.7	3.0	3.1	2.9	2.4	2.8	2.7	2.4	2.1	−3.31**	−4.08
≥ 12	3.0	3.2	3.0	2.5	2.9	2.7	2.5	1.6	1.8	1.5	1.3	1.6	1.7	1.3	−6.91**	4.03
Geographic region
Northern	3.2	3.1	3.3	2.9	2.7	2.8	2.5	1.7	1.4	1.6	1.0	1.6	1.0	0.8	−9.72**	−11.10
Northeastern	3.7	3.2	3.0	2.9	2.7	2.5	2.9	2.2	2.1	1.6	1.6	1.3	1.4	1.2	−8.00**	−6.61*
Midwestern	3.9	4.0	4.3	3.7	4.2	2.8	3.4	2.4	3.1	2.9	2.3	2.1	2.3	2.6	−5.14**	−3.09
Southeastern	5.2	5.6	5.4	4.7	5.2	5.0	4.9	4.3	3.6	4.1	3.8	3.3	3.1	2.9	−4.65**	−8.97*
Southern	6.7	6.6	6.8	7.0	6.4	6.3	5.6	5.3	4.8	4.3	3.8	4.9	3.8	3.7	−5.04**	−2.51
Total	4.6	4.7	4.6	4.1	4.3	4.0	4.0	3.4	3.0	3.1	2.8	2.6	2.4	2.3	–5.65**	–7.49*

Source. Vigitel: Surveillance of Risk and Protective Factors for Chronic Diseases Telephone Survey.

^aCorresponding to the coefficient evaluated through Prais–Winsten regression (expressed in percentage per year).

^*P < .05; **P < .001.

Thus, for the total population, the magnitude of reduction in the prevalence of current cigarette smoking strongly decreased in the past 5 years, while the magnitude of the change in heavy smoking increased. The time trend in the prevalence of passive smokers in the workplace showed no significant reduction in the most recent period (2015–2019; Figure 1).

FIGURE 1—

Prevalence of Current Cigarette Smokers, of Adults (Aged ≥ 18 Years) Who Smoked 20 or More Cigarettes per Day, and of Passive Smokers in the Workplace: 26 Brazilian State Capitals and the Federal District, 2006–2019

Note. Information regarding passive cigarette smoking has been available since 2009, whereas the other smoking-related indicators have been available for the entire study period.

*The downward trend was significant (P < .05) not only in the total period (from 2006 to 2019) but also in the most recent period (from 2015 to 2019).

The prevalence of passive smokers at the workplace was reduced from 12.1% in 2009 to 6.6% in 2019, but it stabilized in the recent period (2015–2019). The average magnitude of reduction for passive smokers at the workplace was greater among women (–7.75% per year; P < .001), those aged between 18 and 24 years (–7.77% per year; P < .001), those with an intermediate educational level (9–11 years; –6.31% per year; P < .001), and individuals who lived in the most underdeveloped regions (northern: −8.36% per year; P < .001 and northeastern: −7.18% per year; P < .001; Table A, available as a supplement to the online version of this article at http://www.ajph.org).

DISCUSSION

The data collected systematically in Brazil over a 14-year period indicated a significant decrease in the prevalence of current cigarette smoking, heavy smoking, and passive smoking in the workplace among adults in Brazil, from 2006 to 2019. While the reduction in the prevalence of smoking has decreased in intensity since 2015 (until 2019), the prevalence related to heavy smoking has intensified when compared with the entire study period (2006–2019). Higher prevalence of cigarette smoking was systematically observed among men and those with lower educational level. These same groups presented a smaller magnitude of reduction when compared, respectively, to women and individuals with higher educational level, increasing their disadvantage.

In 2013, the World Health Assembly endorsed the voluntary global target of a 30% relative reduction in tobacco use worldwide among people aged 15 years or older by 2025 (with 2010 levels as baseline).¹³ However, according to projections made for 2025, including data from 175 countries, many countries are not on track to achieve tobacco control targets, mainly low- and middle-income ones.¹³ On the other hand, in Brazil, the prevalence of cigarette smoking has been decreasing since the 1990s,⁷ up to the most recent period (2019), as shown in this study’s results. This scenario can also be confirmed with the recent publication of the National Health Survey of Brazil (it produces national estimates beyond the state capitals), highlighting the reduction in the prevalence of cigarette smoking (from 14.7% in 2013 to 12.3% in 2019) and of the total use of smoked or nonsmoked tobacco (from 14.9% in 2013 to 12.8% in 2019) among Brazilian adults.^14,15

Although it is not possible, based on our data, to identify the cause of the reduction trend observed, it is likely to be affected by the progress in the fight against tobacco use through regulatory measures such as ban on tobacco advertising, warnings about the risks of smoking on cigarette packages, taxation and minimum price policy, smoking prohibition in closed collective environments,⁶ expansion of warnings on the packages, control of the advertising in outlets, and the prohibition of flavor additives in cigarettes carried out in 2011 (Law no. 12 546/2011).¹⁶ In addition, Decree no. 7555/2011 regulated, in articles 14 through 20 of this law, the increase in tobacco taxation (through changes in the imposto sobre produtos industrializados [tax on industrialized products] focusing on cigarettes)¹⁷ and set a minimum retail price for cigarettes.¹⁸

These actions seemed to have a more intense impact on the heavy smoking prevalence, as their relative reduction was always higher than the one identified for the current cigarette smoking prevalence, especially in the period since 2015. It suggests that cigarette smokers are using a strategy of smoking less often to reduce their risk. However, the real benefit of reducing the number of cigarettes smoked daily is yet unclear. On the one hand, this reduction can decrease some of the damage caused by smoking and help people to quit smoking altogether in the long run; on the other hand, it is not enough to restore the health of individuals and may even decrease their motivation to stop smoking completely.¹⁹ This reinforces the need for studies to explore whether smokers are adopting this strategy, and, if so, what are the most effective monitoring, educational, and regulatory measures.

It is worth mentioning that, possibly, even better results could be achieved with the continuity and intensification of these tobacco control measures. However, the smaller magnitude of reduction for current cigarette smoking in the most recent years might indicate a fatigue with this current policy scenario. In 2016, the government decided to end the policy leading to price increase and minimum value per package. In this year, the last decree on the subject was imposed (Decree no. 8656/2016), setting the minimum price of a package at BRL 5.00 and reducing the magnitude of tax increase over cigarettes,¹⁸ which remains to the present day (2019).

The magnitude of reduction of cigarette smoking varied according to sociodemographic characteristics of the population. Despite women increasingly starting to smoke at the same age as men,²⁰ men have a higher prevalence of cigarette smoking because of historical and cultural encouragement for men to smoke as a symbol of their masculinity.²¹ Although all cigarette-use indicators showed a higher smoking prevalence among men, women observed a greater decrease in smoking prevalence. Culturally speaking, women tend to be more careful about their health, avoiding some risk factors for NCDs such as unhealthy eating and consuming tobacco and alcohol products.¹⁵

Regarding age, the prevalence of current cigarette smoking and heavy smoking was higher among older adults, while the prevalence of passive smoking in the workplace was higher among younger adults. Secondhand tobacco smoking corresponds to a significant burden of deaths and illnesses in the Brazilian population.⁹ It is related to the increased risk of death from heart diseases²² and is an important risk factor for early smoking among adolescents.²³ Brazil already has a law regulating smoking-free environments since the mid-1990s (Law no. 9294/1996), which restricted smoking in public offices, hospitals, primary care units, classrooms, libraries, collective workspaces, theaters and movie theaters, and aircrafts and other means of public transportation. These restrictions were later reinforced and strengthened by Law no. 12 546/2011 and Decree no. 8262/2014, which essentially prohibited smoking in any closed environments, public or private, for collective use. Thus, the high prevalence of secondhand smoking in the workplace at the beginning of the study period (2009), 12.1%, may in fact be considered surprising. Even though this was reduced by almost half (6.6%) by 2019, it may be still considered high because of the previously mentioned legal restrictions as it is equivalent to 2.4 million adults regularly exposed to secondhand smoking in the work environment in the Brazilian state capitals and the Federal District.

Although the prevalence of cigarette smoking is almost twice as high among adults with lower educational level, the reduction observed was more modest than that identified for those with higher schooling. These findings could be partially explained by the level of knowledge about the hazards of tobacco to health or even because they are replacing cigarettes with another type of drug.²⁴ On the other hand, the prevalence of former smokers among adults with lower educational levels has increased over the period, which is positive, considering that these individuals are more vulnerable to the illness process.²⁵ Efforts should focus on identifying and investing in targeted approaches to support socioeconomically disadvantaged smokers to quit.

The tobacco industry lobby has been one of the main challenges for the progress of policies under the FCTC.² The tobacco industry depreciates scientific research, manipulates public opinion to gain respectability, attempts to capture political and legislative processes, and intimidates governments with litigation or threats of litigation. In this context, the FCTC secretariat has initiated a process to expand the establishment of tobacco industry monitoring centers in the BRICS (Brazil, Russia, India, China, and South Africa) nations.²⁶ Brazil is the largest exporter and one of the main producers of tobacco in the world.²⁷ In 2014, about 719 Brazilian municipalities had tobacco-growing areas, of which 90% were located in the southern region.²⁸ This may explain the higher prevalence of smokers and intense smokers in the southern and southeastern regions of Brazil.

Among the effective tobacco control policies recommended by the WHO Framework Convention Alliance, tobacco taxation is highlighted as one of the most effective interventions to reduce the demand for cigarettes.²⁹ The increase in taxation and the minimum price of cigarettes were last established in 2011 but are currently surpassed by the accumulated inflation in the period and by the widespread sale of cheaper illicit tobacco products.³⁰ At the same time, there was a sustained trend of increase in the estimated proportion of illicit cigarette use in Brazil, from 28.8% in 2014 to 42.8% in 2016.³¹ The weakening of the Brazilian government’s regulatory agendas and the strong interference of the tobacco industry could partially explain this.

In 2019, to reduce the consumption of foreign cigarettes (illegally imported, especially from Paraguay), the Ministry of Justice and Public Security of Brazil instituted a working group to evaluate the convenience and opportunity of reducing the taxation of cigarettes manufactured in Brazil.³² There was no consensus on the benefits of reducing the tax burden as a strategy to combat the sale of illicit cigarettes.³² According to WHO report on the global tobacco epidemic of 2019, based on the experiences of several countries, it is not necessary to reduce the price and taxes of tobacco products to successfully reduce their illicit commerce. To that end, measures such as strengthening tax and customs administration, as well as improving law enforcement capacity, are essential.³³

Limitations

The questionnaire used in the survey is composed of closed, short, and objective questions, specially developed (and tested) to be applied by telephone interview in large population samples.¹⁰ However, the questions do not allow detailed quantitative and qualitative evaluation of the studied factors. The indicators adopted for monitoring smoking do not explicitly include the types of cigarettes (e.g., whether they are traditional or electronic cigarettes). Household passive smoking exposure was not included because it cannot be the object of public policies in Brazil. However, we also observed similar trends to the ones observed in smoking exposure at work for household exposure (data not shown). Furthermore, it is known that self-reported tobacco smoking information is more subject to inaccuracies than those biochemically validated as part of research projects. However, this approach is considered valid and widely used in large surveys of health and lifestyle conditions¹⁵ because of its simplicity and low cost. Also, the self-reported data, over time, usually reflect a consistent bias, and so they remain valuable for trend analyses.

Public Health Implications

The present study indicated a decline in the prevalence of current cigarette smoking, heavy smoking, and passive smoking in the workplace among Brazilian adults. However, the reduction in the intensity of the decline of cigarette smoking prevalence in the recent period is worrying and indicates that, although the current policy scenario seems effective to curb heavy smoking prevalence, it seems insufficient to reduce total smoking prevalence. It is necessary to work toward a country essentially free from the sale (legal and illegal) of tobacco products. It reinforces the need to intensify actions to promote health and protect the population of modifiable risk factors associated with NCDs.