STATUS DA POLÍTICA

WHO Framework Convention on Tobacco Control (WHO FCTC)

The WHO Framework Convention on Tobacco Control (WHO FCTC) is the first treaty negotiated under the auspices of the World Health Organization. Its objective is “to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke by providing a framework for tobacco control measures to be implemented by the Parties at the national, regional and international levels in order to reduce continually and substantially the prevalence of tobacco use and exposure to tobacco smoke” (article 3).

On October 27, 2005, Brazil's adherence to the FCTC was ratified by the Senate. Since the implementation of the FCTC measures became the National Policy on Tobacco Control in Brazil.

The National Commission for FCTC Implementation (CONICQ) is responsible to propose, implement, consolidate and evaluate the measures for WHO FCTC implementation in Brazil.

The National Commission for FCTC Implementation in Brazil (CONICQ)

Aligned with Article 5.2 of the treaty, the National Commission for Implementation of the Framework Convention on Tobacco Control (CONICQ), created by the Decree of August 1st of 2003, is chaired by the Minister of Health and composed of representatives from each of the government sectors listed below, as Decree S / No. of March 16, 2012. The National Cancer Institute (INCA) act as its Executive Secretariat.

I – Ministry of Health; II - Ministry of Foreign Affairs; III - Ministry of Finance; IV - Ministry of Planning, Budget and Management; V – Civil House of Presidency of the Republic; VI - Ministry da Agriculture, Food and Rural Affairs; VII - Ministry of Justice; VIII - Ministry of Education; IX - Ministry of Labor and Employment; X - Ministry of Development, Industry and Foreign Trade; XI - Ministry of Agrarian Development; XII - Ministry of Communications; XIII - Ministry of Environment; XIV - Ministry of Science and Technology; XV - Secretariat of Policies for Women of the Presidency; XVI – National Secretariat for Drug Policies of the Ministry of Justice; XVII – Attorney General’s Office (AGU); e XVIII – National Health Surveillance Agency (ANVISA).

The CONICQ holds quarterly ordinary meetings, restricted to its members, to discuss, develop and evaluate actions and policies that address the various obligations of the Framework Convention. The CONICQ also conducts opened seminars to civil society during the process of preparing for the sessions of the Conference of the Parties in order to collect subsidies that contribute to defining the position of the Brazilian delegation representing the country in these sessions.

The Procedure Rules of the National Commission to implement the Framework- Convention for Tobacco control (CONICQ) can be accessed here.

Prevalence

The National Policy on Tobacco Control in Brazil contributed to a significant decline in adult smoker’s percentage. In 1989, 34.8 % of the population above 18 years used to smoke[i]. A significant decline was observed in 2003, when the percentage was 22.4 %[ii]. In 2008 this percentage was 18.5%[iii]. The latest data, to 2013, indicate the percentage of 14.7% adult smokers[iv]. Considering the period 1998-2010 the percentage of smokers in Brazil decrease 46% and 420,000 deaths were avoided[v].(1) (2) (3).

In addition to household surveys presented above, the percentage of smokers in Brazil is also estimated since 2006 through annual monitoring by phone - Annual Surveys on Risk and Protective Factors for Chronic Diseases (VIGITEL). This survey is conducted in 26 Brazilian capitals and the Federal District with adults 18 years or more by telephone line.  According to data from 2016 VIGITEL, the smokers percentage aged 18 or more in Brazil is 10.2%, represented by 12.7% of men and 7,3% of women.

According to 2012 National Survey on Student Health (PeNSE), 19.6% of students had experimented cigarettes. The highest frequency of experimentation was in the Southern region (28.6%) and lowest in the Northeast (14.9%). There was no significant difference in gender distribution. It was higher among students in public schools (20.8%), than private schools (13.8%). It also showed that a number of students who have experienced smoking at least once in life decreased from 24.2% in 2009 to 22.3% in 2012. The data include not only the Capital, but other municipalities too (4) (5).

Diseases, mortality and costs 

Among the diseases that cause more deaths in Brazil, the cardiovascular diseases are at first place (more than 29% per year) and cancer is in the second place (more than 15% per year). The data to 2003 indicate the lung cancer it’s the cancer that cause more deaths in men and is the second cause to death in women with cancer disease.

A study conducted by a researcher at the FIOCRUZ Marcia Pinto based on 2011 monetary values, entitled "The burden of smoking-related diseases in Brazil", estimated the cost attributable to smoking was 21 billion Reais a year to the health system. The study analyzed a total of 2,442,038 diseases and of these, 34% were attributable to smoking (6).

In 2015, the same researcher published the article " The burden of smoking-related diseases in Brazil: mortality, morbidity and costs" which evaluated the Years of Life Lost (YLL) attributable to smoking at the population level, and estimated two components: Potential Years of Life lost due to premature death (YPLL) and YLL to live with reduced quality of life (YLL-QOL). With the inclusion of these variables the total cost to the health system attributable to smoking spent reached 23.3 billion Reais per year (7).

The data from the 2011 survey were updated and its results showed that in the year 2015, smoking generated health care costs associated with smoking in Brazil by almost 40 billion reais, equivalent to 8.04% of all expenses in Health, and indirect costs reached more than 17 billion reais due to productivity lost due to premature death and disability. Total results point to an annual loss of 56 billion reais, equivalent to 0.96% of national GDP. On the other hand, the total tax revenue from the sale of tobacco and derivatives products reached approximately 13 billion reais in 2015, an amount that covers only 33% of the direct costs caused by smoking to the health system, which represents only 23% Of the total expenditure attributable to smoking (8).

"Deaths from lung cancer and chronic obstructive pulmonary disease (COPD) accounted for 81% and 78%, respectively, while 21% of deaths from heart disease and 18% for stroke were also associated with this risk factor (tobacco). All the tumors revealed that 31% of deaths were due to the consumption of tobacco. Secondhand smoking and perinatal causes totaled 16,920 deaths". In 2011, there were 147.072 deaths from tobacco related diseases (6).

Tobacco Production

Between 1990 and 2003, Brazil produced an average of 554,000 tons of tobacco a year. Since 2004, Brazil has achieved a higher level of production when compared to previous years, maintaining a volume of 800-900 thousand tons per year.

Between 2006 and 2013, production fluctuated and showed slight decline. Production in 2010 was the lowest since 2006. In 2015, Brazil produced 867.355 tons of tobacco leaf. The evolution chart can be found by the path: DADOS E NÚMEROS/PRODUÇÃO DE FUMO, graphic 1.

The Tobacco Growers Association of Brazil (AFUBRA) already alerts a declining perspective in the upcoming years.

According to AFUBRA, in the last ten years, the number of tobacco growers (families) was reduced by 18%. In the same period, the planted area in hectares decreased by 26%.

Brazil is the second largest tobacco producer in the world. The first producer is China.

Tobacco Exportation

Data from national tobacco exports extracted from Aliceweb2, Ministry of Development, Industry and Foreign Trade (MDIC) system, indicate that Brazil had exported in the first half of the last decade (2000 to 2004), an average of 353,000 tons per preprocessed tobacco year. From 2007, the country has raised this amount to over 500 thousand tons, higher than had been observed. In 2010, there was a decrease in the amount of exported tobacco, but the trend of exports of tobacco pre and post-processing grew until 2012. In 2013 it is noticed a slight drop in the volume of exports, which was confirmed in 2014 (-24%), achieving a volume even lower than in 2010.

According to 2016 data, the main importing countries are: Belgium (19%), United States (11%), China (9%), Russia (7%), the Netherlands (4%), and Paraguay (3%).

The evolution chart can be found by the path: DADOS E NÚMEROS/EXPORTAÇÃO DE FUMO, graphic 1

Per Capita Consumption

The apparent official per capita consumption of cigarettes decreased by 65% between 1980 and 2010 (the downward trend began in the late 90's, from which we observe a more intense and continuous decrease in consumption). In 2015, Brazil had the lower per capita cigarette consumption (369 units) of the whole period.

The consumption decrease directly affected the production of cigarette packs containing 20 units, according to the Federal Revenue Secretariat. Between 2007 and 2016, there was a 53% decrease in cigarette production.

The evolution chart can be found by the path: DADOS E NÚMEROS/CONSUMO PER CAPITA, graphic 1.

Estimating the size of illicit tobacco consumption in Brazil: findings from the global adult tobacco survey

Brazil experienced a large decline in smoking prevalence between 2008 and 2013. Tax rate increases since 2007 and a new tobacco tax structure in 2012 may have played an important role in this decline.
However, continuous tax rate increases pushed up cigarette prices over personal income growth and, therefore, some consumers, especially lower income individuals, may have migrated to cheaper illicit cigarettes.
Total proportion of illicit daily consumption increased from 16.6% to 31.1% between 2008 and 2013.
The study observed a pattern of unadjusted absolute decreases in cigarette smoking prevalence and increases in the proportion of illicit consumption, irrespective of gender, age, educational level, area of residence and amount of cigarettes consumed (9). Read the full article .

 

Main Measures Adopted

Graphic Health Warnings

One of the most cost-effective measures available, because communication costs fall on the manufacturer. The industry pays for the packaging, so they pay for the printing.

Warnings are scientifically demonstrated to be effective in informing the society about the tobacco use risks.

Many years before Brazil ratified the FCTC/WHO, the government started to adopt the warning labels on the cigarette packaging. It started in the 80´s and it passed by four important phases.

First Phase: In August 1988 the Ministry of Health required the tobacco companies to print the following sentence on all packages: “The Ministry of Health Warns: smoking is harmful to health”.

Second Phase: In 1996, with the advent of Federal Law, health warnings began to be required by law and not by a voluntary agreement.

Also in 1999, the Ministry of Health created the National Sanitary Surveillance Agency – ANVISA (Federal Law number 9.782), mandating, among other things, to regulate control and inspect tobacco products, with the technical cooperation of the National Cancer Institute – INCA.

Third Phase: 2001 -Based on World Health Assembly recommendations and on the positive experience of Canada, which was the pioneer in the inclusion of pictorial health warnings in 2000, the National Commission for Tobacco Control (known today as CONICQ), recommended in August 2000 that the Brazilian government adopt a similar strategy. Thus, Brazil was the second country to adopt it.

Forth Phase: In 2003 the Ministry of Health launched the second group of health warnings with stronger messages and pictures, published in ANVISA´s Resolution Number 335, which also required their inclusion on tobacco product advertising. The objective of this initiative was to ensure the renewal of the content of the messages and pictures, which had become ineffective after a long period of use. The concept was based on a phone poll conducted by quit line  “Disque Saúde – Pare de Fumar”, which found that 90% of 89 thousand people interviewed stated that the images launched in 2001 needed to be more shocking. It is worth emphasizing that 80% of them were smokers.

2008 - Given that images must be replaced regularly, the Ministry of Health began efforts to be innovative in the design of new warnings.

With this goal, INCA created a Study Group formed by INCA itself, the National Health Surveillance Agency (ANVISA), the Neurobiology Laboratory at the Federal University of Rio de Janeiro (UFRJ), the Behavior Neurophysiology Laboratory at the Fluminense Federal University (UFF) and the Department of Arts & Design at the Catholic University of Rio de Janeiro (PUC-Rio).

The objective of this group was to produce and select pictures and messages for health warning labels, based on their emotional impact on young people aged 18 to 24. The project was conducted in six stages.

2015 - ANVISA published a new regulation to include health warning in, at least, 30% of the front face, printed in white letters on a black background. The warning should print the messages:
"This product causes cancer”
“Stop Smoking”
“Dial-Health: 136"

2017- In December , 2017, ANVISA published the new normative which included:
New phrases correlating the toxic substances present in the product with people's daily items as well as illnesses caused by their use on a bright yellow background (more contrasting); 
The forbidden sale message for people under 18 will be in a red background, so that there is also a greater visibility of the message. 

The new GHW Should be on the packaging after may 25th,2018. (RDC Nº 195, DE 14 DE DEZEMBRO DE 2017)

The Brazil-2008-Health-Warnings-on-Tobacco-Products-Report can be accessed here

Bans on Tobacco Advertising, Promotion and Sponsorship

The advertising, promotion and sponsorship were banned on the media since 2000. In December, 14, 2011, the law nr. 12.546, banned the advertising in the places of sale too.  Today, in these places are only permitted the products exposure, as long as accompanied by health warning about the dangers of consumption and its price list.

Protection from Exposure to Tobacco Smoke

Since 2014 is forbidden the use of Products Tobacco in all collective places, public or private in the country. This ban applies to restaurants, pubs, night clubs, universities, hotels, guesthouses, concert halls, workplaces, government offices, health institutions, public and private vehicles to public transportation and others, even the environment partially enclosed by a wall, partition, roof or awning.

In addition to the outdoor areas (such as parks and squares), the smoking ban does not apply: the establishments specifically intended for the marketing of tobacco products (tobacco); the studios and filming or recording of audiovisual productions, when necessary for the production of the work; places  for research and development of tobacco products or tobacco not derivatives ; religious services (if part of the ritual) and the health care institutions that have patients allowed to smoke by the doctor who assists them. These locations can be installed designated smoking areas, which should present isolation conditions, ventilation and exhaust air and worker protection measures, according to the Ministerial Ordinance MTE / MS Nr. 2.647, of December 4, 2014.

Taxation

In December 2011, the national pricing policy and tax achieved a major breakthrough with the sanction of Law 12,546 amending the system of Industrialized Product Tax and establishing a policy of minimum prices for cigarettes.

In January 2016, another decree established the new ad valorem rate for packets of 20 cigarettes from May 1st, 2016 (63.3%), and further increase after December 1st, 2016 (66.7%). The decree also raised the minimum price of the package of 20 cigarettes to R $ 5.00 (USD 1.40) after May 1st , 2016.

National Program for Diversification in Areas of Tobacco Cultivation

By the ratification of the Framework Convention on Tobacco Control, the Ministry of Agrarian Development (MDA) assumed an important commitment to the implementation of the National Program for Diversification in Areas of Tobacco Cultivation. Based on the principles of sustainable development, food security, diversification of production and social participation, the program operates in the qualification of the production and development process in the areas of tobacco farming, as well as from the perspective of ecological production, by reducing the use of pesticides.

Brazil is one of the key facilitators of the International GT Articles 17 and 18 of the FCTC. This group was created in 2006 during the 1st Conference of the Parties (COP 1), as a study group status and at COP3 it acquired the status of Working Group.

The Brazilian government has held two meetings (2013 and 2016) in the Southern region to receive FCTC Parties who have come to know the experiences of Brazil over the past 15 years on the livelihoods methodology adopted at COP 6 in Russia. This methodology is being implemented in the Technical Assistance and Rural Extension (ATER) public call for diversification,  currently coordinated by the Special Secretariat for Family Agriculture and Agrarian Development/Civil House of the Presidency of the Republic.

You can find the visit´s reports below and the Ministry of Agrarian Development actions in Brazil:

Brazil - Actions of the ministry of Agrarian development in Brazil

Report of WG 17 e 18-PELOTAS_Brazil_2013

Report of International Cooperation on Art17_Brazil_2016

A  Network to enhance the National Program for Diversification in Areas of Tobacco Cultivation

More than 20 organizations, including civil society representatives, are committed to the implementation of Articles 17 and 18 of the FCTC / WHO working in partnership with the Government on Technical Assistance and Rural Extension (Ater) to tobacco growers who choose to diversify their production in order to reduce economic dependence on tobacco.

There is also a community radio network with spots of 30 seconds to publicize actions for the implementation of articles 17&18.

Impacts of tobacco growing on health, life and family economy

The prevalence of smoking is higher than the national average, child labor in agriculture, green leaf disease, depression, suicide rates higher than the Brazilian average, poisoning by pesticides, contamination of soil, food, fauna and rivers, and deforestation are some of the direct documented damage associated with tobacco production.

The Ministry of Health, with support of Oswaldo Cruz Foundation, INCA and other institutions, is developing a Protocol to prevent, diagnose and treat occupational risks for tobacco growers and their families.


 

Sale to Underage

In Brazil, since 1990 the Statute of Children and Adolescents (Law No. 8.069 / 1990) prohibits sell or deliver the child or adolescent products whose components may cause physical or psychological dependence, as is the case of tobacco products. In 2003 this ban became more expressed in Law No. 10,702 / 2003, which prohibits the sale of any tobacco products to persons under 18 years.

Cessation Treatment

The National Cancer Institute (INCA), as the Ministry of Health body responsible for coordination of the National Program for Tobacco Control and considering the complexity that involves dependence and smoking cessation, met in 2000, different scientific societies and professional advice of health in Brazil to develop the "Consensus Approach and Smoker Treatment" containing general guidelines on methods to quit smoking.

The approach of network and smoking treatment follows the logic of the Brazilian Health System, and is found in many cities, thus contributing to achieving the important goal of controlling the tobacco epidemic in Brazil.

Challenges

Plain Package

Since the ban on tobacco product advertising in the media, the packaging of cigarettes and other tobacco products have been used as a strategy to attract new smokers. To counter this strategy and inform smokers about the dangers of smoking, since 2001 the government requires that tobacco manufacturers and importers of products include health warnings on their packages, accompanied by photos that take up 100% of the principal surfaces and the number of the Health Hotline - Stop Smoking, but the adoption of standardized packaging is still in the legislative process for consideration.

Fundraising

The establishment of a mechanism to finance the government and Brazilian society for the burden and social costs caused by tobacco related diseases would be a way to compensate the Health System and Social Security.

The goal is to get resources to make possible to implement alternatives to tobacco production programs, intersectoral actions for the prevention and control of smoking, as well as reduce the burden that smoking has imposed the health system due to tobacco disease treatment costs related.

References

(1) Instituto Brasileiro de Geografia e Estatística-MPOG e Insituto Nacional de Câncer-MS. (2009, 11 11). Pesquisa Nacional por Amostra de Domicílios-Tabagismo-PETab. Retrieved 03 29, 2015, from Instituto Brasileiro de Geografia e Estatística:

http://www.ibge.gov.br/home/estatistica/populacao/trabalhoerendimento/pnad2008/suplementos/tabagismo/pnad_tabagismo.pdf

(2) Instituto Brasileiro de Geografia e Estatística-MPOG e Fundação Oswaldo Cruz-MS. (2014, 01 15). Pesquisa Nacional de Saúde 2013-Percepção do estado de saúde, estilos de vida e doenças crônicas. Retrieved 03 30, 2015, from Pesquisa Nacional de Saúde:

http://loja.ibge.gov.br/pesquisa-nacional-de-saude-2013-percepc-o-do-estado-de-saude-estilos-de-vida-e-doencas-cronicas.html

(3) Instituto Nacional de Alimentação e Nutrição-MS. (1990, setembro 15). Pesquisa Nacional sobre Saúde e Nutrição: perfil da população brasileira de 0 a 25 anos. Retrieved 04 02, 2015, from Portal da Saúde: http://189.28.128.100/dab/docs/portaldab/documentos/boletimSisvan/pnsn1.pdf

(4) Instituto Brasileiro de Geografia e Estatística-MPOG e Secretaria de Vigilância em Saúde-MS. (2009, 12 30). Pesquisa Nacional da Saúde do Escolar2009. Retrieved 03 30, 2015, from Instituto Brasileiro de Geografia e Estatística: http://www.ibge.gov.br/home/estatistica/populacao/pense/pense.pdf

(5) Instituto Brasileiro de Geografia e Estatística-MPOG e Secretaria de Vigilância em Saúde-MS. (2012, 12 20). Pesquisa Nacional de Saúde do Escolar 2012. Retrieved 03 31, 2015, from Instituto Brasileiro de Geografia e Estatística-Estimativas de População: http://www.ibge.gov.br/home/estatistica/populacao/pense/2012/pense_2012.pdf

(6) Márcia Teixeira Pinto, A. P.-R. (2012). ACT+. Acesso em 01 de julho de 2014, disponível em Custo do Tabagismo para o Brasil:

http://www.actbr.org.br/uploads/conteudo/721_Relatorio_Carga_do_tabagismo_Brasil.pdf

(7) Pinto, M., Riviere, A., & Bardach, A. (2015). A Estimativa da Carga do Tabagismo no Brasil: mortalidade, morbidade e custos. Caderno de Saúde Pública 31(6), 1283-1297. Disponível em: http://www.scielo.br/pdf/csp/v31n6/0102-311X-csp-31-6-1283.pdf

(8)  Pinto M, Bardach A, Palacios A, Biz AN, Alcaraz A, Rodríguez B, Augustovski F, Pichon-Riviere A. Carga de doença atribuível ao uso do tabaco no Brasil e potencial impacto do aumento de preços por meio de impostos. Documento técnico IECS N° 21. Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina. Maio de 2017. Disponível em: www.iecs.org.ar/tabaco

(9) Iglesias,R., Szklo,A., Souza,M., Almeida,L. (2016). Estimating the size of illicit tobacco consumption in Brazil: findings from the global adult tobacco survey.

Additional Reading:

Levy , D., Almeida, L., & Szklo, A. (2012). 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 Medicine, pp. 9(11), 1-12.

Disponível em: http://actbr.org.br/uploads/conteudo/776_artigo_PLOS.pdf

Monteiro, C., Cavalcante, T., Moura, E., Claro, R. M., & Szwarcwald, C. L. (2007). Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989-2003). Bulletin of the World Health Organization, pp. 85:527-534. Disponível em:

http://www.microsofttranslator.com/bv.aspx?ref=SERP&br=ro&mkt=pt-BR&dl=pt&lp=EN_PT&a=http%3a%2f%2fwww.who.int%2fbulletin%2fvolumes%2f85%2f7%2f06-039073%2fen%2f


 

 


 


[i] Pesquisa Nacional sobre Saúde e Nutrição (PNSN).

[ii] Pesquisa Mundial de Saúde (PMS).

[iii] Pesquisa Especial sobre Tabagismo (PETab).

[iv] Pesquisa Nacional de Saúde (PNS).

[v] The Brazil SimSmoke Policy Simulation Model.