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Objectives To assess the cost-effectiveness of varenicline in comparison to currently funded smoking cessation strategies in Brazil. Methods We modeled the lifetime direct costs and health-related quality of life of a hypothetical cohort of smokers with a single attempt to quit smoking using one of the following: (1) cognitive behavioral therapy (CBT) without any pharmacological intervention, (2) varenicline, (3) bupropion, (4) nicotine replacement therapy (NRT) with transdermal patch, (5) bupropion in combination with NRT transdermal patch, and (6) combined NRT (oral plus transdermal). All drug alternatives were considered with concomitant CBT. The analysis relied on a Markov model based on the Benefits of Smoking Cessation and Outcomes study and used different age and sex categories in the consideration of relative risks and incidence rates of the diseases included in the model. The analysis was conducted from the healthcare system perspective, and a 3% discounting rate for costs and outcomes was applied. Model parameter values were sourced from published literature. Probabilistic and deterministic sensitivity analyses assessed robustness. Results Among the smoking cessation alternatives available in Brazil, varenicline and combined NRT were estimated to have higher effectiveness; varenicline, however, was dominated due to its higher average cost. In the base-case analysis, combined NRT had an incremental gain of 0.25 quality-adjusted life-years (QALYs) in comparison to the second-best option (bupropion in combination with NRT transdermal patch) and an incremental cost-effectiveness ratio of R$2173.47/QALY ($595.45/QALY). Conclusions Combination of oral and transdermal NRT (coupled with CBT) was the most effective smoking cessation option and was 100% cost-effective within a conservative willingness-to-pay threshold.

Objective: To draw up an up-to-date scenario of compliance with the law prohibiting the sale of cigarettes to minors. Methods: We used data about youth access to cigarette purchase that were obtained through a nationwide survey conducted in 2015 among students aged 13-17 years. We estimated simple proportions of attempts to buy cigarettes, success of attempts, purchase of cigarettes on a regular basis, and purchase of cigarettes on a regular basis in a store or bar. All estimates were stratified by gender, age group, and Brazilian macro-region. Crude absolute difference and adjusted absolute difference in the proportion of smokers in each category by variable of interest were analyzed by a generalized linear model with binomial distribution and identity link function. Results: Approximately 7 in every 10 adolescent smokers attempted to buy cigarettes at least once in the 30 days prior to the survey. Of those, approximately 9 in every 10 were successful, and individuals aged 16-17 years (vs. those aged 13-15 years) were less often prevented from buying cigarettes (adjusted absolute difference, 8.1%; p ≤ 0.05). Approximately 45% of all smokers aged 13-17 years in Brazil reported buying their own cigarettes on a regular basis without being prevented from doing so, and, of those, 80% reported buying them in a store or bar (vs. from a street vendor). Conclusions: Our findings raise an important public health concern and may contribute to supporting educational and surveillance measures to enforce compliance with existing anti-tobacco laws in Brazil, which have been disregarded. RESUMO Objetivo: Fornecer um cenário atualizado do cumprimento da lei que proíbe a venda de cigarros para menores de 18 anos de idade. Métodos: Foram utilizados dados de acesso à compra de cigarros obtidos por meio de uma pesquisa de âmbito nacional, realizada em 2015, entre jovens escolares de 13 a 17 anos. Foram estimadas as proporções simples de tentativa de comprar cigarros; sucesso dessa tentativa; compra regular de cigarros; e compra regular de cigarros em lojas ou botequins. Todas as estimativas foram estratificadas por sexo, faixa etária e macrorregiões brasileiras. Para avaliar as diferenças absolutas, brutas e ajustadas, das proporções das categorias consideradas em relação às variáveis analisadas, foi utilizado um modelo linear generalizado com distribuição binomial e função de ligação identidade. Resultados: Aproximadamente 7 em cada 10 fumantes adolescentes tentaram comprar cigarros pelo menos em uma ocasião nos 30 dias anteriores à pesquisa. Desses, aproximadamente 9 em cada 10 obtiveram sucesso, sendo que jovens entre 16-17 anos (vs. 13-15 anos) foram menos impedidos de comprar cigarros (diferença absoluta ajustada = 8,1%; p ≤ 0,05). Aproximadamente 45% de todos os fumantes brasileiros entre 13 e 17 anos de idade referiram ter comprado regularmente os seus próprios cigarros sem serem impedidos, e, desses, 80% relataram tê-los comprado em lojas/botequins (vs. vendedores ambulantes). Conclusões: Nossos achados trazem um importante alerta de saúde pública e podem contribuir para apoiar ações educativas e de fiscalização no sentido de reforçar o cumprimento das leis antitabaco já existentes no Brasil, que vêm sendo desrespeitadas.

Papanicolaou test screening remains an effective approach for the control of cervical cancer. However, for successful control of the disease, patients need to have access to the test results and complete the treatment. The aim of this study was to investigate the factors associated with lack of access to results from the most recent Papanicolaou test in women living in the municipality of Rio de Janeiro who used the Brazilian Unified Health System. Overall prevalence of lack of access to test results was 18.4%. Access to test results was lower for younger women of Black race/skin color origin, those who had difficulties in making an appointment, those who received no information about when to pick up the test results, and those who evaluated the assistance provided by the health professional who collected the Papanicolaou test. Issues related to the organization and infrastructure of the health unit were the most frequently reported cause by the interviewees. The Brazilian Unified Health Service should improve its knowledge of users and service conditions to prevent interruption of the screening flow.

Objective: To evaluate third- and sixth-year medical students in Brazil in terms of their knowledge of and attitudes toward the WHO MPOWER policies to reduce tobacco use. Methods: The WHO Global Health Professions Student Survey was applied in five cohorts of medical students evaluated in their third and sixth years of medical school, between 2008 and 2015. Comparisons were drawn between the two years of medical school in terms of the proportions of students who experimented with or used tobacco products in the last 30 days prior to the survey; knowledge of and compliance with smoke-free policies on the university campus; formal training on smoking cessation strategies; and self-recognition as role models for patients/society. Results: Of the 943 students who completed the survey, approximately 6% had smoked cigarettes in the last 30 days prior to the survey. Comparing the third and sixth years of medical school, we observed a significant increase in the proportion of students who were knowledgeable about smoking cessation strategies (22.74% vs. 95.84%; p < 0.001) and in that of those who recognized their role as models for patients/society (84.5% vs. 89.7%; p = 0.023). Student knowledge of the smoking policies on the university campus was associated with an increase in self-recognition as role models (adjusted absolute difference = 6.7%; adjusted p = 0.050). Conclusions: Knowledge of smoking cessation strategies and self-recognition as role models for patients/society increase over the course of medical school and are associated with the implementation of smoke-free policies. RESUMO Objetivo: Avaliar estudantes de medicina do terceiro e sexto anos no Brasil em relação a seu conhecimento e atitudes sobre as políticas MPOWER da OMS para redução do uso do tabaco. Métodos: A Pesquisa Global de Estudantes de Profissões da Saúde da OMS foi aplicada em cinco coortes de estudantes de medicina avaliados no terceiro e sexto anos da graduação, entre 2008 e 2015. Foram feitas comparações entre os dois anos da graduação em relação às proporções de estudantes que experimentaram ou fizeram uso de produtos de tabaco nos últimos 30 dias antes da pesquisa; conhecimento e cumprimento das políticas antifumo no campus universitário; treinamento formal sobre estratégias de cessação do tabagismo; e autorreconhecimento como modelo de comportamento para pacientes/sociedade. Resultados: Dos 943 estudantes que preencheram a pesquisa, aproximadamente 6% haviam fumado cigarro nos últimos 30 dias antes da pesquisa. Ao compararmos o terceiro e sexto anos da graduação, observamos um aumento significativo na proporção de estudantes que tinham conhecimento sobre estratégias de cessação do tabagismo (22,74% vs. 95,84%; p < 0,001) e na daqueles que reconheciam seu papel como modelo para pacientes/sociedade (84,5% vs. 89,7%; p = 0,023). O conhecimento dos estudantes sobre as políticas de tabagismo existentes no campus universitário associou-se ao aumento no autorreconhecimento como modelo de comportamento (diferença absoluta ajustada = 6,7%; p ajustado = 0,050). Conclusões: O conhecimento sobre estratégias de cessação do tabagismo e a autorreconhecimento como modelo de comportamento para pacientes/sociedade aumentaram ao longo da graduação e estão associados à implementação de políticas antifumo.

Background Brazil experienced a robust decline in smoking prevalence rates as a consequence of public policies. Since lung cancer is strongly associated with smoking, trends in lung cancer mortality rates may be used as a delayed effectiveness indicator of smoking prevention interventions. Objectives The aim of this study was to estimate lung cancer mortality trends from 1980 through 2017 and to predict temporal trends in lung cancer mortality rates, in Brazil from 2016 through 2040. Methods Time trends in lung cancer mortality rates were evaluated using data from available public databases. Crude and age-standardized mortality rates were calculated for each year sex-specific mortality predictions were made for each five-year period from 2016 to 2020 through 2036–2040 using an age-period-cohort (APC) model. Sex ratios were estimated using age-standardized lung cancer mortality rates. Results A decline in age-standardized lung cancer mortality rates has been observed for males since 2005 and for all predicted periods. It is expected that females aged 55 or younger will experience a reduction in lung cancer mortality from 2021 to 2026 onwards, but for those aged 75 or over rates are predicted to continue increasing through 2036–2040. Conclusion Smoking prevention and cessation policies are essential, and it is important to commit to an ethical framework whereby equity in tobacco control activities between genders is achieved. This will avert many premature and preventable smoking-related deaths in the next decades.

ObjectiveTo examine the associations of partial and comprehensive smoke-free legislation with neonatal and infant mortality in Brazil using a quasi-experimental study design.DesignMonthly longitudinal (panel) ecological study from January 2000 to December 2016.SettingAll Brazilian municipalities (n=5565).ParticipantsInfant populations.InterventionSmoke-free legislation in effect in each municipality and month. Legislation was encoded as basic (allowing smoking areas), partial (segregated smoking rooms) or comprehensive (no smoking in public buildings). Associations were quantified by immediate step and longer term slope/trend changes in outcomes.Statistical analysesMunicipal-level linear fixed-effects regression models.Main outcomes measuresInfant and neonatal mortality.ResultsImplementation of partial smoke-free legislation was associated with a −3.3 % (95% CI −6.2% to −0.4%) step reduction in the municipal infant mortality rate, but no step change in neonatal mortality. Comprehensive smoke-free legislation implementation was associated with −5.2 % (95% CI −8.3% to −2.1%) and −3.4 % (95% CI −6.7% to −0.1%) step reductions in infant and neonatal mortality, respectively, and a −0.36 (95% CI −0.66 to−0.06) annual decline in the infant mortality rate. We estimated that had all smoke-free legislation introduced since 2004 been comprehensive, an additional 10 091 infant deaths (95% CI 1196 to 21 761) could have been averted.ConclusionsStrengthening smoke-free legislation in Brazil is associated with improvements in infant health outcomes—particularly under comprehensive legislation. Governments should accelerate implementation of comprehensive smoke-free legislation to protect infant health and achieve the United Nation’s Sustainable Development Goal three.

The complexity of the supply chain, with a multiplicity of suppliers and organizations imposes challenges to its traceability, affecting the possibility of making it more sustainable. The declaration of Greenhouse Gas (GHG) by companies has been a response to pressures from stakeholders and regulations towards a sustainable supply chain management (SSCM). However, there are still some setbacks. The verification process of the inventories is a time-consuming task and the utilization of traditional renewable energy certificates can cause distortions in the perception of those who are consuming renewable energy but are not buying certificates. A blockchain-based application could address those problems by tracking transparent records of product history. Therefore, we propose a blockchain-based artifact in the form of a level 1 architecture diagram to improve the Brazil GHG Protocol Program inventory process on scope 2, which includes indirect carbon emissions from consumption of purchased electricity, heat or steam; main supply chain components. Using the Design Science Research (DSR) approach, we combine knowledge from business participants and environmental experts to understand the Program problems, propose and evaluate the artifact, and analyze its contributions. We find out that not all actors may want greater transparency in the supply chain and that traditional certificate issuers are expected to resist, while a new generation of blockchain-based certificates challenges the more traditional competitors. Additionally, the economic benefits observed in implementing blockchain points out that the organization and resistance of the actors, therefore, could be as important as costs in the implementation of new technologies in supply chains. There are two main contributions from this study. First, it introduces the discussion on blockchain adoption in the GHG Protocol Program. Second, it uses DSR as an instrument to both articulate a solution around a theoretical artifact and make its potential contribution understandable for actors not familiar with blockchain technologies. We propose that future studies could: (i) produce a proof-of-concept or a pilot implementation of this artifact; (ii) include other actors from the energy and trading certificates chain on the artifact, such as energy producers, regulators and the Brazilian Electricity Trading Chamber (CCEE); (iii) reproduce the same proposition focusing on GHG Protocol’s scope 3.

Brazil has experienced a large decline in cigarette consumption in the last 25 years. However, the most recent annual reports from the tobacco industry market leader in Brazil did not show a decrease in its gross profits. This is particularly important because tobacco industry donations/sponsorships come directly from the industry's reported gross-profits and are used to subvert health policies. The aim of the present study was to estimate (i) tobacco industry's gross-profit from legal cigarettes sales, and (ii) all-cause smoking-attributable deaths (SADs) among current Brazilian smokers who consumed legal cigarettes in 2013. We collected information on prevalence of legal cigarette use, cigarette consumption, price per cigarette pack among individuals aged ≥ 35 years from the Global Adult Tobacco Survey, legal cigarettes sales (e.g., average costs and total volume of sales) provided by the Federal Secretariat of Revenues, and population mortality from the available vital statistics. With a gross-profit of US$1.378 billion (1.307–1.434) from sales of 54.6 billion sticks of cigarettes (53.4–55.5) to 8,424,510 smokers aged 35 years and older in Brazil in 2013, cumulative SADs were estimated at 96,012 (85,647–107,654) (around 34% of cumulative SADs also including current smoking of illegal cigarettes and past smoking), i.e., one SAD was equivalent to a gross-profit of US$14,352 (12,140–16,743). Our results revealed the association between sales of cigarettes, gross-profits, and deaths in Brazil. As tobacco industry donations/sponsorships originate from industry's gross profits, which, in turn, depend on cigarette sales, our findings may be useful for increasing “moral pressure” on individuals and institutions and help countries in stopping tobacco industry interference in health policies.

Objective To investigate factors associated with gynecology health professionals’ failure to perform clinical breast examinations (CBEs) during clinical visits. Methods A cross-sectional, interview-based survey was conducted in 2010 among women aged at least 18 years who had undergone a cervical smear in 2007 at primary-care units in Rio de Janeiro, Brazil. Binomial regression was used to generate prevalence ratios and absolute differences between visits for routine examinations or gynecologic complaints. Results Analyses included 982 women, of whom 182 (18.5%) did not have a CBE during their visit. Significant interactions were observed between age and primary reason for the visit: the prevalence ratio for no CBE during a visit for gynecologic complaints versus routine examination was 3.2 for women aged at least 40 years, and 1.3 among younger women ( P for multiplicative interaction = 0.001). Absolute differences were 6.4% and 18.5% for younger and older women, respectively ( P for additive interaction = 0.04). Conclusion A high proportion of eligible women do not undergo a CBE during cervical smear appointments at primary-care units in Rio de Janeiro, particularly older women presenting with gynecologic complaints. Understanding of health professionals’ barriers to following and implementing guidelines for secondary prevention of breast cancer is urgently needed.

Background Because of the uncertainty about the health impact of Electronic Cigarettes (EC), Brazil established strict regulatory requirements in 2009 that prohibit the sale, import, and advertising of them until a manufacturer can demonstrate that the devices are safe and/or effective as cessation aid. This paper examined self-reported: (1) EC awareness and ever-use; (2) correlates of awareness and ever-use. Methods Data were analyzed from the 2012/2013 (n=1,830) and 2016/2017 (n=1,828) waves of the International Tobacco Control Survey in Brazil.We calculated the differences over time in the proportion of individuals who have ever heard about ECs, and have ever tried an EC, stratified by smoking status. All estimates were adjusted for sampling weights and time in sample, taking also into consideration intraindividual correlation of data from participants observed at both waves. Moreover, a log-Binomial regression model was used to estimate the association between sociodemographic covariates and EC awareness (and ever-use). Results The proportion of EC awareness increased over time for both smokers (37.5% to 71.9%) and non-smokers (28.8% to 61.6%).The proportion of EC ever-use also increased over time for both smokers (7.8% to 18.3%) and non-smokers (1.1% to 2.2%). However, among EC users interviewed in 2016/2017 (n=218), the proportion of recent/regular EC use was very low (daily use, 2.5%; weekly use, 0.6%, monthly use, 2.6%; less than monthly, 20.7%; not all, 73.6%). Irrespective of the smoking status, EC awareness and ever-use were associated with younger ages, having higher income, and being better-educated. Conclusions Despite strict EC regulatory requirements in Brazil (i.e.,EC are de facto banned), this was not sufficient to prevent EC awareness and consumption among Brazilians. Our findings may help in the discussion about what can happen to Brazil´s strong reduction in the prevalence of ordinary cigarette smokers achieved in the last few years if the current EC regulatory regime is changed to allow smokers/non-smokers to have legal access to non-combusted sources of nicotine.

Background In Brazil the National Program for Tobacco Control is working for more than 30 years, and as consequence we can observe the reduction of smokers. The aim of this study is to evaluate the temporal trends in lung cancer mortality rates in Brazil observed from 1980 to 2015, and predicted estimates by 2040, by gender. Methods A time series study was carried out, using data from the Mortality Information System and information on the resident population obtained from the Brazilian Institute for Geography and Statistics. Crude, specific and age-standardized mortality rates per 100,000 men (and women) were calculated for each year between 1980 and 2015. Mortality predictions were made for the period 2016-2040 utilizing Nordpred program based on the period of 1980-2015, using the APC (age-period-cohort) model. Results While the decline in age-standardized lung cancer mortality rates has been most clearly observed for men since 2006, for women we will still experience a period of growth of these rates (2016-2025) followed by a period of stagnation (2026-2040) (Figure 1). Projections indicate that women aged 55-59 or younger will begin to experience a reduction in especific lung cancer mortality rates from 2021 onwards, but for women aged 75 or over these rates will continue to increase until 2040. [Figure 1] Conclusions The decline in lung cancer mortality among men since 2006, but not among women, reflects not only the different stages in the tobacco epidemic by gender, i.e., women started smoking after men, but also the successful implementation of a set of tobacco control actions in Brazil in the last 30 years. The last contributed to a strong reduction in the prevalence of smokers and, as a consequence, to a decline in current (and future) smoking-related morbidity and mortality.

Background In 2000, Brazil implemented a comprehensive ban on tobacco advertising (except point-of-sale), promotion, and sponsorship, including sponsorship by tobacco brands of national sporting and arts events, then in 2005 adding international sport events. However, a loophole in the law permits company names for sponsorship. This study examines whether this loophole has been exploited by the industry via Brazilians' awareness of tobacco company sponsorship of sporting and arts events between 2009 and 2016-17. Methods Data were from Waves 1 to 3 (2009, 2012-13, 2016-17) of the International Tobacco Control (ITC) Brazil Survey - a cohort survey of approximately 1200 adult smokers and 600 non-smokers in Rio de Janeiro, São Paulo, and Porto Alegre. At all three waves, respondents were asked whether they had seen or heard about (1) sport or sporting events and/or (2) music, theatre, art or fashion events sponsored by or connected with cigarette companies. At Waves 2 and 3, tobacco company name recognition was tested by asking respondents whether the following are tobacco companies: Souza Cruz, Nestle, and Pirelle. Data were analyzed using GEE logistic regression models. Results Awareness of a sport or sporting event sponsored by a cigarette company decreased between 2009 and 2016-17 among both smokers (from 8.7% to 4.7%; p=0.004) and non-smokers (from 11.8% to 5.7%; p=0.008). Awareness of an arts event sponsored by a tobacco company decreased among smokers (from 6.3% to 1.4%; p< .001), but not significantly among non-smokers (from 6.1% to 3.8%; p=0.235). Over 93% of smokers and non-smokers correctly stated that Souza Cruz is a tobacco company and over 98% correctly stated that Nestle and Pirelle are not. Conclusions Although Brazil has not specifically banned tobacco company sponsorship, public awareness of tobacco company sponsorship has decreased over 7 years, possibly suggesting that the industry has not (yet) taken advantage of the loophole.

Objectives. To estimate the proportions of illicit cigarette consumption in Brazil from 2012 to 2016, a period of sharp increases in cigarette taxes. Methods. We used an approach based on legal sales provided by the Secretariat of Federal Revenues and self-reported consumption data from an annually conducted telephone survey (VIGITEL) to estimate the changes over time in illegal cigarette use in Brazil. For that purpose, we also used available information on the proportion of illegal cigarette consumption from a nationwide household survey conducted in 2013 to calculate a constant proportion of underreporting from VIGITEL in relation to total consumption and sales in Brazil. Results. There was an increase in the estimated proportion of illicit cigarette use from 2012 to 2013 (from 28.6% to 32.3%), then a decrease from 2013 to 2014 (32.3% to 28.8%), and then a sustained trend of increase from 2014 to 2016 (28.8% to 42.8%). Conclusions. Novel and feasible approaches to estimate changes over time in the illegal market are important for helping the effective implementation of tobacco excise tax policy.

Abdominal obesity is even a stronger risk factor than overall obesity for noncommunicable chronic diseases. We examined the association between smoking and abdominal obesity among adolescents. Analyses were based on 38,813 subjects aged 15-17 years from the Study of Cardiovascular Risks in Adolescents (ERICA), a Brazilian school-based national survey. Abdominal obesity was defined considering waist circumference (WC) percentiles. Statistical analyses, stratified by sex, considered the sample complex design. Poisson regression with robust variance was used to estimate smoker-to-nonsmoker abdominal obesity prevalence ratio (PR), adjusting by sociodemographic and lifestyle variables. Higher prevalence of abdominal obesity was observed among adolescents who consumed >1 cigarettes/day, comparing to nonsmokers: considering WC >80th percentile, adjusted-PR for boys was 1.27 [95%CI:1.05,1.52] and, for girls, 1.09 [95%CI:1.00,1.19]; using the 90th percentile, adjusted-PR were 2.24 [95%CI:1.70,2.94] and 1.27 [95%CI:1.12,1.46], respectively for male and female adolescents. Our findings suggest a positive association between cigarette consumption and the prevalence of abdominal obesity, for both boys and girls. Although other studies had found this association in adults, our study contributes to this discussion by assessing it in adolescents using a nationwide representative sample of medium and large municipalities.

Background Cigarette smoking prevalence is declining, however, other tobacco products have emerged recently, such as electronic cigarettes (e-cigarettes) and narghile (hookah/shisha/waterpipe). Narghile sales are not prohibited in Brazil, but e-cigarettes are. Accurate estimates of such products are key for proper monitoring and control. Objective To describe the prevalence of e-cigarettes and narghile use and to investigate whether sociodemographic characteristics of individuals who are using these products differ from those who are using manufactured cigarettes. Methods Using a nationally representative sample survey of Brazilians aged 12–65 years in 2015, we estimated the prevalence rates of each tobacco products within the last 12-months, stratified by macro-region, municipality size, sex-at-birth, sexual orientation, color/race, age-group, and monthly income. Multivariable logistic models were fitted to understand determinants of each tobacco product use, considering the complex sample design. Results E-cigarette, narghile, and cigarette prevalence rates were estimated at 0.43%, 1.65% and 15.35%, respectively, corresponding to around 0.6million e-cigarette users, 2.5 million narghile users and 23.5 million cigarette users. Non-heterosexual individuals were a most-at-risk group for both e-cigarette/narghile and cigarette use. Despite similarities, e-cigarette/narghile users were younger and had higher socioeconomic status than cigarette users. Additional analyses showed that recent cigarette use seems to be more associated with e-cigarette/narghile use among youth than among adults. Conclusions Our findings may provide valuable information about e-cigarette/narghile use in Brazil. Prevention strategies targeted to youth to both narghile and e-cigarettes use should be implemented together, which might be one strategy to prevent the emergency of a new generation of smokers in Brazil.

OBJECTIVE To estimate the prevalences of tobacco use, tobacco experimentation, and frequent smoking among Brazilian adolescents. METHODS We evaluated participants of the cross-sectional, nation-wide, school-based Study of Cardiovascular Risks in Adolescents (ERICA), which included 12- to 17-year-old adolescents from municipalities of over 100 thousand inhabitants. The study sample had a clustered, stratified design and was representative of the whole country, its geographical regions, and all 27 state capitals. The information was obtained with self-administered questionnaires. Tobacco experimentation was defined as having tried cigarettes at least once in life. Adolescents who had smoked on at least one day over the previous 30 days were considered current cigarette smokers. Having smoked cigarettes for at least seven consecutive days was an indicator for regular consumption of tobacco. Considering the complex sampling design, prevalences and 95% confidence intervals were estimated according to sociodemographic and socio-environmental characteristics. RESULTS We evaluated 74,589 adolescents. Among these, 18.5% (95%CI 17.7-19.4) had smoked at least once in life, 5.7% (95%CI 5.3-6.2) smoked at the time of the research, and 2.5% (95%CI 2.2-2.8) smoked often. Adolescents aged 15 to 17 years had higher prevalences for all indicators than those aged 12 to 14 years. The prevalences did not differ significantly between sexes. The highest prevalences were found in the South region and the lowest ones, in the Northeast region. Regardless of sex, the prevalences were found to be higher for adolescents who had had paid jobs, who lived with only one parent, and who reported having been in contact with smokers either inside or outside their homes. Female public school adolescents were found to smoke more than the ones from private schools. CONCLUSIONS Tobacco use among adolescents is still a challenge. Intending to reduce the prevalence of tobacco use among young people, especially the ones under socioeconomic vulnerability conditions, Brazil must consolidate and increase effective public health care measures. RESUMO OBJETIVO Estimar as prevalências de tabagismo, experimentação e fumo frequente em adolescentes brasileiros. MÉTODOS Foram avaliados os participantes do Estudo de Riscos Cardiovasculares em Adolescentes (ERICA), estudo transversal de base escolar e abrangência nacional. Participaram adolescentes de 12 a 17 anos de municípios com mais de 100 mil habitantes. A amostra foi estratificada e conglomerada e tem representatividade nacional, regional e para as 27 capitais. As informações foram obtidas usando-se questionário autopreenchível. Experimentação foi definida como: ter experimentado cigarros alguma vez na vida. Foram considerados fumantes atuais de cigarros aqueles que fumaram pelo menos um dia nos últimos 30 dias. Utilizou-se como indicador de uso frequente de tabaco ter fumado cigarros por pelo menos sete dias seguidos. Considerando-se o desenho complexo da amostra, prevalências e intervalos de confiança de 95% foram estimados segundo características sociodemográficas e socioambientais. RESULTADOS Foram avaliados 74.589 adolescentes; dentre esses, 18,5% (IC95% 17,7-19,4) fumaram pelo menos uma vez na vida, 5,7% (IC95% 5,3-6,2) fumavam no momento da pesquisa e 2,5% (IC95% 2,2-2,8) fumavam com frequência. Adolescentes de 15 a 17 anos tiveram prevalências mais elevadas de todos os indicadores comparados aos de 12 a 14 anos. As prevalências não apresentaram diferenças significativas entre sexos. Maiores prevalências foram observadas na região Sul e menores na região Nordeste. Independentemente de sexo, as prevalências foram maiores para adolescentes que tinham tido trabalho remunerado, nos que não moravam com os dois pais e que referiram ter tido contato com fumante em casa ou fora. Adolescentes do sexo feminino de escolas públicas fumavam mais do que as de escolas privadas. CONCLUSÕES O tabagismo entre adolescentes ainda é um desafio. Visando a redução da prevalência de tabagismo entre jovens, em especial os que se encontram em situação de vulnerabilidade socioeconômica, o Brasil deve consolidar e ampliar medidas de saúde pública efetivas.

Between 2008 and 2013, Brazil experienced a large decline in smoking prevalence, with an innovative round of aversive pictorial health warnings implemented on cigarette packs and at points of sale in 2009. The objective of this study was to examine changes over time in the distribution of quitting attempts and self-reported thoughts about quitting due to health warnings among current smokers. We conducted a pre-post study to evaluate data from two nationally-representative surveys conducted in 2008 and 2013. Responses to questions on smokers' quitting attempts in the last year (yes vs. no) and whether health warnings led them to think about quitting in the last month (yes vs. no) were combined into four categories, for which the distribution of the Brazilian smoking population by year was estimated. A multinomial model was used to obtain proportions for each category, adjusted by socio-demographic variables and nicotine dependence. The proportion of smokers who reported making a quitting attempt in the last year and stated that health warnings led them think about quitting smoking statistically increased over time (from 30.0% to 33.1%; p-value=0.010). The percentage of those who answered "no" to these two questions also increased over time (from 23.5% to 32.9%; p-value≤0.001). These findings suggest that innovative warnings introduced in Brazil likely served as a "reminder" for continuing to think about cessation among those who attempted to quit in the last year. These warnings may have also triggered more avoidance of thinking about their contents than the previous warnings, which some studies have found to promote subsequent quitting activity.

Ensaio clínico randomizado conduzido para avaliar efetividades dos métodos de abordagem cognitivo-comportamental e terapia de reposição de nicotina com adesivos para cessação de fumar. Participaram 1.199 voluntários, adultos, do Município do Rio de Janeiro, Brasil, alocados aleatoriamente em dez grupos: aconselhamento breve (GB) intensivo de 1 ou 2 sessões (G1-G2) e de 3 ou 4 sessões (G3-G4), com/sem terapia de reposição de nicotina. Proporções de abstinência foram estimadas durante os 12 meses. Essas proporções nos grupos sem adesivo foram 20% (GB), 17% (G1-G2) e 23% (G3-G4). Nos grupos com adesivo foram aproximadamente 30% (GBA), 34% (G1A-G2A) e 33% (G3A-G4A). Após ajuste múltiplo, as razões de proporção de abstinência parecem seguir padrão consistente com efeito "dose-resposta": comparadas com GB foram 0,85 (G1-G2); 1,13 (G3-G4); 1,51 (GBA); 1,66 (G1A-G2A) e 1,75 (G3A-G4A) (p < 0,05). Os resultados sugerem que acrescer terapia de reposição de nicotina aumenta a proporção de abstinência na cessação. Padrões tipo "dose-resposta" encontrados nas razões de proporção de abstinência sugerem que a abordagem cognitivo-comportamental pode ser uma opção razoável no tratamento do fumante. Randomized clinical trial carried out to investigate the effectiveness of the cognitive-behavioral approach and nicotine replacement therapy with nicotine patches for smoking cessation. Participated 1,199 adults, volunteers, in Rio de Janeiro, Brazil, randomly assigned to 10 different groups: intensive brief counseling group (GB), with 1 or 2 sessions (G1-G2), and with 3 or 4 sessions (G3-G4), with/without nicotine replacement therapy (NRT). Abstinence proportions were estimated during 12 months. These proportions among participants not assigned to NRT were 20% (GB), 17% (G1-G2), and 23% (G3-G4); and among assigned NRT groups were 30% (GBA), 34% (G1A-G2A), and 33% (G3A-G4A). After multiple adjustments, the abstinence proportions ratios seemed to follow a "dose-response" pattern: compared to GB, the ratios were 0.85 (G1-G2), 1.13 (G3-G4), 1.51 (GBA), 1.66 (G1A-G2A), and 1.75 (G3A-G4A). The results suggest that use of NRT increases the abstinence proportion for cessation. The "dose-response" pattern suggests that cognitive-behaviorial could be the reasonable option in the smoking cessation therapy.

This paper concerns the prevalence of intimate partner violence in 15 State capital cities and the Federal District of Brazil. A population-based multi-stage survey in 2002/2003 involved 6,760 15-69-year-old women (respondents). Using the Conflict Tactics Scales Form R, the overall prevalence of psychological aggression and "minor" and severe physical abuse within couples was 78.3%, 21.5%, and 12.9%, respectively. Prevalence rates varied distinctively between cities. For instance, total physical abuse ranged from 13.2% to 34.8%. On the whole, prevalence was higher in the North and Northeast cities than in the Southeast, South, and Central West. Also, all types of intimate partner violence were more frequent in couples including women who were younger (< 25 years) and had less schooling (< 8 years). After stratifying by gender, although women tended to perpetrate at least one act of physical abuse more often, scores were consistently higher among male partners who were perpetrators. The results are compared to international findings. Regional, demographic, and gender differentials are discussed in light of the growing role of the Brazilian health sector in relation to intimate partner violence. Este artigo apresenta a prevalência de violência entre parceiros íntimos em 15 capitais brasileiras e no Distrito Federal. Um inquérito de base-populacional em múltiplos estágios foi realizado em 2002/2003, envolvendo 6.760 mulheres (respondentes) de 15 a 69 anos. Usando o instrumento Conflict Tactics Scales Formulário R, a prevalência global de agressão psicológica, abuso físico "menor" e grave no casal foi de 78,3%, 21,5% e 12,9%, respectivamente. Prevalências variaram distintamente entre as cidades, o abuso físico total indo, por exemplo, de 13,2% a 34,8%. Como um todo, as prevalências foram mais altas nas cidades do Norte/Nordeste do que nas do Sudeste/Sul/Centro-oeste. Também, todos os tipos de violência entre parceiros íntimos foram mais freqüentes entre casais formados por mulheres jovens (< 25 anos) e com menos escolaridade (< 8 anos). Desagregando por gênero, ainda que mulheres tendessem a perpetrar pelo menos um item de abuso físico mais amiúde, os escores foram consistentemente mais altos entre parceiros positivos. Os resultados são comparados à literatura externa. Os diferenciais regionais, demográficos e de gênero são discutidos à luz da crescente responsabilidade do setor saúde em relação à violência entre parceiros íntimos.

Background Brazil has experienced a large decline in smoking prevalence due to several tobacco control policies that were implemented in the past 25 years. Previous population-wide studies found a consistent reduction over time in daily cigarette consumption among all socioeconomic groups. Objective To examine changes between 2008 and 2013 in tobacco behaviours and health-related conditions of smokers. Methods We used data obtained from two nationally-representative surveys conducted in 2008 and 2013 to estimate the prevalence of self-reported psychological and physical morbidity, and nicotine dependence markers, stratified by gender and sociodemographic groups. Generalised linear models were used to understand whether absolute differences in prevalence rates over time differed by categories of selected variables. Results For both genders, as smoking prevalence declined in Brazil, there has been an increase in the proportion of ever smokers who have quit. In addition, remaining smokers seem to be making more quitting attempts. Among men with low educational level or younger than 25 years-old, as compared to their counterparts, cessation rate showed an even greater increase over time. Moreover, the proportion of light smokers, which represent the vast majority of smokers, did not decrease. The percentage of poor health-conditions among remaining smokers nevertheless increased, particularly among women, which can make future cessation more challenging. Conclusions In Brazil, quitting rate is increasing, thus suggesting that tobacco control interventions implemented in Brazil in the past years seem to be effectively reaching the smoking population. This is strong evidence against the ‘hardening hypothesis’, which posits that remaining smokers decrease their willingness and ability to quit.

Introduction Numerous studies from high-income countries document the causal relationship between cigarette smoking during pregnancy and adverse maternal and child health (MCH) outcomes. Less research has been conducted in low and middle income countries, but a burgeoning literature can be found for Brazil. Methods We review Brazilian studies of the prevalence of maternal smoking, the relative risk of smoking-attributable adverse MCH outcomes, and present new estimates for these outcomes, using the attributable fraction method. Results We found that Brazilian studies of the relative risks of smoking-attributable adverse MCH outcomes were broadly consistent with previous reviews. Based on a comparison of maternal smoking over time, smoking during pregnancy has declined by about 50% over the last 20 years in Brazil. For 2008, we estimate that 5,352 cases of spontaneous abortion, 10,929 cases of preterm birth, 20,717 cases of low birth weight, and 29 cases of sudden infant death syndrome are attributable to maternal smoking. Between 1989 and 2008, the percent of smoking-attributable adverse MCH outcomes in Brazil was at least halved. Conclusions The results show that over a 20-year period, during which Brazil implemented numerous effective tobacco control measures, the country experienced a dramatic decrease in both maternal smoking prevalence and smoking-attributable adverse MCH outcomes. Countries that implement effective tobacco control measures can expect to reduce both maternal smoking and adverse MCH outcomes, thereby improving the public health.

Objective The use of pictorial warning labels on cigarette packages is one of the provisions included in the first ever global health treaty by the World Health Organization against the tobacco epidemic. There is substantial evidence demonstrating the effectiveness of graphic health warning labels on intention to quit, thoughts about health risks and engaging in cessation behaviors. However, studies that address the implicit emotional drives evoked by such warnings are still underexplored. Here, we provide experimental data for the use of pictorial health warnings as a reliable strategy for tobacco control. Methods Experiment 1 pre-tested nineteen prototypes of pictorial warnings to screen for their emotional impact. Participants (n = 338) were young adults balanced in gender, smoking status and education. Experiment 2 (n = 63) tested pictorial warnings (ten) that were stamped on packs. We employed an innovative set-up to investigate the impact of the warnings on the ordinary attitude of packs’ manipulation, and quantified judgments of warnings’ emotional strength and efficacy against smoking. Findings Experiment 1 revealed that women judged the warning prototypes as more aversive than men, and smokers judged them more aversive than non-smokers. Participants with lower education judged the prototypes more aversive than participants with higher education. Experiment 2 showed that stamped warnings antagonized the appeal of the brands by imposing a cost to manipulate the cigarette packs, especially for smokers. Additionally, participants’ judgments revealed that the more aversive a warning, the more it is perceived as effective against smoking. Conclusions Health warning labels are one of the key components of the integrated approach to control the global tobacco epidemic. The evidence presented in this study adds to the understanding of how implicit responses to pictorial warnings may contribute to behavioral change.

The assessment of temporal differences in cigarette consumption may help in understanding whether a smoking population is becoming more resistant to quitting over time. We calculated absolute differences in average cigarette consumption, stratified by birth cohort and age group. Data were obtained from random samples from two Brazilian national household surveys (1989, N = 12,782; 2008, N = 6,675). A linear regression model was used to adjust estimates by gender, educational level, and place of residence. Birth cohort analysis found that average daily cigarette consumption increased for individuals born after 1964 and decreased for those born before 1955 (adjusted p-values < 0.001). Age-specific analysis found that the remaining smoking population aged 64 years-old or less decreased cigarette consumption between 1989 and 2008 (adjusted p-values < 0.001). Brazil's anti-tobacco policy changes and rapid economic growth may be principally related to temporal changes in cigarette consumption for most age groups, rather than to a change in the relationship between age and cigarette consumption. A avaliação temporal das mudanças no consumo de cigarros pode ajudar a entender se os fumantes estão se tornando mais resistentes à cessação. Calcularam-se as diferenças absolutas no consumo médio de cigarros, estratificadas por coorte de nascimento e faixa etária. Utilizaram-se dados provenientes de dois inquéritos domiciliares nacionais brasileiros (1989, N = 12.782; 2008, N = 6.675). Um modelo de regressão linear foi usado para ajustar as diferenças por sexo, escolaridade e residência. A análise por coorte de nascimento mostrou que o uso de cigarros diários aumentou entre os indivíduos nascidos após 1964 e diminuiu entre aqueles nascidos antes de 1955 (valores de p ajustados < 0,001). A análise por faixa etária mostrou que a população remanescente de fumantes com menos de 65 anos reduziu o uso de cigarros entre 1989 e 2008 (valores de p ajustados < 0,001). Mudanças nas políticas antitabaco e o rápido crescimento econômico do Brasil podem estar preferencialmente relacionados a mudanças temporais no consumo de cigarros na maioria dos grupos etários, ao invés de uma mudança na associação entre idade e consumo de cigarro.

The Global Adult Tobacco Survey (GATS) was conducted in Brazil to provide data on tobacco use in order to monitor the WHO FCTC implementation in the country. It was carried out in 2008 using an international standardized methodology. The instrument included questions about tobacco use prevalence, cessation, secondhand smoke, knowledge, attitudes, media and advertising. Weighted analysis was used to obtain estimates. A total of 39,425 interviews were conducted. The prevalence of current tobacco use was 17.5%, (22.0%, men; 13.3%, women). The majority of users were smokers (17.2%) and their percentage was higher in rural areas (20.4%) than in urban areas (16.6%). About 20% of individuals reported having been exposed to tobacco smoke in public places. Over 70% of respondents said they had noticed anti-smoking information in several media and around 65% of smokers said they had considered quitting because of warning labels. About 30% of respondents had noticed cigarette advertising at selling points and 96% recognized tobacco use as a risk factor for serious diseases. Data in this report can be used as baseline for evaluation of new tobacco control approaches in Brazil, vis-à-vis WHO FCTC demand reduction measures.

According to the World Health Organization, smoking is an important cause of death worldwide. To encourage smoking cessation, persuasive messages can be used to raise smokers' risk perception. This article discusses challenges and solutions in designing a study to evaluate the effect of two different communication strategies ("gains from quitting" vs. "losses from continuing smoking") in encouraging calls to a quitline. The authors conducted an intervention study in two subway stations for 4 weeks, considering only 1 strategy per station. Large posters containing non-age-specific images and texts, on the basis of the theme"shortness of breath," were displayed on central dividing columns on the boarding platforms. Call rates from the selected stations, and respective rate ratios, overall and per study week, were calculated. Passengers who were smokers, exposed to the positive-content message, called on average 1.7 times more often than did those exposed to the negative-content message (p = .01). Moreover, call rate ratios did not decline over the 4 weeks of the study (p = .40). The effectiveness findings suggest that antismoking campaigns could use positive-content messages in order to recruit a larger smoker population. The proposed methodology can also be used to evaluate effectiveness of messages for "capturing" individuals with other health problems (e.g., alcohol abuse), thereby increasing its potential impact.

David Levy and colleagues use the SimSmoke model to estimate the effect of Brazil's recent stronger tobacco control policies on smoking prevalence and associated premature mortality, and the effect that additional policies may have., Background Brazil has reduced its smoking rate by about 50% in the last 20 y. During that time period, strong tobacco control policies were implemented. This paper estimates the effect of these stricter policies on smoking prevalence and associated premature mortality, and the effect that additional policies may have. Methods and Findings The model was developed using the SimSmoke tobacco control policy model. Using policy, population, and smoking data for Brazil, the model assesses the effect on premature deaths of cigarette taxes, smoke-free air laws, mass media campaigns, marketing restrictions, packaging requirements, cessation treatment programs, and youth access restrictions. We estimate the effect of past policies relative to a counterfactual of policies kept to 1989 levels, and the effect of stricter future policies. Male and female smoking prevalence in Brazil have fallen by about half since 1989, which represents a 46% (lower and upper bounds: 28%–66%) relative reduction compared to the 2010 prevalence under the counterfactual scenario of policies held to 1989 levels. Almost half of that 46% reduction is explained by price increases, 14% by smoke-free air laws, 14% by marketing restrictions, 8% by health warnings, 6% by mass media campaigns, and 10% by cessation treatment programs. As a result of the past policies, a total of almost 420,000 (260,000–715,000) deaths had been averted by 2010, increasing to almost 7 million (4.5 million–10.3 million) deaths projected by 2050. Comparing future implementation of a set of stricter policies to a scenario with 2010 policies held constant, smoking prevalence by 2050 could be reduced by another 39% (29%–54%), and 1.3 million (0.9 million–2.0 million) out of 9 million future premature deaths could be averted. Conclusions Brazil provides one of the outstanding public health success stories in reducing deaths due to smoking, and serves as a model for other low and middle income nations. However, a set of stricter policies could further reduce smoking and save many additional lives. Please see later in the article for the Editors' Summary, Editors' Summary Background Tobacco kills up to half its users—more than 5 million smokers die every year from tobacco-related causes. It also kills more than half a million non-smokers annually who have been exposed to second-hand smoke. If current trends continue, annual tobacco-related deaths could increase to more than 8 million by 2030. In response to this global tobacco epidemic, the World Health Organization has developed an international instrument for tobacco control called the Framework Convention on Tobacco Control (FCTC). Since it came into force in February 2005, 176 countries have become parties to the FCTC. As such, they agree to implement comprehensive bans on tobacco advertizing, promotion, and sponsorship; to ban misleading and deceptive terms on tobacco packaging; to protect people from exposure to cigarette smoke in public spaces and indoor workplaces; to implement tax policies aimed at reducing tobacco consumption; and to combat illicit trade in tobacco products. Why Was This Study Done? Brazil has played a pioneering role in providing support for tobacco control measures in low and middle income countries. It introduced its first cigarette-specific tax in 1990 and, in 1996, it placed the first warnings on cigarette packages and introduced smoke-free air laws. Many of these measures have subsequently been strengthened. Over the same period, the prevalence of smoking among adults (the proportion of the population that smokes) has halved in Brazil, falling from 34.8% in 1989 to 18.5% in 2008. But did the introduction of tobacco control policies contribute to this decline, and if so, which were the most effective policies? In this study, the researchers use a computational model called the SimSmoke tobacco control policy model to investigate this question and to examine the possible effect of introducing additional control policies consistent with the FCTC, which Brazil has been a party to since 2006. What Did the Researchers Do and Find? The researchers developed Brazil SimSmoke by incorporating policy, population, and smoking data for Brazil into the SimSmoke simulation model; Brazil SimSmoke estimates smoking prevalence and smoking-attributable deaths from 1989 forwards. They then compared smoking prevalences and smoking-attributable deaths estimated by Brazil SimSmoke for 2010 with and without the inclusion of the tobacco control policies that were introduced between 1989 and 2010. The model estimated that the smoking prevalence in Brazil in 2010 was reduced by 46% by the introduction of tobacco control measures. Almost half of this reduction was explained by price increases, 14% by smoke-free laws, 14% by marketing restrictions, 8% by health warnings, 6% by anti-smoking media campaigns, and 10% by cessation treatment programs. Moreover, as a result of past policies, the model estimated that almost 420,000 tobacco-related deaths had been averted by 2010 and that almost 7 million deaths will have been averted by 2050. Finally, using the model to compare the effects of a scenario that includes stricter policies (for example, an increase in tobacco tax) with a scenario that includes the 2010 policies only, indicated that stricter control policies would reduce the estimated smoking prevalence by an extra 39% between 2010 and 2050 and avert about 1.3 million additional premature deaths. What Do These Findings Mean? These findings indicate that the introduction of tobacco control policies has been a critical factor in the rapid decline in smoking prevalence in Brazil over the past 20 years. They also suggest that the introduction of stricter policies that are fully consistent with the FCTC has the potential to reduce the prevalence of smoking further and save many additional lives. Although the reduction in smoking prevalence in Brazil between 1989 and 2010 predicted by the Brazil SimSmoke model is close to the recorded reduction over that period, these findings need to be interpreted with caution because of the many assumptions incorporated in the model. Moreover, the accuracy of the model's predictions depends on the accuracy of the data fed into it, some of which was obtained from other countries and may not accurately reflect the situation in Brazil. Importantly, however, these findings show that, even for a middle income nation, reducing tobacco use is a “winnable battle” that carries huge dividends in terms of reducing illness and death without requiring unlimited resources. Additional Information Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001336. The World Health Organization provides information about the dangers of tobacco (in several languages), about the Framework Convention on Tobacco Control, and about tobacco control in Brazil The Framework Convention Alliance provides more information about the FCTC The Brazilian National Cancer Institute (INCA) provides information on tobacco control policies in Brazil; additional information about tobacco control laws in Brazil is available on the Tobacco Control Laws interactive website, which provides information about tobacco control legislation worldwide More information on the SimSmoke model of tobacco control policies is available in document or slideshow form SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking

O consumo de outros produtos de tabaco fumado vem crescendo no mundo pelo fato de serem socialmente aceitos e pela crença generalizada de causarem menos dano à saúde do fumante, ajudados também pela globalização das indústrias do tabaco. Recentemente, no Brasil, os profissionais envolvidos com o controle do tabaco atentaram para a importância de monitorar este consumo. Analisaram-se os dados provenientes do Vigescola conduzido, em 2009, em três cidades. As prevalências de uso de outros produtos de tabaco fumado nos últimos 30 dias entre os escolares de 13 a 15 anos foram elevadas em Campo Grande (18,3%; IC95%: 14,4%-22,9%) e São Paulo (22,1%; IC95%: 19,0%-25,6%). Em Vitória, a prevalência encontrada não foi tão alta quanto às demais (4,3%; IC95%: 3,1%-5,7%). Não houve diferenças estatisticamente significativas por sexo. Entre os fumantes, o narguilé se destacou por seu alto consumo. É possível que a queda da prevalência de fumantes de cigarro observada nos últimos anos no Brasil tenha favorecido o uso de outros produtos do tabaco como o narguilé, sobretudo entre estudantes. Smoking of non-cigarette tobacco products is increasing worldwide because of their high social acceptability, misperceptions about their purported harmlessness, and globalization of the tobacco industry. In Brazil, tobacco control experts have recently focused their attention on the importance of monitoring the use of such products. We analyzed data from the Global Youth Tobacco Survey (2009) in three cities. Prevalence rates of non-cigarette tobacco smoking in the previous 30 days among students 13 to 15 years of age were high in Campo Grande (18.3%; 95%CI: 14.4%-22.9%) and São Paulo (22.1%; 95%CI: 19.0%-25.6%), while Vitória showed comparatively lower prevalence (4.3%; 95%CI: 3.1%-5.7%). No statistical differences were observed in prevalence rates according to gender. Water pipes were the most frequent form of non-cigarette tobacco smoking. The decline in cigarette smoking in Brazil in recent years may have contributed to other forms of tobacco smoking, especially among students.

Objective To evaluate the differences in cigarette smoking prevalence rates in Brazil between 1989 and 2008. Methodology We calculated absolute and relative differences in smoking prevalences, overall and stratified by gender, age, place of residence, educational level and birth cohort. Data were obtained from random samples from two National Household Surveys (1989,n = 39,969; 2008,n = 38,461). GLM models were specified to obtain estimates and assess whether differences in proportions of smokers differed by categories of the stratification variables. Results Adjusted absolute and relative differences in smoking prevalence rates between 1989 and 2008 were, respectively, − 12.4% and − 41.0%. Individuals aged 15–34 years and those with 9 or more years of education presented larger relative declines than their counterparts (ps ≤ 0.001). After stratification by birth cohort, men presented larger reductions than women, only in the absolute scale (ps ≤ 0.001), with the exception of the youngest birth cohort (i.e.,1965–1974). Conclusions In Brazil, several tobacco control measures have been adopted since 1986, in particular increasing taxation of tobacco products and strong health warnings, which may have contributed to the marked decline in smoking prevalence. It is important to understand the evolution of the tobacco epidemic to propose new actions to prevent initiation and encourage cessation among those who started/continued smoking.

Criatividade e inovação das estratégias de recrutamento de fumantes são fundamentais para aprimorar as ações de controle do tabagismo. Atualmente, no Brasil, por meio das imagens de advertência presentes nos maços de cigarros, há uma divulgação permanente e intensa de mensagens que provocam sentimentos de perda associados ao tabagismo, os quais são importantes para estimular o acesso a linhas telefônicas de apoio à cessação. Comparou-se a taxa de ligação para aconselhamento telefônico observada após introdução de nova estratégia de recrutamento reativo focada no tema "fumar é perder fôlego" e adaptada ao cenário do metrô do Rio de Janeiro, com as taxas verificadas para duas outras estratégias reativas existentes. Independentemente da faixa etária, houve maior resposta para a nova estratégia proposta. Apesar da grande sensibilização, no Brasil, quanto aos malefícios do tabaco, novos formatos de comunicação abordando temas de relevância pessoal podem aumentar a quantidade e diversidade da população de fumantes recrutada para serviços de aconselhamento telefônico de suporte à cessação. Creative and innovative strategies to recruit smokers are essential for improving tobacco control activities. Currently in Brazil, through health warning messages on cigarette packs, there is a permanent and intense spread of messages that provoke feelings of loss associated with smoking, which is important to encourage access to smoking quitlines. The study analyzed the call rate for telephone counseling after introducing a new strategy for reactive recruitment focused on the theme "smoking causes shortness of breath", adapted to the subway setting in Rio de Janeiro, as compared to the rates for two existing reactive strategies. Regardless of age bracket, there was a higher response to the new proposed strategy. Despite the major awareness-raising in Brazil concerning the ills of tobacco, new communications formats approaching personally relevant themes can increase the number and range of smokers recruited for telephone counseling to support cessation.

Tobacco is a major public health issue. It is estimated that the annual deaths attributable to smoking are approximately 5 million and will double in 2025. Brazil has one of the highest smoking populations in the world (approximately 24 million adult smokers), thus representing an important public health concern. In 2008, we began a pragmatic intervention study aimed at promoting the use of a telephone counselling service for people wishing to stop smoking. The intervention used large (220 400 cm) posters placed at eye level on the central dividing columns of the boarding platforms of two subway stations in Rio de Janeiro, Brazil. We were keen to show not only the adverse effects of continuing to smoke (Photo 1), but also the gains that can be achieved by quitting smoking (Photo 2). The study specifically aimed to assess whether the profile of individuals calling the quit line differed by the two stimuli displayed at subway stations, i.e. ‘gains from quitting’ or ‘losses from continuing’ to smoke. The posters focused on ‘shortness of breath’ as a key symptom of continuing to smoke because this is something individuals are aware of and a symptom that can change over a shorttime frame. It is a symptom that affects younger and older smokers, as well as women and men, and would be potentially notable for subway users who have to ascent a lot of steps. The posters were designed with photos of real subway stairs in the background showing someone struggling to breathe on them or ascending without problems. The posters attracted the attention of our potential target audience (Photos 3 and 4). The school children were hopefully too young to be smoking and requiring a quit line (Photo 5), but these images may have informed them about the adverse consequences of starting to smoke.

Smoking is a worldwide public health problem, and various communication strategies aimed at its cessation have been used. The objective of this paper was to explore differences over time of two communication strategies (gain-framed versus loss-framed) in encouraging calls to a Quitline, according to smoker's degree of dependence. A study was conducted for four weeks among passengers of two selected subway stations in the city of Rio de Janeiro-Brazil (N(average) = 12,500 passengers a day per station). The interventions - large posters with images and text based on central theme "shortness-of-breath" - also contained the Quitline number. Call rate differences between the strategies, overall and specific per study week, were calculated. Light smokers exposed to the positive-content message called on average 2.2 times more often than those exposed to the negative-content message (p < 0.001). The absolute difference in call rates decreased after the first week of the study (p for the additive interaction between intervention and study week, 0.02). For heavy smokers, no differences between the two stations were observed. Additive interaction was found between type of smoker - light or heavy - and intervention (p = 0.02). The results suggest that short-term positive-content campaigns based on issues pertaining to individuals' daily routine could be effective in capturing light smokers. These results may have considerable public health impact, as the prevalence of less dependent smokers is much higher than that of heavier smokers.

Statisticians are accustomed to processing numerical, ordinal or nominal data. In many circumstances, such as socio-economic, epidemiologic sample surveys and documentary data bases, this data is juxtaposed with textual data (for example, responses to open questions in surveys). This article presents a series of language-independent procedures based upon applying multivariate techniques (such as correspondence analysis and clustering) to sets of generalized lexical profiles. The generalized lexical profile of a text is a vector whose components are the frequencies of each word (graphical form) or ‘repeated segment’ (sequence of words appearing with a significant frequency in the text). The processing of such large (and often sparse) vectors and matrices requires special algorithms. The main outputs are the following: (1) printouts of the characteristic words and characteristic responses for each category of respondent (these categories are generally derived from available nominal variables); (2) graphical displays of the proximities between words or segments and categories of respondents; (3) when analysing a combination of several texts: graphical displays of proximities between words or segments and each text, or between words or segments and groupings of texts. The systematic use of ‘repeated segments’ provides a valuable help in interpreting the results from a semantic point of view.

It is important to stimulate smokers to acquire some level of risk perception associated with their current behavior in order to motivate smoking cessation. The present article attempts to understand how the content of short-term fear appeal government tobacco messages may interact with different levels of daily cigarette consumption in order to affect smokers' vulnerabilities, expressed by self-perceived health status. A Poisson model was used to estimate the prevalence ratio of fair or poor self-perceived health status (FPHS) according to daily cigarette consumption. We also calculated the proportions of smokers who stated that selected health warning pictures on cigarette packets encourage people to quit smoking, stratified by self-perceived health status and daily cigarette consumption. The proportion of smokers with FPHS was 25% higher among those who smoked > 20 cigarettes/day (p = 0.01). Among smokers with FPHS, heavy smokers showed the highest proportions of responses in favor of selected warning pictures most closely related to losses in ordinary daily living, such as shortness of breath and being bothered by cigarette addiction. Short-term loss-framed tobacco control messages seem to have raised awareness of vulnerability among heavier smokers.

É fundamental compreender que os fumantes não são iguais e que determinados fumantes precisam ser conquistados como "potenciais clientes" de programas de intervenção voltados às suas necessidades específicas. O objetivo do estudo foi comparar os perfis de fumantes recrutados para um estudo de intervenção para cessação de fumar com os da população geral de fumantes no município do Rio de Janeiro, nos anos 2002-2003. As heterogeneidades encontradas indicam que diferentes estratégias de captação associadas às intervenções existentes devem ser elaboradas para motivar o maior e mais diversificado número possível de indivíduos elegíveis. It is essential to understand that not all smokers are equal, and that certain smokers need to be "won" as "potential clients" of an intervention program aimed at addressing their specific needs. Thus, the objective of the article was to compare the profile of smokers recruited for a smoking cessation clinical trial with that of the general smoking population in the city of Rio de Janeiro, in the years 2002-2003. Heterogeneities observed may indicate the need for adopting different recruitment strategies, associated with the existing interventions, to encourage as many and as diverse eligible individuals as possible.

This paper reviews published articles describing several instruments used currently to "capture" the attention of smokers for quit-smoking interventions and emphasizes the distinction between the strategies used to reach eligible individuals and those used to recruit them for the proposed smoking cessation intervention. The search for articles was conducted using MEDLINE, PsychARTICLE, and LILACS. Key words for the search included recruitment, enrollment, reach, smoking cessation, quitline, and helpline mentioned in the abstracts and titles of the articles. Articles published in English, Portuguese, and Spanish through November 2006 that emphasized capture instruments related to different populations and specific interventions were included in this review. Twenty-nine studies met the inclusion criteria. Studies that used active and mixed strategies reached, on average, a smaller and less diverse possible number of eligible individuals and had greater participation proportions than those that used reactive strategies. Future studies are needed to evaluate the effectiveness of new associations between current interventions and reactive capture strategies, in view of the potential for increasing the population impact related to reactive capture. Este artigo revisou artigos publicados sobre diversos instrumentos empregados atualmente para "capturar" a atenção dos fumantes, ressaltando a diferença existente entre alcance e recrutamento da população elegível para intervenção proposta. Realizou-se uma busca nas bases MEDLINE, PsychARTICLE, e LILACS. Os descritores de busca combinaram as palavras recruitment, enrollment, reach, smoking cessation, quitline, e helpline presentes nos resumos/títulos dos artigos. Artigos publicados em inglês, português e espanhol até novembro de 2006, que deram importância a instrumentos de captação empregados, associando os mesmos a populações diferentes e a intervenções específicas foram incluídos na revisão. Vinte e nove estudos atenderam os critérios de inclusão. Estudos que utilizaram estratégias ativas ou mistas alcançaram, em média, um menor e menos diversificado número possível de indivíduos elegíveis e obtiveram maior proporção de participação do que aqueles que utilizaram estratégias reativas. Estudos futuros são necessários para se avaliar a efetividade de novas associações entre as intervenções existentes e estratégias reativas de captação, dada a potencialidade de aumento do impacto populacional relacionada à captação reativa.

The statistical methods discussed in the previous chapters are applicable mainly in the exploratory phase (also known as the descriptive phase) of an analysis. However, data exploration is more dynamic and interactive than simple data description. It uses multivariate statistics to obtain visualizations or groupings of elements that can be either whole texts or items within texts. It looks for associations and structures as well as interesting summaries.

The typologies and visualizations of the preceding chapter produce global panoramas of lexical tables. These panoramas can be generated whether or not the data are aggregated, whether or not they are natural partitions of a body of work (chapters, works of one author, articles, discourses, etc.), whether or not they result from artificial groupings (open-ended responses organized by categories, documents organized by subject matter, etc.).

The need to compare texts quantitatively arises in many different disciplines of scientific research. In each particular case, the use of quantitative methods is motivated by different requirements and often very divergent objectives (comparative stylometric analyses of texts written by different authors, typologies of individual responses to a single open question, information retrieval, etc.).

How do we go about applying the multivariate techniques defined through the pedagogical examples in the preceding chapters to real-life situations? The information is so complex, and the possible points of view so numerous, that it is impossible to recommend a single path leading from the problem to a definitive solution. In this chapter we shall rather attempt to recognize different ways of delaying somewhat the moment when the user must necessarily intercede in an interpretative manner. Our aim, briefly, is to extend the scope of the analysis that is controllable and reproducible — we choose to use these simple words instead of the perhaps more controversial terms objective and automatic.

Cross-tabulations or contingency tables are among the most common data structures used for analyzing qualitative data. By looking simultaneously at two partitions at a time of a population or sample, a cross-tabulation enables us to work with variations in the data by response categories, a necessary step for the initial interpretation of results. Furthermore, analyses and descriptions of cross-tabulations are the basis for the statistical treatment of survey data.

In many cases, a great deal of external information is available concerning texts compiled into a corpus: author, type, date (when texts by different authors are grouped into a corpus); socio-economic categories, age categories, educational level (in the case of aggregated open responses). This information can be used to establish a series of relationships (same author, similar or consecutive dates, same type, etc.).

Clustering techniques constitute a second family of data analysis techniques in addition to principal axes methods. These methods are used for representing proximities among the elements of a lexical table (rows or columns) through groupings or clusters.

Objective To evaluate the differences in cigarette smoking prevalence in Brazil between 1989 and 2008. Methodology We compared absolute and relative differences in smoking prevalence, overall and stratified by selected socio-demographic variables and birth cohort (20-year interval from 1925 to 1934 onwards). Data were obtained from National Household Survey on Health and Nutrition (1989, n=39 969) and Global Adult Tobacco Survey (2008, n=38 461). Generalised linear models with binomial family distribution, and either gaussian or logarithmic link function, were specified in order to obtain estimates, as well as to assess potential effect modification. Results Crude and adjusted overall differences in smoking prevalences between 1989 and 2008 were, respectively: absolute, 15.4% and 11.8; relative, 47.5% and 38.7%. We observed the highest declines in smoking prevalences among individuals aged 25–34 years-old (additive or multiplicative interaction p s Conclusions A large amount of laws against tobacco consumption have been adopted in Brazil since 1986, which may have contributed to the observed decline in smoking prevalence. It is of paramount importance to better understand the effectiveness of tobacco control actions implemented in a country and the evolution of its tobacco epidemic in order to improve/develop actions targeted to those who continued to smoke and/or started smoking in a “more hostile” environment.