Artigos

Conteúdo (article):

Tobacco Control Policy in Brazil from 2016 to 2022: advances, setbacks and challenges.

AUTHORS:
1- Leonardo Henriques Portes

Universidade do Estado do Rio de Janeiro.
Policlínica Universitária Piquet Carneiro
Coordenação de Fisioterapia
Av. Marechal Rondom 381. São Franciso Xavier. CEP:20950-003

Universidade Federal do Rio de Janeiro
Hospital Universitário Clementino Fraga Filho
Serviço de Epidemiologia e Avaliação
R. Prof. Rodolpho Paulo Rocco, 255 - Cidade Universitária da Universidade Federal do Rio de Janeiro, Rio de Janeiro - RJ, 21941-617

leonardo.portes@ppc.uerj.br
https://orcid.org/0000-0003-2421-8891

2- Mariana Coutinho Marques de Pinho

ACT Promoção da Saúde.
Av. N. Sa. Copacabana, 330/1107
CEP 22020-001, Rio de Janeiro, RJ
mariana.pinho@actbr.org.br
https://orcid.org/0000-0002-8372-9272

3- Cristiani Vieira Machado

Escola Nacional de Saúde Pública Sérgio Arouca/Fiocruz
Rua Leopoldo Bulhões, 1480 - Manguinhos, Rio de Janeiro. CEP: 21041-210.
Rio de Janeiro – RJ
cristiani.machado@fiocruz.br
https://orcid.org/0000-0002-9577-0301

4- Vera Luiza da Costa e Silva

Centro de Estudos sobre Tabaco e Saúde
Escola Nacional de Saúde Pública Sérgio Arouca/Fiocruz
Rua Leopoldo Bulhões 1480, sala 320. Manguinhos. CEP: 21041-210.
Rio de Janeiro – RJ
vera.silva@fiocruz.br
https://orcid.org/0000-0002-5608-7497

Secretaria-Executiva da CONICQ
Instituto Nacional de Cancer/MS
Praça da Cruz Vermelha, 23 – Centro – CEP: 20230-130
vera.silva@inca.gov.br

5- Silvana Rubano Barretto Turci

Centro de Estudos sobre Tabaco e Saúde
Escola Nacional de Saúde Pública Sérgio Arouca/Fiocruz
Rua Leopoldo Bulhões 1480, sala 320. Manguinhos. CEP: 21041-210.
Rio de Janeiro – RJ
srubano@ensp.fiocruz.br
https://orcid.org/0000-0003-0811-9252

6- Cristiane Almeida Pires Tourinho

Universidade do Estado do Rio de Janeiro.
Policlínica Universitária Piquet Carneiro
Serviço de Pneumologia
Av. Marechal Rondom 381. São Franciso Xavier. CEP:20950-003
cristiane.tourinho@ppc.uerj.br
https://orcid.org/0000-0003-2757-1690

ABSTRACT
Smoking continues to be an important public health problem. Brazil introduced tobacco control measures forty years ago and is considered an international reference. This study assessed Brazil’s National Tobacco Control Policy from 2016 to 2022 by predominantly qualitative means and with contributions from political economy and policy analysis. During this period, Brazil maintained the bases of the policy and its international recognition. However, government coordination was observed to weaken in the unfavourable, strongly neoliberal, political context. These adversities were weathered by virtue of the policy’s institutional framing and the resistance of governmental and non-governmental actors committed to tobacco control in Brazil. Stronger tobacco control policies are essential to protecting population health and promoting healthier lifestyles.
Keywords: national tobacco control programme; tobacco; public health policy.

INTRODUCTION
Smoking continues to be an important public health problem. There are more than 1.3 billion smokers in the world and it is estimated that smoking is responsible for 8 million deaths a year, making it the leading cause of premature mortality worldwide1.
Also of concern are the high annual economic costs of smoking, which account for 1.8% of world gross domestic product2 and include tobacco-related environmental harm, including soil contamination, fires and deforestation3. Figures from the Institute for Clinical and Healthcare Effectiveness (Instituto de Efetividade Clínica e Sanitária, IECS) for 2020 show that smoking cost Brazil around R$ 125 billion, equivalent to 23% of total spending on the Covid-19 pandemic that same year (R$ 524 billion)4. Government revenue from taxation of tobacco products would cover only 10% of the total cost of smoking to the health care system5.
The power of scientific evidence, the protagonism of certain leaders and the restrictions imposed on the tobacco industry have been fundamental to reducing smoking globally6. Since the 2000s, policies to reduce the adverse impact of smoking have expanded in a number of countries7.
The WHO Framework Convention for Tobacco Control (FCTC)8, a treaty in force since 2005, is the outcome of binding, negotiated, international legislation based on the constitutional prerogatives of the World Health Organisation (WHO)9. It depends for its success on countries’ ability to implement effective policies to reduce the supply and demand for tobacco products, including policy coordination mechansisms10.
Brazil, has tobacco control measures in place for forty years, and is considered an international example. From the introduction of early regulatory measures, including health warnings on cigarette packs, to comprehensive policies, such as the ban of smoking in public places and progressive taxation on tobacco products, Brazil has shown its firm commitment to reducing the prevalence of smoking. Awareness-raising on tobacco-related diseases has been driven by educational campaigns that have contributed to a changing cultural norms in relation to consumption of tobacco products11.
Brazil was one of the countries that played a leading role in negotiating the FCTC and applied an inter-ministerial model of management tasked with orchestrating the country’s National Tobacco Control Policy (Política Nacional de Controle do Tabaco, PNCT ). The commission set up in 1999 to inform negotiations on the convention12 went on, in 2003, to become the National Commission for Implementation of the Framework Convention for Tobacco Control (Commissão Nacional para a Implementação da Convenção-Quadro para Controle do Tabaco, Conicq). In addition to coordinating Brazil’s compliance with obligations set out in the FCTC, Conicq is responsible for advising the government on the subsidiary bodies promoted by the convention, such as the sessions of the Conference of Parties (COP)13. Together with other actors, including researchers, decision makers and civil society, Conicq has been fundamental to advancing tobacco control in Brazil14 and is considered internationally to be a success as a model in tobacco control governance15.
Civil society participation is essential in shaping tobacco control policies and achieving the convention’s goals in Brazil. Of particular importance is the Association for Tobacco Control, Health Promotion and Human Rights – ACT Health Promotion (Associação para o Controle do Tabagismo, Promoção da Saúde e dos Direitos Humanos, ACT Promoção da Saúde). ACT was set up in 2006 with a focus on tobacco control and, from 2013 on, came to include advocacy for policies directed to healthy diet, physical activity and alcohol control16. Since 2016, representatives of governmental and non-governmental organisations, academics and advocates for the cause have met periodically to plan and arrange measures through the Tobacco Control Partners group, coordinated by ACT Health Promotion.
Brazil’s considerable progress in tobacco control has been fostered by national policies and a participatory, inter-sector model of governance, as well as by mobilisation by numerous social actors, despite the difficulties and market interests opposing regulation of tobacco products11,14.
The situation in Brazil has changed considerably since 2013: both economy and State have undergone severe disorganisation, while relations among elections, representation and policy were unstable17. There are signs that the political cycle of class conciliation has ended, as signalled by the disintegration of the government’s parliamentary base and the application of a fiscal adjustment18. Milestone events were the impeachment of President Dilma Rousseff and the sanctioning of Constitutional Amendment No. 95/2016 (EC 95) in 201619, which imposed a twenty-year freeze on public funding for primary expenditures, including on health care. In 2018, after the election of Jair Bolsonaro as president, the neoliberal project introduced by former president, Michel Temer, was pursued more radically, with repercussions on the health sector. Lastly, the Covid-19 pandemic aggravated the economic, social and political crisis in Brazil. Restrictions were also placed on social participation and there were setbacks in several areas of health sector policy20.
In that connection, it is relevant to examine how changes in national conditions affected the PNCT, whose trajectory thus far had been one of positive gains. This study drew up a balance on the PNCT from 2016 to 2022, particularly with regard to policy governance and the measures taken in that period.
METHODS
The study is based on contributions from the framework of political economy21 and policy analysis22, particularly historical institutionalism23,24, and was predominantly qualitative in nature.
The analysis took two thematic axis considering, firstly, policy governance and actors, which entailed describing the formation, composition and structure of the Conicq and analysing the participation and positions of commission members and their relations with internal and external actors.
The study also examined the content of the commission’s narrative and its ability to implement its proposals.
In the second thematic axis, it examined the most important PNCT policy measures in the study period, to highlight the advances and setbacks observed by considering a prior balance drawn up after the policy had been in place for 30 years14.
A narrative literature review of relevant articles was conducted by consulting Pubmed and Scielo (Brazil and Public Health) data bases, using a combination of descriptors relating to tobacco (“tobacco”, “smoking” and “nicotine”) and health policies (“policy”, “health policy”, “public health policy” and “smoke-free policy”). A documentary analysis of laws, standards and publications available in the media was also undertaken.
Although the study focused primarily on the period from 2016 to 2022, attendance lists and minutes of Conicq meetings were consulted for the period from its inception to the latest meeting held (2003 to 2021), given that Conicq did not meet in 2022.
The timeframe chosen for this analysis was divided into three periods of similar duration: the early years of the Conicq (2003-2009); a development period (2010-2015); and a more recent period (2016-2021). Analysis of the actors’ attendance and the issues discussed followed the model of a prior study on the same subject25. The heterogeneous presentations and structure of the minutes over the study period made it impossible to analyse them on more specific criteria, such as explicit recommendations made by the meetings.

RESULTS and DISCUSSION
Governance and political actors
Since its inception in 2003, Conicq has incorporated additional federal bodies (in 2010 and 2012), raising its membership to 18 government representatives, which then held stable in the years that followed. The commission comprises the Minister of Health as chair, the Director-General of the National Cancer Institute (Instituto Nacional de Câncer, INCA) as vice-chair, and INCA being also responsible for the Executive Secretariat (SE-Conicq). Since 2016, with the Temer government, changes made to the structure of government were not reflected in the composition of Conicq, although no rules were issued regarding the commission composition specifically (Figure 1).
Early in 2019, the new president, Bolsonaro, signed a decree with the extinction of collegiate bodies of the direct federal administration, quasi-government groups and foundations26, prompting controversy as to whether this would entail the extinction of Conicq. In 2021, however, on the basis of a prior decision by the federal Supreme Court recognising collegiate bodies set up by law, the Attorney-General of the Union ruled for the commission to continue. That decision found that international treaties and conventions, such as the FCTC, enjoyed the status of ordinary law and were subject to judicial review27. Even though the decision assured a legal footing for its function, Conicq was clearly weakened. In 2021, for example, representatives of Conicq Executive Secretariat were excluded from the official Brazilian delegation to the 9th Conference of the Parties (COP9) and the 2nd Meeting of the Parties (MOP2) to the Protocol to Eliminate Illicit Trade in Tobacco Products, which triggered a reaction from civil society28. In addition, when the Executive Secretary of the Conicq retired in February 2022, at the same time as structural changes were also made to INCA, no successor was appointed to the position. Conicq, which had previously advised INCA Director-General directly, was reallocated to the Division for the Control of Tobacco Use and Other Risk Factors (Divisão de Controle do Tabagismo e Outros Fatores de Risco, Ditab)29,30.
Conicq members’ participation in regular meetings is important to leverage the commission’s inter-sectoral potential. Analysis of the 55 attendance lists for regular Conicq meetings from 2003 to October 2021 (the last meeting held within the study timeframe) revealed variation in members’ proportional participation in meetings.
In the periods from 2003 to 2009 and 2010 to 2015, members’ mean proportional participation was 63% and 60%, respectively. Between 2016 and 2021, however, that mean fell to 34% (Figure 2).
Starting in 2016, Conicq meetings began to address international discussions involving COP established working groups, the Conferences of the Parties (COPs) and Meetings of the Parties (MOPs) to the Protocol to Eliminate Illicit Trade in Tobacco Products and their preparatory meetings: COP7 (2016), COP8 (2018) and COP9 (2021), the latter, virtual; and MOP1 (2018) and MOP2 (2021), the latter, virtual. Note that Conicq did not meet in 2020, probably due to the onset of the Covid-19 pandemic, and that in 2021 meetings were resumed on line, with a focus on preparing for international commitments. There were no Conicq meetings in 2022, suggesting that the commission encountered difficulties and was discouraged from fulfilling its domestic and international mandate.
Between 2016 and 2021, all the government bodies, except the Ministry of the Economy, participated less in meetings than in the previous periods (2003-2009 and 2010-2015). From 2016 onwards, participation by the Ministry of Health, the portfolio for economic affairs (Ministry of the Economy from 2016 on) , Attorney-General’s Office, Foreign Ministry, National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária, Anvisa) and the Presidential Civil Staff was less assiduous. However, the Minister of Health and the Director-General of the INCA were conspicuously absent, while other government bodies that had participated substantially up to 2015, such as the agrarian development portfolio, the Ministries of Agriculture and Livestock, Science and Technology and Education and Culture, were less present (Figure 3). It is important to note that Conicq executive secretariat - SE-Conicq has attended all meetings since the commission was set up, performing the role of convener and organiser of the meetings.
In the periods from 2003 to 2009 and 2010 to 2015, the issues addressed by Conicq and discussed at more than half the meetings considered were tobacco production and diversification of income and care of plantations, measures to combat illicit trade and public awareness building on the harm of smoking. However, Conicq meetings between 2016 and 2021 generally addressed a smaller variety of issues. In that period, issues relating to treatment and smoke-free environments did not appear as agenda points in the minutes examined (Figure 4).
The figures for Conicq members’ attendance at meetings and the issues addressed in the periods from 2003 to 2009 and 2010 to 2015 were similar, suggesting that continuity in the federal executive’s model of management and greater stability in the overall political, economic and health situation in those periods may have endowed solidity to the institutional framework of the National Tobacco Control Policy.
Despite the fragilities identified, the period from 2016 to 2021 was marked by strategic interventions by SE-Conicq to inform and enable the federal government and units of the federation to advance, or at least not to backslide, in tobacco control policies in Brazil. These interventions included prominently one supported by other sectors of the Ministry of Health to reverse the recommendations of the Ministry of Justice working group set up in 2016 to consider reducing taxation on cigarettes manufactured in Brazil31,32. Conicq has also continued to support the Contribution for Intervention in the Economic Domain-Tobacco (Contribuição de Intervenção no Domínio Econômico-Tabaco, CIDE-Tabaco), as a source of revenue for the public Unified Health System (Sistema Único de Saúde, SUS) and for tobacco control measures, including crop diversification in areas under tobacco33. In addition, Conicq published reports on smoking and Covid-19, as well as technical notes on economic aspects of smoking34, and proposed a 2021-2030 Plan to Strengthen the National Tobacco Control Policy, which included suggestions from civil society organistions35.
Policy measures
The work done by Brazil continued to gain international recognition. In 2019, the country attained the highest level of fulfilment of the measures contained in the MPOWER package, a minimum set of tobacco control measures established by the WHO, comprising Monitoring the smoking epidemic, Protecting people from the adverse effects of smoking, Offering treatment to quit smoking, Warning against the adverse effects of smoking through campaigns and health alerts, Enforcing restrictive measures prohibiting publicity, promotion and sponsorship and Raising the prices of, and taxes on, tobacco products36,37.
Note particularly the measures to fulfil the commitment to protect national tobacco control policies from interference by the tobacco industry, which were maintained even in adverse conditions. One example of a government based scientific institution that supported the tobacco control policies was the Observatory on Tobacco Industry Strategies of Fiocruz Centre for Studies of Tobacco and Health (Cetab). In organised civil society, the newsletters published by ACT Health Promotion were important to monitoring and exposing tobacco company tactics. Since 2018, Cetab/Fiocruz and ACT have been active in supporting the preparation a Tobacco Industry Interference Index, which identified an increasing tobacco industry interference in Brazil between 2019 and 202138. Improved monitoring capability in Brazil has contributed in part to identifying actions pursued by the tobacco companies.
In addition to the requirement that Conicq members declare any conflict of interests39,40, in 2020 the SE-Conicq proposed to INCA Directorate-General that the institution public integrity programme includes mechanisms to preclude tobacco industry interference by way of partnerships and funding. The proposal is still being processed internally, but it is a sign of efforts by government bodies to extend protection of policies against interference from tobacco companies41.
As regards price and taxes policy, the federal income tax authorities seem not to have tabled discussion of the Minimum Price Policy for cigarettes. Furthermore, the last year for which legal provision was made for a progressive R$0.50 annual increase in the minimum price of a cigarette pack was 2015. Since 2019, discussions of tax reform and selective taxation earmarked for health prevention and promotion policies have intensified in Brazil’s national Congress42.
As regards the policy on exposure to environmental tobacco smoke, after the 2014 decree, exposure to passive smoking at home and in work environments decreased43. Vigitel figures indicate that the percentage of people exposed to tobacco smoke in closed work environments then increased between 2018 and 2019 (4.7% to 5.5%), alerting to a possible increase in the social acceptance of smoking44. There appear also to be uncertainties in the National Health Surveillance System as to how to oversee and guide commercial establishments on the ban of consumption of electronic smoking devices. To correct that situation, Anvisa published a technical note asserting that use of electronic cigarettes and consumption of heated tobacco products should be in accordance with the legislation that prohibits smoking in enclosed collective environments45.
In this period, important PNCT-related milestones were passed in regulating tobacco product constituents. Although the Federal Supreme Court initially upheld the constitutionality of Anvisa ruling prohibiting aroma and flavour additives in cigarettes46, that issue is scheduled for further discussion47. Since 2019, under pressure to review the rule that prohibits the sale, publicity and importation of electronic cigarettes, the Anvisa has discussed this issue with Brazilian society, in response to a series of actions to promote the legal sales of these devices48,49. In 2022, Anvisa released a regulatory impact analysis report that recommended refining the normative instrument and expanding communication and oversight mechanisms50.
The activities of Anvisa’s tobacco product analysis laboratory were considerably restricted in this period, despite the partnership established with the National Institute of Technology. The budget for expanding analyses is reported to have been on the agenda of the agency’s collegiate board, but no decision has yet been taken on this matter. The amounts deposited in court resulting from registration fees questioned by the tobacco companies continue inaccessible and are estimated to total R$ 170 million51.
Smoking is treated at SUS under a Clinical Protocol and Therapy Guidelines for Tobacco Use, which was updated in 2020 by introducing methodological adjustments under the guidance of a national commission on technology incorporation by SUS (Comissão Nacional de Incorporação de Tecnologias no Sistema Único de Saúde, Conitec). In 2022, guidelines were published for organising services and care for tobacco users in SUS52. The approach continued to be cognitive and behavioural, allied to drug-based therapy by nicotine replacement (patches and lozenges) and bupropion. States and municipalities have reported shortfalls in supply of drugs distributed by the federal government and have encountered procurement difficulties, when no tenders are submitted, while pharmacies offer the products for sale normally. During the pandemic, efforts were made to support smokers quitting by offering remote care and running social media campaigns.
Brazil ratified the Protocol to Eliminate Illicit Trade in Tobacco Products in 2018. In 2021, during the pandemic, the worsening macroeconomic scenario boosted the price of illegal cigarettes. Discussions of contraband have also included electronic smoking devices, because these products tend to be sold after entering the country illegally.
Brazil is a major producer of tobacco leaf – second only to China and India – and the world’s leading exporter. Since the treaty was ratified, some 60,000 families have stopped growing tobacco, probably because contracts have not been renewed and production is being concentrated in larger, more productive properties53. Nonetheless, 86.5% of tobacco-producer families are smallholders, 22.6% of whom do not own the land they work54. Note that the Tobacco Sector Chamber, a collegiate body comprising workers, corporate and government representatives connected with the tobacco production chain, has continued to meet regularly in the Ministry of Agriculture and Livestock55.
The National Programme to Diversify Crops in Areas under Tobacco (Programa Nacional de Diversificação em Áreas Cultivadas com Tabaco) needs to be restored as a strategy for safeguarding farmers and for tackling food insecurity in Brazil, in view of the country’s return to the world hunger map. Importantly, Cetab/Fiocruz is acting as a Knowledge Centre for the FCTC Secretariat on Articles 17 and 18, and cooperates with producer countries by way of related technical cooperation, studies and content production46.
Figure 5 summarises the advances, limitations and challenges, by the various PNCT measures, between 2016 and 2022.
Final remarks
Despite the adverse national context between 2016 and 2022, Brazil largely maintained the bases of its National Tobacco Control Policy in place throughout the period and retained international recognition for its achievements by managing to keep implementingthe most important tobacco control measures endorsed by WHO56.
The creation of the Conicq has proven to be of utmost importance to maintaining firm positions that were decisive to Brazil’s solid tobacco control policy. Between 2016 and 2021, regular participation by its members diminished and the diversity of issues addressed at meetings declined, perhaps suggesting that the commission had weakened. However, it is important to consider the constraints imposed by the pandemic from 2020 onwards and the possibility that certain agenda items may have been dealt with in other decision-making spaces, such as INCA’s Tobacco Use Control Division (Divisão de Controle do Tabagismo, Ditab) and Specialised Health Care Secretariat (Secretaria de Atenção Especializada à Saúde, SAES) of the Ministry of Health.
It is important to note that no Conicq meetings were held in 2022 and further meetings were not resumed until 2023, when a new Executive Secretary was appointed to the commission. The discontinuance of even remote regular meetings of Conicq throughout 2022 was seen as a serious probem, coming as it did at a time when diverse sectors of society were gradually resuming activities that had been strongly affected by the mobility constraints imposed by the Covid-19 pandemic. The weakening of the commission may be related to the context given by a federal government that saw little value in collegiate management, as formally proclaimed by the 2019 Presidential Decree ordering the extinction of a series of commissions and casting doubt as to the continued existence of Conicq.
The SE-Conicq’s strategic interventions in relation to other actors and the leading role played by Conicq with regard to tobacco control policy management suggest that this body prevailed, even in a period of changes in federal executive management and an adverse political, economic and health sector conjuncture. From 2016 on, the strengthening of neoliberal groups in federal government decision-making spaces led to a national conjuncture unfavourable to public policy endeavours, with adverse effects on Conicq’s ability to act and organise meetings and coordinate the implementation of the FCTC, as compared with the previous period. Of particular note was the tobacco industry’s interference, through the Tobacco Sector Chamber (Câmara Setorial do Tabaco), to hinder Conicq’s work in a more structured manner in the Ministry of Agriculture 57.
However, the prominence attained by tobacco control internationally, with the FCTC figuring large in regular events and actions at the regional and world levels, worked in favour of Conicq’s endurance. Of particular importance in withstanding the adversities of the context from 2016 to 2022 was the institutional framework of Brazil’s tobacco control policy, allied to resilience by governmental and non-governmental actors committed to the cause since the 1980s.
Despite the advances of the PNCT, there are important challenges to be met, particularly:
- introducing a tax reform stipulating selective taxation on tobacco products and earmarking resulting revenue for SUS;
- aligning tobacco control with other SUS policies, particularly as regards controlling other risk factors for Non-Communicable Chronic Diseases and health care at different levels;
- containing illicit trade in electronic cigarettes, particularly when involving young adults as its target public;
- resuming the national programme to diversify crops in areas under tobacco (Programa Nacional de Diversificação em Áreas Cultivadas com Tabaco);
- implementing in full the Protocol to Eliminate Illicit Trade in Tobacco Products;
- protecting public policies from tobacco industry interference; and
- regularly reaffirming Conicq’s relevance as the locus for inter-sector management of tobacco control policies by the federal government.
Decisive in that regard is publication and implementation of the 2021-2030 Plan to Strengthen the National Tobacco Control Policy in Brazil. That document will be important to guide strategies and confirm Brazil commitment to health promotion, its contribution to Agenda 2030 of the Sustainable Development Goals and to the 2021-2030 National Plan to Control Non-Communicable Chronic Diseases, whose goal is to reduce the prevalence of smoking by 40%.
The reestablishment of Conicq by presidential decree58 and the appointment of a new Executive Secretary to the commission59 in 2023 contributed to creating a favourable scenario to ensure an institutionally strong PNCT with a marked inter-sector component. Another salient event in 2023 was approval of the National Tobacco Control Programme within the Unified Health System (Sistema Único de Saúde, SUS), which will bring greater agility to the programme 60.
Stronger tobacco control policies are fundamental to protecting population health and promoting healthier lifestyles. Working on a comprehensive approach, Brazil will pave the way to a future with less tobacco, thus helping reduce tobacco-related diseases and deaths, as well as improving people’s quality of life.

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