Strong tobacco control policies in Brazil credited for more than 400,000 lives saved

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This is an example of a health warning placed on cigarette packages in Brazil. Credit: Ministerio da Saude

High cigarette prices, smoke-free air laws, marketing restrictions and other measures, all part of Brazil's strong tobacco control policies, are credited for a 50 percent reduction in smoking prevalence between 1989 and 2010. The reduction contributed to an estimated 420,000 lives saved during that time period. Those are the findings of a new study published today in PLOS Medicine by a team of researchers from Georgetown Lombardi Comprehensive Cancer Center and the Brazilian National Cancer Institute.

07 nov 2012--Adding to the dramatic conclusion of the study, which used modeling to determine projections, the researchers say the Latin American country's policies could result in as many as 7 million lives saved by 2050.

Tobacco kills up to half its users—more than 5 million smokers die every year in the world from tobacco-related causes, says David Levy, Ph.D., a professor of oncology at Georgetown Lombardi. It also kills more than half a million non-smokers annually who have been exposed tosecond-hand smoke.

Brazil has played a pioneering role among low and middle income countries in providing support for tobacco control measures. It introduced its first cigarette-specific tax in 1990, and in 1996 placed the first warnings on cigarette packages and introduced smoke-free air laws. Many of these measures have subsequently been strengthened, including stronger advertising restrictions, higher taxes and bold and graphic warnings.

To determine the impact of these measures on smoking prevalence and deaths, researchers developed the Brazil SimSmoke Policy Simulation Model. Using policy and population and smoking data for Brazil, the model assesses the effect of several initiatives on premature deathsincluding cigarette taxes, smoke-free air laws, mass media campaigns, marketing restrictions, packaging requirements, cessation treatment programs and restrictions to youth access.

This is an example of a health warning image placed on cigarette packages in Brazil. Credit: Ministerio da Saude

The model estimated that the smoking prevalence in Brazil since 1989 was reduced by 46 percent by 2010, because of the introduction of tobacco control measures. Almost half of this reduction was explained by price increases, 14 percent by smoke-free laws, another 14 percent by marketing restrictions, 10 percent by cessation treatment programs, 8 percent by health warnings, and 6 percent by anti-smoking media campaigns.

Levy has developed similar models for 30 different nations. He says one distinguishing factor in Brazil's tobacco policies is its use of graphic health warnings on cigarette packages.

"While our model credits only eight percent of the reduction in smoking to health warnings, this is likely greatly underestimated because the value assigned in the model was based on current literature. We believe that value doesn't accurately represent the impact health warnings have in Brazil – particularly for youths." Levy continues, "Brazil has extensively tested its warnings with younger smokers and found a greater impact on reducing smoking than is found in the other studies."

He points out that the U.S. Court of Appeals for the District of Columbia rejected a government mandate requiring the use of nine specific graphic health warnings on cigarette packaging based, in part, on its views of the proper role of warning labels and its questioning of evidence presented on the effectiveness of graphic warning labels. Levy suggests rigorous testing with graphic warnings in the youth population in the U.S. might also demonstrate a significant impact on smoking behaviors.

Levy also noted that Brazil recently decided to ban menthol cigarettes, and that the U.S. Food and Drug Administration, which is charged with regulating product content, is considering a similar policy in this country.

While the U.S., particularly states such as California, have seen success in reducing smoking rates by implementing strong policies, none have had the kind of success seen in Brazil in such a short period of time.

"Everyone knows smoking exacts a devastating toll leading to premature death and suffering, but getting people to give up the habit or prevent it has proved challenging," Levy says. "Brazil's strong cigarette control policies should be a lesson to us all. If we are to implement policies here in the U.S. that will make a lasting impact we'll need the political will and the courts' support."

Levy conducted his research in collaboration with two scientists from the Brazilian National Cancer Institute including Liz Maria de Almeida, Ph.D., and André Szklo, Ph.D. The work in this study is supported by contracts with the Tobacco Control Research Branch of the National Cancer Institute and by Bloomberg Philanthropies. The authors report having no personal financial interests related to the study.

More information: Levy D, de Almeida LM, Szklo A (2012) The Brazil SimSmoke Policy Simulation Model: The Effect of Strong Tobacco Control Policies on Smoking Prevalence and Smoking-Attributable Deaths in a Middle Income Nation. PLoS Med 9(11): e1001336. doi:10.1371/journal.pmed.1001336

Provided by Georgetown University Medical Center

Comprehensive Tobacco Control Programs May Reduce Smoking Prevalence

June 22, 2007 — The immediate effects of two comprehensive antitobacco media campaigns confirm their importance in reducing smoking prevalence, according to a report in the June 22 issue of the Morbidity and Mortality Weekly Report.
"In 2002, after a decade with no decrease in smoking prevalence, New York City began implementation of a five-point tobacco-control program consisting of increased taxation in 2002, establishment of smoke-free workplaces in 2003, public and health-care-provider education, cessation services, and rigorous evaluation, including annual cross-sectional, citywide telephone surveys using the same measures as [the Centers for Disease Control and Prevention's] CDC's state-based Behavioral Risk Factor Surveillance System (BRFSS)," write J. A. Ellis, PhD, and colleagues from the New York City Department of Health and Mental Hygiene. "During 2002-2004, estimated adult smoking prevalence decreased from 21.5% to 18.4%, representing nearly 200,000 fewer smokers. However, in 2005, no change in adult smoking prevalence occurred, either among New York City residents overall or among demographic subpopulations."
To further reduce smoking in New York City, in 2006 the New York City Department of Health and Mental Hygiene (DOHMH) began an extensive, television-based antitobacco media campaign using graphic imagery of the health effects of smoking, which aired simultaneously with a large New York state antitobacco media campaign.
During the first year of the media campaigns, adult smoking prevalence decreased significantly in men (11.6% decrease) and in Hispanics (15.2% decrease), confirming the importance of comprehensive tobacco-control programs and suggesting that this intensive, broad-based media campaign has reduced smoking prevalence among certain subgroups.
The 2006 DOHMH media campaign, with advertisements in both English and Spanish, focused on increasing smokers' motivation to quit by providing testimonials from sick and dying smokers and graphic images of the diseased lungs, arteries, and brains of smokers. During January to October 2006, the television campaign broadcast for 23 of 40 weeks, with 100-600 gross ratings points (GRPs) per week (total, approximately 6500 GRPs).
At the same time, the New York State Department of Health aired a separate, simultaneous statewide television-based antitobacco media campaign that also targeted New York City, with advertisements featuring graphic images of the effects of smoking and highlighting the effects of secondhand smoke on children. From January through December 2006, New York City adult smokers were exposed to nearly 11,000 GRPs as a result of both campaigns combined, equating to the average viewer in NYC seeing an advertisement approximately 110 times during the year.
Population-based, random-digit-dialed health surveys of approximately 10,000 adult New York City residents conducted by the DOHMH annually since 2002 has evaluated smoking status. Smoking prevalence data for 1993-2001 were obtained from surveys of New York City residents, excerpted from the annual New York state BRFSS.
For New York City residents, smoking prevalence decreased from 21.5% in 2002 to 18.4% in 2004 (P < .001), with decreases in all major age, race/ethnicity, sex, and education subgroups and by location of birth. From 2004 to 2005, smoking prevalence did not change significantly among New York City residents overall, and there were no changes within any subgroup.
In 2006, during the television campaigns, smoking prevalence did not change significantly among New York City residents overall (17.5% in 2006 vs 18.9% in 2005; P = .055). However, smoking prevalence did decrease in men (from 22.5% to 19.9%; P = .021) and in Hispanics (from 20.2% to 17.1%; P =.027).
The 17.5% smoking prevalence in New York City residents during 2006 corresponds to a 19% decrease from 2002, representing 240,000 fewer adult smokers and an average annual rate of decrease of 5%. Young adults (aged 18-24 years) had the largest decrease (35%) from 2002 to 2006.
An accompanying editorial notes that the foremost measure proven to reduce tobacco use is taxation; other measures include legislation that makes workplaces and other public areas smoke-free.
Limitations of these survey data include an inability to draw conclusions regarding causality of the relation between any decreases and any intervention, including the media campaign; reliance on self-reported smoking behaviors; exclusion of certain populations; and lack of nationwide data for comparison purposes.
"Jurisdictions can make additional progress in reducing tobacco use, particularly by further increasing taxes, expanding smoke-free public places, and airing sustained, graphic, and pervasive anti-tobacco advertising," the editorial concludes. "The data presented in this report suggest that, in the context of increases in taxation and implementation of smoke-free workplace legislation, additional well-funded media campaigns that have graphic content and are aired with high frequency might further reduce smoking prevalence."
MMWR Morb Mortal Wkly Rep. 2007;56(24):604-608.