1 Wednesday, August 21, 2013 Brazil, Tobacco and Lung Cancer: Facts and Figures Introduction André Medici Kaizô Beltrão May 31 st is celebrated by the World Health Organization (WHO) as theworld No Tobacco Day. Why? (a) Because tobacco is a major risk factor for a number of chronic diseases such as cardiovascular disease, cancer of the lungs, trachea and bronchi, respiratory problems and many, many others, and (b) because 20% of the adult world population consume tobacco products. About two-thirds of users are concentrated in fifteen countries. They are China (27.2%), India (10.4%), Indonesia (4.5%), Russia (4.1%), Bangladesh (2.3%), Brazil (2.2%), Pakistan (2.0%), Poland (1.9%), the Philippines and Turkey (each with 1.5%), Vietnam (1.4%), Mexico and Thailand (each with 1.1%), Egypt and Ukraine (each 1%) (1). According to these data, the BRICS (2) (excluding South Africa) concentrate almost 44% of smokers, which shows that the future health of this group of countries is still somewhat smoggy. It is estimated that in 2011, 6 million deaths were directly related to tobacco, 80% of which occurred in middle and lowincome countries. But tobacco does not cause damage only to those smoking by their own free will. Exposure to tobacco leaves many sequels to those who, even without smoking, live daily with smokers in housing, the workplace, in social living
2 spaces such as restaurants, bars, markets, and other public and private spaces. Even based on 2011 estimates, about 600,000 people (an additional 10% to the number of deaths directly related to tobacco) died from exposure to tobacco every day without ever having smoked, of whom 75% were women and children (3). Moreover, even quitting smoking, the derived tobacco health sequelae remain in the ex-smokers burden of disease. So the best would be to invest in campaigns that encourage young people not to smoke, or if they do, to stop smoking as soon as possible, because the sooner this occurs, the lower the future health sequelae due to tobacco. Based on this argument, many governments and health plan operators, worldwide, have invested in economic and social policies against tobacco. Governments try to increase taxes on tobacco to avoid the habit of early smoking among young people and the poorest, often with good results. But as a corollary, the Ministries of Finance are hostages of revenues from taxes levied by tobacco and sometimes are the first to resist more radical measures that reduce the consumption or production of tobacco through other routes, such as the prohibition of smoking in public places, a ban on cigarette advertising or incentives to replace tobacco production areas for other less profitable plantations, using public subsidies to producers (given the high economic return of agricultural production of tobacco, which usually occurs in oligopsonic conditions with prices fixed by the sector multi-national companies). Moreover, for the lower-middle income groups, especially those with lower education as "the new affluent middle classes", cigarette consumption is relatively inelastic to higher prices and
3 thereby, increase the taxation passed on to consumer prices ends ceasing to be effective as a policy to reduce consumption. With regard to health plans, strategies that have worked are those based on the use of higher premiums affecting smokers, subsidies linked to treatment for those who want to quit smoking and decreases in the value of premiums for those who leave the addiction. Operators of U.S. health, such as Kaiser Permanente, have used this very expedient. The sources additionally spent with subsidies and premium cuts for those who quit smoking, is saved on future cash flows for avoiding hospital costs associated with chronic and acute cases treatment, especially in terminal patients with incurable consequences of tobacco. However, the best solution for governments and health plans is to educate the population to quit smoking. One successful way to prevent the increase of tobacco consumption are campaigns through media or even the smokers' health warnings with horrendous pictures placed on cigarette packs, as has been done in Brazil. Many other countries have implemented this program and it reduced tobacco consumption over the past few years, through planting an anti-smoking seed in the hearts and minds of current and potential smokers and in the whole society. Tobacco Consumption in Brazil Brazil is the sixth largest tobacco consumer s country in the world with respect in absolute figures. Countries like the United States, with a population 50% larger than the Brazil consumes less tobacco. However, Brazil has been the target of successful public campaigns (lead by the Ministry of Health or the State
4 and Local Governments) in reducing tobacco, passing by: (a) restricting the use of smoking in public spaces(bars, restaurants and workplaces); (b) reducing planted areas dedicated to tobacco production and promoting its replacement by other crops, through a program implemented by the Ministry of Agrarian Development (MDA) (4), and; (c) promoting a great deal of anti-tobacco advertising, financed by the Government through various forms of media. From the point of view of education and promotion of antismoking campaigns, the National Cancer Institute (INCAautarchy linked to the Ministry of Health) manages the National Program to Combat Smoking. These campaigns, among other actions, train professionals from State and Municipal Health Departments for educating the public on the evils of smoking in schools, businesses, hospitals and communities, with activities developed in partnership with the three levels of government (federal, state and municipal). Moreover, levels of tobacco taxation in Brazil are high. In some areas of the country, this fact leads to increased smuggling and illegal entry of tobacco products in Brazilian territory, from other countries, such as Paraguay. But even in spite of all the risks to the contrary, such actions have intensified in the last twenty years, bringing the number of people who smoke in Brazil to reduce. Between 2003 and 2008, according to data from the national house hold (PNAD) produced by the Brazilian Institute of Geography and Statistics (IBGE), the percentage of smokers in Brazil was reduced from 18% to 17% of the population over 15 years, reaching about 25 million people in
5 2008 and reversing the upward trend that still prevailed in the previous decade. Participation rates of smokers by gender in 2008 were quite different: 21% among men and 13% among women. The first graph shows the percentage of people aged 15 and over who use tobacco in Brazil, according to Region (Brazil is divided into 5 regions: North, Northeast, Southeast, South and Mid-West). The data show that in all regions the prevalence of smoking is higher among men than among women. It also indicates that in two regions (North and South) the prevalence among men is higher than in other regions, while among women, the highest prevalence of smoking is found in South and Southeast. Anyway, it is emphasized that the South is the Region with the highest proportion of smokers compared to the others, for both men (23%) and women (16%). The lowest rates of smoking prevalence among men occur in the Southeast and Midwest (21%) and the lowest for women in the North (10%). However, according PNAD 2008, regional differences in the prevalence of smoking among men are not large, while among women are significant.
6 On the other hand, as showed in Table 1, the number of smokers in Brazil is larger than the number of ex-smokers, indicating that there were massive behavioral changes that have taken large numbers of smokers to quit the habit. In 2008, the proportion of people over 15 who gave up smoking was 17% (19% for men and 14% for women). Table 1: Percentage of people over 15 who quit using tobacco by region: Brazil (IBGE - PNAD 2008) Region Total Men Women Brazil 17.2 19.3 13.9 North 17.6 20.1 15.2 North East 16.7 18.1 15.6 South East 15.8 19.3 12.7 South 17.0 20.9 13.4 Mid West 17.2 20.1 14.5 In some regions, the proportion of women who quit smoking was higher than the proportion of women smokers, such as the North, Northeast and Midwest, but this does not occur among women in South and Southeast and among men of any Region. Graph 2 shows the ratio between smokers and people who have quit smoking. In regions where this ratio is lower than 1, there is a slower pace to quit smoking, while where this ratio it is greater
7 than one, the number of former smokers already exceeds that of smokers. Another relevant factor is the intensity of smoking. The 2008 PNAD researched, in this respect, the daily or occasional smoking habit for smokers and for former smokers. Table 2 shows the percentage of frequent smokers and former smokers who smoked daily. Table 2: Percentage of People over 15 who are daily smokers and former smokers who smoked daily by Region: Brazil (PNAD - 2008) Regions Percentage of Population Who Smoke Daily Percentage of Former Smokers who Smoked Daily Men Women Men Women Brazil 18.9 11.6 16.1 10.7 North 17.2 8.6 14.5 10.2 North East 18.1 10.4 14.7 12.1 South East 19.0 12.3 16.5 9.9 South 21.1 13.9 17.9 10.4 Mid-West 19.0 10.7 17.2 11.0 The data reveal that the number of daily smokers is greater than the former smokers who smoked daily for both men and women. It is noted that the total number of female daily smokers was smaller than the number of women former smokers who used tobacco daily (5). Latest data on smokers and nonsmokers in Brazil are in VIGITEL (6), which is a survey of risk factors for chronic diseases made by telephone, conducted by the Ministry of Health. The 2011 VIGITEL data has many methodological and conceptual differences regarding the variables associated with tobacco surveyed by PNAD and therefore both surveys cannot
8 be compared. VIGITEL investigates the smoking habit among the population over18 years (meanwhile PNAD used 15 years and more) and has different forms of regional aggregation of data. The representativeness of the PNAD is national, while VIGITEL is limited to state capitals. VIGITEL also investigates the issue of passive smoking and the degree of their exposure to tobacco. According to data from VIGITEL 2011, the proportion of adults who smoke in the capitals ranged between 8% (Maceio) and 23% (Porto Alegre). The largest proportions of smokers were found among men, in Porto Alegre (25%), Curitiba (24%) and São Paulo (22%), and among women, in Porto Alegre (21%), São Paulo (17%) and Curitiba (17%). The lowest proportions in males occurred in Salvador (11%), Maceio (11%) and Recife (13%) and, among females, in Aracaju (4%), Maceio (5%) and João Pessoa (6%). Considering the aggregate population of the state capitals and the Federal District surveyed by VIGITEL, one can see that the proportion of smokers was 15%, higher among males (18%) than among females (12%). For both sexes, the proportion of smokers tended to be lower before age 25 or after age 65. The proportion of smokers was particularly high among men and women with up to eight years of schooling (23% and 15%, respectively), exceeding by almost twice the proportion observed among individuals with 12 or more years of schooling. Thus, larger investments in education, while raising awareness and capacity for discernment of the population, could reduce the proportion of smokers among the young population.
9 VIGITEL data show that, the proportion of former smokers adults in the state capitals had varied in a range between 16% (Aracaju) and 29% (Rio Branco). The highest proportion of former smokers were observed among men in Manaus, Rio Branco and Boa Vista (all three capitals with 33%) and among women in Rio Branco (26%), Porto Velho (23 %) and Curitiba (22%). The lowest proportions of former smokers among men were observed in Salvador, Recife and Aracaju, all with 20%, and among women in Aracaju (14%), Federal District (14%) and Goiania (15%). Another important subject is the intensity of smoking. VIGITEL researched the proportion of individuals who reported smoking 20 or more cigarettes per day (heavy smokers), which in 2011 ranged between 1% (Salvador) and 11% (Porto Alegre). Among men, the highest proportions of heavy smokers were observed in Porto Alegre (13%), Curitiba (9%) and Campo Grande (8%), and among women, in Porto Alegre (9%), Rio de Janeiro (6%) and São Paulo (4%). The lower proportions of heavy smoking among men were found in the Distrito Federal, Maceio, Salvador and Belém (all with 2%) and among women in Salvador (0.6%), Boa Vista (0.9%), Teresina and São Luís (1.1%). VIGITEL also surveyed the issue of second hand or passive smoking - those people who live or work in the presence of active smokers - being involuntarily exposed to tobacco. The proportion of people considered passive smokers in households varied between 9% (Maceio) and 17% (Macapá). Among men, the highest proportions were observed in João Pessoa (15%), Boa Vista (15%) and Macapá (14%) and among women in
10 Macapá (19%), Recife (17%) and Teresina (17%). The lowest proportions among men were observed in Maceió (6%), Goiânia (7%) and Rio de Janeiro (8%) and among women, in Victoria (10%), Distrito Federal (10%) and Curitiba (11%). Given that it is difficult to avoid passive smoking at the households by public enforcement, the best way to control directly passive smoking is at the workplace. In Brazil it is forbidden by law to smoke in the work place since the early 2000s, but companies and even government agencies do not enforce the law in their premises. In consequence, VIGITEL data shows that in 2011, the proportion of passive smoking in the workplace ranged between 8% (Florianopolis) and 19% (Porto Velho). Among men, the highest rates of passive smoking at workplace were observed in Porto Velho (28%), Belo Horizonte (23%) and Palmas (22%) and among women in Belem (11%), Macapá (10%) and Boa Vista (10%). The lowest proportions among men were observed in Florianopolis (11%), Curitiba (14%) and São Paulo (15%) and among women occurred in Manaus (4%), João Pessoa (5%) and Porto Alegre (5%). Based on these data, we could test a large set of hypotheses about the effects of smoking on the population health status. However, it is not always possible to have all the evidence to produce reliable statistics based on causal models. What is known is that one of the direct consequences of smoking is lung, trachea and bronchi cancers. What could be said about that in Brazil?
11 The Consequences of Smoking in the incidence of cancer in Brazil Pulmonary Cancer (including lung, trachea and bronchus cancers) is the second highest incident cancer among men and the 5 th most common among women in Brazil. Of the 27,600 new cases expected in 2012, 65% may occur among men and 74% are concentrated in the Southeast, according to estimates from the National Cancer Institute - INCA (7). Although the incidence is correlated with age, it is estimated that 80% of cases are associated to tobacco consumption. Avoiding tobacco consumption should be the best way to reduce the incidence. The remaining cases of lung cancer may be associated with urban quality of life. Unhealthy household environments and workplaces, air pollution as result of transport systems based in cars, buses and trucks, industrial production without environmental safeguards and lack of green spaces, especially in big cities, also favors the emergence of pulmonary cancer. Table 3 shows the incidence rates of lung, trachea and bronchi cancers in 2012 in Brazil and Regions. Observe that, for both sexes, this incidence was higher in the South, where is also the highest proportion of smokers among the population over 15 years. The North presents itself as having the second largest share of smokers in the male population and next to the lowest share of smokers in the female population, but their estimates of cancer incidence for both sexes are the smallest of all the regions. The Southeast is the second region with the highest incidence rates of pulmonary cancer, which are also associated with a high proportion of smokers in the population.
12 Table 3: Incidence of lung, trachea and bronchi by Region: Brazil 2008 Regions Estimated Incidence Rates of Pulmonary Cancer per 100 thousand inhabitants (INCA 2012) Men Women Brazil 17.90 10.80 North 8.11 5.12 North East 8.52 5.64 South East 19.73 11.22 South 37.02 18.58 Mid-West 16.64 9.3 Having all this data, even at the risk of falling into the ecological fallacy (8), some correlations between smokers and ex-smokers (according to data from the National Household Survey 2008) and estimates of the incidence of lung, trachea and bronchi (according to the data INCA 2012) were build. Table 4 shows how the regression coefficients (R2) associated with the different correlations performed. Table 4 - Regression Coefficients for Different Correlations between variables related to population data on smoking (PNAD 2008) Estimates of Incidence of Lung Cancer, trachea and bronchi in Brazil (INCA 2012) second Sex and Region Variables Used to make correlations with the pulmonary cancer incidence Percentage of smokers as a share of the total population aged 15 years and more Percentage of the former smokers as a share of the total population aged 15 years and more Percentage of smokers and former smokers as a share of the population aged 15 years and more Percentage of daily smokers as a share of the population aged 15 years and more Percentage of daily former smokers as a share of the population aged 15 years and more Percentage of daily smokers and daily former smokers as a share of the population aged 15 years and more Percentage of smokers as a share of the population aged 15 years old and more adjusted by the average age of the population by Region and gender Percentage of daily smokers as a share of the population aged 15 years old and more adjusted by the average age of the population by Region and gender Regression Coefficient (R2) Linear Exponential Model Model 0.3515 0.3994 0.2393 0.1945 0.3228 0.3292 0.4892 0.5575 0.3950 0.3780 0.4665 0.4975 0.5810 0.6275 0.6774 0.7842
13 Although the interval between variables with smoking and incidence of lung cancer is 4 years, it is worth noting that the PNAD data are collected in September 2008. On the other hand, estimates of cancer incidence for 2012 were built in 2011 based on historical series of incidence from 2000 to 2010. In this sense, there is not a great time delay between the real data of smoking and the incidence of lung, trachea and bronchi, according the data used. The data showed that the correlations between pulmonary cancer incidence and former smokers are not high. Some explanations can be linked to the fact that PNADs data on former smokers contains no information about the time when the person quit smoking. The strongest correlations were found between the percentage of frequent smokers and the incidence of lung cancer. Even so, given that the Regions have different age structures, the age variable could be affecting the correlation of variables such as lung cancer incidence and smoking. That's because Regions with an older profile (such as South and Southeast) have a larger number of people who smoke for a longer time (everything else constant), being more likely to suffer from lung cancer which is also associated with age. To circumvent this problem graph 3 correlates smoking population with lung, trachea and bronchi cancer incidence, using, as variable to represent smoking population, the percentage of frequent smokers with the average age of the population of each region by gender. It results a correlation (the exponential model) close to 0.8, which coincides with international evidence that says that 80% of cases of lung cancer
14 are related to smoking. The graph has 12 points (Brazil and 5 Regions for men and women). Final Thoughts The fight against tobacco has yet to face a long journey to achieve the reduction of the incidence of cancer. Socioeconomic factors such as low educational level of the population, the effect of rising incomes and rapid demographic and epidemiological transition may prevent, in the coming years, faster than desired reductions in tobacco consumption among users of the SUS (Brazilian public Health system), in spite of the Government efforts in promotion and prevention programs and television campaigns against tobacco, besides legislation and enforcement on the reduction of public spaces for tobacco use. Among the private health plans insured population, the use of more effective incentives to quit smoking such as premium reductions or rewards benefiting new non-smokers, could accelerate the reduction in tobacco consumption.
15 But both among users of SUS and those who use the private health plans, there remains the hope to reduce tobacco consumption, allowing that the national day against tobacco should be not just one, but every day of the year. The political economy to implement these policies is not so easy, since even a ban on smoking in public spaces, in Brazil, has the risk of civil disobedience given the high costs and lack of staff to enforce it. For these cases, the most effective way is to rely on the conscience of everyone in the process to respect the law and monitor compliance. End Notes (1) According to Bloomberg Philanthropies Website, 2012, available at http://www.mikebloomberg.com/bloombergphilanthropies2011tobaccoreport.pdf (2) Group of Countries including Brazil, Russia, India, China and South Africa, considered as the future drivers of world economic development. (3) Estimates of the central area of health, population and nutrition of the World Bank. (4) Brazil, Ministry of Agrarian Development: Actions of the Ministry of Agrarian Development for the Diversification of Production and Income in Areas of Tobacco Cultivation in Brazil, MDA-SAF, 2010. (5) Data from IBGE-PNAD 2008 allow a more detailed analysis of the conditions that could explain the transitions between the smoking habits for the condition of non-smokers. (6) Brazilian Ministry of Health VIGITEL Data investigates the population of the state capitals and the Federal District. (7) Ministry of Health, INCA, Estimate 2012 - Incidence of cancer in Brazil, Ed INCA, Rio de Janeiro (RJ), 2011, 118p. (8) In epidemiology, ecological fallacy occurs when performing analyzes with results derived from aggregate values per unit area, implying that these values correspond to the individual level. This type of analysis can generate results that can give rise to incorrect analysis about a particular phenomenon. Posted byandre MEDICI'S BLOGat4:06 AMNo comments: Labels:Brazil,Pulmonary Cancers,Tobacco
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