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.
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 to second-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 deaths including cigarette taxes, smoke-free air laws, mass media campaigns, marketing restrictions, packaging requirements, cessation treatment programs and restrictions to youth access.
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.
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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