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REVISTA BRASILEIRA DE CANCEROLOGIA
Brazilian Journal of Cancerology
july/august/september/2011
57 3
rio de Janeiro, rJ

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Contents SUMÁRIO suMario
BRAzILIAN JOuRNAL Of CANCEROLOGy
v.57 n.3 2011
Presentation APRESENTAÇÃO PresentaCión 289
eDitorial EDITORIAL eDitorial 291
artiCles ARTIGOS artÍCulo
Legislation and Tobacco Control in Brazil Between the Late 20th and Early 21st Centuries 295
Legislação e Controle do Tabaco no Brasil entre o Final do Século XX e Início do XXI
la legislación y el Control del tabaco en Brasil entre finales del siglo XX y Principios del siglo XXi
luiz antonio teixeira, tiago alves Jaques
23 Years of Tobacco Control in Brazil: the 1988 Brazilian Tobacco Control Program Today 305
23 Anos de Controle do Tabaco no Brasil: a Atualidade do Programa Nacional de Combate ao Fumo de 1988
23 años de Control del tabaco en Brasil: actualidad del Programa nacional de Combate al tabaquismo de 1988
luiz Carlos romero, Vera luiza da Costa e silva
Air Quality in Bars of São Paulo/Brazil before and after the Smoke-Free Law in Indoor Places 315
Qualidade do Ar em Bares de São Paulo/Brasil antes e depois da Lei de Ambientes Fechados Livres de Fumo
la Calidad del aire en los Bares de são Paulo/Brasil antes y después de la ley libre de humo en lugares Cerrados
Mônica andreis, Jessica elf, Paula Johns, adriana Carvalho, Jie yuan, Benjamin apelberg
Tobacco and Health-Related University Students in the City of Rio de Janeiro 321
O Tabagismo no Contexto dos Futuros Profissionais de Saúde do Rio de Janeiro
el tabaquismo en el Contexto de futuros Profesionales de la salud de rio de Janeiro
andré salem szklo, Mariana Miranda autran sampaio, luís felipe leite Martins, elaine Masson fernandes, liz Maria de almeida
Quality of Life of Smokers Seeking Help to Quit Through Telephone Counseling 329
Qualidade de Vida em Tabagistas que Buscaram Auxílio para Deixar de Fumar por meio de Aconselhamento
Telefônico
Calidad de Vida en los fumadores que Buscan ayuda para Dejar de fumar a través de asesoramiento telefónico
taís de Campos Moreira, luciana rizzeri figueiró, Maristela ferigolo, simone fernandes, Melaine Czerminski larré, helena M. t. Barro
Tobacco Quitline in Brazil: an Additional Information Source to the Population 337
Disque Saúde Pare de Fumar no Brasil: uma Fonte de Informação a mais para a População
línea de salud para Dejar de fumar en Brasil: una fuente de información para la Población
Cristina de abreu Perez, Claudia teresa Pinheiro, stella Bialous, Valéria Cunha, tânia Maria Cavalcante
Evaluation of the Level of Anxiety, Depression and Motivation of Smokers Seeking Treatment for
Smoking Cessation in the Federal District 345
Avaliação do Grau de Ansiedade, Depressão e Motivação dos Fumantes que Procuraram Tratamento para
Deixar de Fumar no Distrito Federal
evaluación del Grado de la ansiedad, de la Depresión y de la Motivación de los fumadores que solicitan tratamiento
para Dejar de fumar en el Distrito federal
Maria suélita de lima, Carlos alberto de assis Viegas
Impact of Tobacco and Alcohol on the Body Composition of Youth 355
Impacto do Tabagismo e Álcool sobre a Composição Corporal de Jovens
impacto del tabaquismo y el alcohol en la Composición Corporal en la Juventud
ellencristina da silva Batista, tatiana do nascimento Campos, flávia Xavier Valente, sílvia eloiza Priore, sylvia do Carmo
Castro franceschini, Céphora Maria sabarense, Maria do Carmo Gouveia Peluzio
SumARY

Ratings for Popular Movies in Brazil and their Implications for Youth Tobacco Smoking 365
A Classificação Indicativa de Filmes de Popularidade nos Cinemas Brasileiros e sua Implicação para o
Tabagismo entre Jovens
la Clasificación de las Películas Más taquilladas en Brasil y su implicación en el tabaquismo entre Jóvenes
rosa Vargas, James Thrasher, James sargent
Comparison between Postpartum Smokers and Ex-Smokers as to Breastfeeding Duration and its
Impact on the Health of Newborns 379
Comparação entre Puérperas Fumantes e Ex-fumantes com Relação ao Tempo de Amamentação e suas
Consequências sobre a Saúde dos Recém-Nascidos
Comparación entre los fumadores y ex fumadores Después del Parto con respecto a la Duración de la
lactancia Materna y su impacto en la salud de los recién nacidos
adriani oliveira Galão, Bruno rocha de Macedo, rafaela Vanin Pinto ribeiro, roberto Vanin Pinto ribeiro, Carla Maria De Martini Vanin
Cervical-Uterine Precursor Lesion Associated to Tobacco Smoking: A Study about the Knowledge
among Women who Smoke 387
Lesões Precursoras do Câncer Cervicouterino Associado ao Tabagismo: um Estudo sobre o
Conhecimento entre as Mulheres que Fumam
lesiones Precursoras del Cáncer Cervical uterino asociado al tabaquismo: un estudio sobre el Conocimiento
entre Mujeres que fuman
Maria Cristina de Melo Pessanha Carvalho, Carmen lucia de Paula, ana Beatriz azevedo Queiroz
oPinion artiCle ARTIGO DE OPINIÃO artÍCulo De oPinión
Advances and Challenges in Tobacco Control: a Parallel between the World and Brazil 395
Avanços e Desafios no Controle do Tabagismo: um Paralelo entre o Mundo e o Brasil
avances y Desarollos en el Control del tabaco: un Paralelo entre el Mundo y Brasil
Douglas William Bettcher, Vera luiza da Costa e silva
literature reVieW REVISÃO DE LITERATURA reVisión De la literatura
Article 8 of the World Health Organization Framework Convention on Tobacco Control from the
Perspective of the Right to Health and Workers' Protection 401
O Artigo 8 o da Convenção-Quadro para o Controle do Tabaco da Organização Mundial da Saúde sob a
Perspectiva do Direito à Saúde e Proteção do Trabalhador
el artículo 8 o del Convenio Marco de la organización Mundial de la salud para el Control del tabaco
bajo la Perspectiva del Derecho a la salud y Protección al trabajador
Cristiane Galhardo ferreira Vianna, Maria helena Barros de oliveira, felipe lacerda Mendes, tania Maria Cavalcante
Nursing Interventions on Tobacco Control: an Integrative Review 411
Intervenções de Enfermagem no Controle do Tabagismo: uma Revisão Integrativa
intervenciones de enfermería en el Control del tabaquismo: una revisión integradora
Marcione aparecida de souza Moura, Maria de fátima Batalha de Menezes, renata Dória Mariano, Vagnára ribeiro da silva,
luana Pinheiro de sousa
Genetic Polymorphisms in the Nicotinic Receptors and Lung Cancer: an Overview 421
Polimorfismos Genéticos nos Receptores Nicotínicos e Câncer de Pulmão: uma Visão Geral
Polimorfismos Genéticos en los receptores nicotínicos y Cáncer de Pulmón: una Visión General
alessandra Bernadete trovó de Marqui, Vera lúcia Bonfim, Mariangela torreglosa ruiz
reVieW RESENHA reseÑa
Global Adult Tobacco Survey – Brazil Report 429
Pesquisa Especial de Tabagismo – Relatório Brasil
encuesta Global de tabaquismo en adultos – informe Brasil
instruCtions for authors INSTRUÇõES PARA AUTORES instruCCiones Para los autores 431

National No Smoking Day: a Milestone for Tobacco Control in
Brazil
During the last 25 years, tobacco control in Brazil has been centrally supported by educational and legislative
measures. The inaugural milestone of this movement was the institution of the national no smoking Day, the first
contribution of the national Congress for tobacco control in Brazil, through the federal law # 7,488, of June 1986.
from this moment on, august 29th has been the yearly celebration date by the Ministry of health. in 2011, year
of the 25th anniversary of the law, it is very appropriate to introduce the subject with a special edition of the Brazilian
Journal of Cancerology (revista Brasileira de Cancerologia – rBC), exclusively devoted to tobacco control. herein,
the reader will find 11 original articles, two of which have historical content; one has an opinion; three are reviews
and one is a commented review. This journal will also be translated into english and distributed at the 15 th World
Conference on tobacco or health, from March 20 to 24 2012, in singapore.
With the law # 7,488, the national Congress contributed to introduce in the agenda of the Brazilian state some
educational actions and public debates on the serious risks of tobacco smoking, which up to the moment had been
conducted almost heroically by some medical leaders. for this reason, it is worth to highlight the fact that this law
was inspired by a pioneer movement, led by the Medical society of the state of Paraná, which, on august 29 th 1980,
promoted the smoking strike, in an effort to warn the population of that state about the serious risks of tobacco smoking.
We are talking about a time when the act of smoking was strongly related to a positive lifestyle, in which tobacco
smoke was imposingly seen, full of glamour, in most social environments. a period when the national media sent, to
all homes in the entire country, cigarette advertisements wrapped in powerful messages and images of beauty, freedom
and success. and a time when the economic pressure of great transnational tobacco companies that were installed in
Brazil inhibited public discussions on this subject.
Throughout these 25 years of celebrations of the national no smoking Day, several activities and messages such
as “quit smoking running”, “sports without smoking are more radical” and “art without smoking is a show”, certainly
contributed to deconstruct the collective ideal of strong associations between cigarettes and sports and/or cigarettes
and the culture created in product advertisements – a strategy that so far the tobacco industry tries to maintain in
order to attract young people to tobacco smoking.
When creating the federal law # 7,488, the national Congress gave the country an important education and
communication tool, which nowadays is translated into a wide social participation in the protection of the national
Policy for tobacco Control against inappropriate interferences, which perhaps is their most important legacy for both
present and future generations.
This date was also the springboard for the appearance of other important actions in the field of tobacco control,
such as the institution of the World no tobacco Day, by the World health assembly, in 1988; the launching, in 2007,
of the Global adult tobacco survey (Gats), a survey to monitor tobacco consumption by adults, implemented in
14 countries and which, in Brazil, was named Pesquisa especial de tabagismo - Petab (special survey on tobacco);
the federal laws that established restrictions to cigarette advertisements; the inclusion of sanitary warnings on tobacco
product packages; and the smoking ban in closed collective places, among others, and the negotiation of the framework
Convention on tobacco Control international treaty, only to mention a few – all properly addressed in articles of
this journal edition.
in the year we celebrate the 25th anniversary of this law, we hope that the national Congress maintains, before
the Brazilian society, the evolution of this unfailing compromise with both health and quality of life of the nation;
and allows that, in september 2011, during the summit meeting of the united nations (un) on chronic noncommunicable
diseases (cnCDs), the Brazilian delegation can pave the way so that the 2014 World Cup be under
the effect of a federal law that makes the country 100% free of tobacco smoke.
Luiz Antonio Santini
Brazilian national Cancer institute - inCa
FOREWORD
Brazilian Journal of Cancerology 2011; 57(3): 289
289

editorial 57-3
it is with the satisfaction of someone who could closely and timely observe the Brazilian success in more than 25
years of tobacco control that i introduce this issue of the Brazilian Journal of Cancerology - rBC, especially dedicated
to this risk factor which is responsible for a world epidemics of exorbitant proportions, not only due to its economic,
social and environmental impact, but mainly due to its consequences on the health and quality of life of the population,
counted by the diseases, deaths and suffering caused by such dependence.
This rBC issue celebrates the efforts of the vanguard institution that hosts this journal, and for which i have
worked intensely and passionately for 20 years – the Brazilian national Cancer institute - inCa, which counting on
the absolutely indispensable financial and human support from the ary frauzino foundation for Cancer research
and Control, has allowed all the steps that were taken in this program and all the achievements that followed them
in Brazil. several were the partners in this process, not only those who were pioneers at the national level, such as the
Brazilian Medical association, the national Division of sanitary Pneumology and the Division of Chronic-Degenerative
Diseases from the Ministry of health, but also the ones which later summed up their efforts in order to face this
Public health burden which was still little recognized in Brazil and in the world in the 1980s, such as several state
and municipal secretariats of health, the national health surveillance agency (anVisa), the secretariat for health
surveillance of the Ministry of health and the national alliance for tobacco Control.
The moment for such rBC initiative could not be more adequate. in Brazil we are reaping the rewards of the
reduction in cigarette consumption, a result of the policy conducted in the country as from 1985. and there are
reasons to celebrate: the article by Romero & Costa e Silva analyzes 23 years of tobacco control in the country and
reports a little of the path of this successful program, telling its history to future generations. its impact has already
been reported in the reduced lung cancer mortality in men under 59 years old i . Marqui et al, in a review article in this
rBC issue, offer an overview on the influence of genetic polymorphisms in nicotinic receptors and in consequence
in the genesis and evolution of lung cancer, a disease that is almost totally avoidable by the control of this risk factor.
We also witnessed a decrease in the number of deaths due to cardiovascular and chronic respiratory diseases in the
Brazilian population ii , proving what has been highlighted in the recent global warning on chronic non-communicable
diseases of the World health organization - Who iii , among the best bets for fighting risk factors of this group of
diseases: tobacco, alcohol, diet and physical activity. This warning, which is approached in more detail in the opinion
article from Bettcher & Costa e Silva, defines what they call the best bets in tobacco control and analyzes its advance in
Brazil when compared to other countries, according to the recently published Global Report of the Tobacco Epidemics iV .
These bets include increase in taxes and prices, definition of smoke free environments, information to the public on
the consequences of tobacco including the sanitary warnings in cigarette packs and the enforcement of the banning
of publicity, promotion and sponsorship of tobacco products. The treatment of the smoker, according to the same
study, could be characterized as a good bet; because, although it is of great importance in the approach of addiction
and in the reduction of consumption for current generations, it does not show the same cost/benefit relationship of
the other policies mentioned (table 1).
Brazil went through this process very quickly. Teixeira & Jacques demonstrated, in an interesting historical analysis,
that the regulation of tobacco products, which was enormously intensified in the late 20 th century and early 21 st century,
suffered influence of the democratization process of the country and the establishment of the Brazilian unified health
system (sus). The strong framework of technical and practical know-how which was built throughout this period,
associated with the impact of specific indicators, such as the reduction in tobacco prevalence and some tobacco-related
diseases, demonstrates, according to the authors, the success of tobacco control in Brazil.
But it is also in the international scenario that we showed part of this work, using our excellent diplomacy when
presiding the negotiation of the only international treaty sponsored by the Who framework Convention on tobacco
Control (fCtC). however, although we are celebrating a milestone in the pathway of our Brazilian Public health,
there is still a lot to be done. Vianna et al portray in this issue the process of the Brazilian compliance to this treaty
i Malta DC, Moura l, souza Mf, Curado MP, alencar aP, alencar GP. lung cancer, cancer of the trachea, and bronchial cancer: mortality trends in Brazil,
1980-2003. J Bras Pneumol. 2007 oct;33(5):536-43.
iischmidt Mi, Duncan BB, silva Ga, Menezes aM, Monteiro Ca, Barreto sM, et al. health in Brazil 4. Chronic non-communicable diseases in Brazil:
burden and current challenges. lancet. 2011 Jun;377(9781):1949-61 [cited 2011 Jun 26]. available from: http://download.thelancet.com/flatcontentassets/pdfs/brazil/brazilpor4.pdf
iiiWorld health organization. Global status report on noncommunicable diseases 2010. Geneva: Who; 2011.
ivWorld health organization. Who report on the global tobacco epidemic, 2011: warning about the dangers of tobacco. Geneva: Who; 2011.
EDITORIAL
Brazilian Journal of Cancerology 2011; 57(3): 291-294
291

Table 1. The best bets in tobacco control for the reduction of mortality due to non-communicable diseases
risk factor interventions-actions
tobacco use
> 50 millions
DALYs* 3.7%
of the global
charge
protect the population
from tobacco smoke
warn about tobacco
harms
enforce the prohibition
of advertising, promotion
and sponsorship
raise taxes on tobacco
products
advise smokers to quit
smoking
and the importance of the already approved guidelines. They specifically approach the implementation of article
8th, which determines the Brazilian obligations regarding the protection against exposure to cigarette smoke, for the
protection of its populations against the risks of second hand smoke. The strong presence of the tobacco industry in
Brazil is felt due to the winding and slow pathways in which the internalization of the treaty has been happening and
by the resistance of some sectors, articulated by the industry itself, which uses organized groups of the society to defend
questionable assumptions. What was observed in the implementation of article 8 th , in spite of the concerns that this
process would generate unemployment and close businesses, was completely different from what actually happened.
Andreis et al demonstrate in rBC how the pioneer intervention of the state of são Paulo, the first to become free
of second hand smoke, promoted a healthy life style and defended the health of the são Paulo population, supporting
the necessity of a federal legislation that guarantees closed environments to be 100% free of smoking to all Brazilians.
fortunately, other states joined in this process, such as Paraná, rio de Janeiro, amazonas, roraima, rondônia and
Paraíba, showing in a cascade effect that this is a viable and unavoidable process and that does not impact at all on the
livelihood of bar, restaurant and service owners and employees. But the fact that all other states still allow areas designated
to smokers should concern not only the health sector as a whole, but also the national Congress and our society. Bill
# 315/2008, by senator tião Viana, proposes the internalization in the Brazilian legislation of the recommendations
from Who-fCtC and from the guidances for implementation of article 8th and needs to be approved immediately
instead of being the target of recurrent requests of appreciation by a large number of Commissions, requests which are
made by politicians associated with the tobacco industry, whose only objective is to delay the approval of the project.
regarding the great relevance of taking care of the health of non-smokers, the smoker is and will always be a
concern in this process. Manipulated by the industry, many times under the echo of the press, the silence of society
and the omission of the health sector, the smokers are unfairly made the culprit of the impact of tobacco on society.
The approach of a program for tobacco control should be against tobacco and should not and cannot be against
smokers. smoking tobacco products is an addiction and, therefore, a disease equivalent to any clinical condition with
recognized importance, such as high cholesterol level or high blood pressure.
Moreira et al published an essay in rBC raising the question of smokers’ quality of life. even though the results
were not statistically significant, smokers can present lower quality of life indicators when compared to non-smokers.
such warning is relevant for further studies about this addiction and its wider consequences on the smoker satisfaction
with their own life and the occasional encouragement to take care of it and quit smoking.
The fact is that a smoker needs less criticism to what, many times, is seen as a bad behavior, in fact he needs to be
respected, informed and treated. after all, he is the victim of a social process in which at a very early age, generally
292 Brazilian Journal of Cancerology 2011; 57(3): 291-294
avoidable
charge
combined
effect of 25-
30 millions of
DALYs* avoided
(>50% of the
total tobacco
charge)
costeffectivity
optimal costeffectivity
good costeffectivity
implementation
cost
very low cost
very low cost
viability
highly viablestrong
legal
framework
(FCTC from
WHO)
viable
(network
for primary
healthcare)
* Dalys: disability adjusted life years. it is the measure of disease charge, which corresponds to the sum of the life years potentially lost due to early death with the
loss of productive life years due to disability.

efore adulthood, he is involved with tobacco due to the appeal of the drug, which is socially accepted and represented.
Besides that, smokers are influenced by the marketing of the tobacco industry, which promotes, through publicity,
the promotion and sponsorship, a cheap and accessible product, yet mortal, responsible for nicotine addiction and
that generates, most of the times, a pathway in which the freedom of personal choice succumbs to the drug effect.
The marketing of the tobacco industry needs to be banished from society and, when it is the component of counteradvertisement,
information is the ground of the formation of social critical mass to support impact regulations. We were
the second country in the world to be able to add warning images initially on cigarette packs and then in all tobacco
products. We were the first in the world to forbid deceiving terms, such as light, mild, etc. to better inform and in a
more directed way regarding the groups that need such information is the objective we need to pursue. adolescents,
women and low school level people: the epidemic of tobacco in Brazil is becoming localized in vulnerable groups that
need to be target of correct information and adequate intervention. Media campaigns targeting this population would
be a good idea, especially after we spent so much time without reaching the big communication media with mass
campaigns, as the ones we are living at the beginning of this century. These could contrapose the subliminar, perverted
and deceitful media used by the tobacco industry. The article by Vargas et al in rBC highlights, for example, that the
movies shown to our adolescents exposes the new generation of Brazilians to tobacco smoking and perpetuates the
encouragement of its consumption, which implicates an unacceptable social acceptance. Where is the censorship for
movies presented in Brazilian cinemas that does not obly the insertion of warnings when there are people smoking? still
allowed in Brazil, the media of publicity in points of sales only worsens this process of exposure to the unacceptable
appeal for the consumption of a drug that kills one out of two regular users. in this sense, the recent anVisa proposal,
which we expect to become a resolution as soon as possible, helps in the process of reducing public exposure to the
product, for determining that the display of cigarette pack shelves in points of sales be prohibited, besides increasing
the size of warnings in the publicity of the product, until an amendment to the federal law comes into force to ban
the use of points of sales as publicity places of the tobacco industry. The resolution that prohibits additives, tastes,
scents and anything else that encourages our children to start smoking has to be published immediately, for the good
of our future generation.
however, no anti-tobacco media activity drives away the focus on those who have the role of caring and healing
and who serve as health models for the population. Galão et al show, in this rBC issue, that the action of healthcare
professionals seems insufficient to inform patients, especially vulnerable groups such as those composed by pregnant
women, of the harms that tobacco use in its most diverse kinds can cause themselves and others. The fact that only
51.3% of postpartum mothers from hospital das Clínicas de Porto alegre have received counseling on the harms of
tobacco for themselves and their babies shows that a lot has to be done to bring awareness to this group, essential for
the population counseling and the behavior model.
But if our healthcare professionals are not prepared to support this demand nowadays, what to say about the future
healthcare professionals? Szklo et al show in rBC that around 80% of the students from the third year of Medical
school, Dentistry and Pharmacy undergraduate courses from both public and private institutions and public nursing
courses in the city of rio de Janeiro (2006/2007) did not receive formal training up to the third year of school on
how to approach a smoker. a cause of concern was the fact that 70% of those were casual smokers themselves and,
as this survey was done before the promulgation of the state law that bans smoking in closed environments in rio
de Janeiro, 34.3% of these students declared to consume tobacco products within the university facilities. Can we
conclude that our universities are not giving enough importance to the subject? What are our curricula like regarding
the essential approach of prevention?
all healthcare professionals should be involved and some have already achieved records of participation. Moura
et al highlight in rBC that the nursing area is extremely important for tobacco control, which is referenced by a
literature review between 2008 and 2010 which brings good results from the action of nurses in this area, especially
giving support in the complex process of smoke quitting.
Perez et al do some interesting analysis of the information coming from the tobacco Quitline, a service freely
provided by the Ministry of health to the Brazilian population, and that counts on the disclosure of the telephone
number for access to the services on cigarette packs, showing it is a resource used by smokers who want to quit, being
more used by young people whose from 12 to 24 years of age and male smokers. regarding the use of the service, the
second most used service from the tobacco Quitline, the study points to the necessity of doing a cost-effect analysis
of the quitting services. This is a strategy in Brazil that deserves more investment and greater penetration, representing
an opportunity for the smoker approach from all classes and regions of the country. This can eventually be coupled
with the use of messages for cell phones, widely used in the country.
Brazilian Journal of Cancerology 2011; 57(3): 291-294
293

Lima and Viegas evaluated smokers submitted to treatment in the federal District and show in rBC that about
30% of the smokers presented probable anxiety and depression levels and, among those, 50% had high motivation to
quit smoking, mainly among women. This study points out not only to issues related to the characteristics of smokers
who look for treatment to quit, but also to issues of gender, very up to date in the context of tobacco control in Brazil.
Check the article that shows that women have a different behavior when compared to men as to the motivations
and results regarding tobacco quitting. They are also different in the process of initiation and reaction to addiction.
Carvalho et al show that the relationship between tobacco and cervical cancer seems to be a reason of conflict and
search for changes in women carriers of precursor lesions of this disease and deserves strategic attention of Public
health programs aiming at offering opportunities of prevention and counseling.
This is a subject about which Brazil will have to search for information and test policies to achieve results that
bring improvements in the approach of smokers, including availability of generic medications in the list of essential
medications.
But the gender issues are not specific for women. Gender policies target men and women, their differences and
similarities and how the social, behavioral and biological contexts influence both and how one influences the other.
Batista et al show in this rBC issue that smokers from 18 to 26 years of age, studied in Viçosa, Minas Gerais, consumed
alcoholic beverages more frequently than non-smokers of the same gender. The weight and waist/hip ratio presented
a positive correlation (p

History
Legislation and Tobacco Control in Brazil
Article submitted on 03/23/11; accepted for publication on 05/26/11
Legislation and Tobacco Control in Brazil Between the Late
20th and Early 21st Centuries
Legislação e Controle do Tabaco no Brasil entre o Final do Século XX e Início
do XXI
La Legislación y el Control del Tabaco en Brasil entre Finales del Siglo XX y
Principios del Siglo XXI
Luiz Antonio Teixeira 1 , Tiago Alves Jaques 2
Abstract
Introduction: This article deals with the process of emergence and consolidation of the anti-smoking policy in Brazil,
discussing the development of the Brazilian legislation in this field between the 1960s and the early 21 st century.
Objectives: to discuss the first legislative regulations to standardize marketing and advertising of cigarettes brought
into discussion in Congress in the 1960s; to evaluate the consequence of tobacco control actions in public health
as well as laws and campaigns for the control and marketing of smoking products, introduced during the country’s
re-democratization process in the 1990s. Method: This study was based on the analysis of legislation and secondary
sources on the development of tobacco control actions in the country. Results: in the period studied, there is intense
strengthening of legislation on tobacco control in the country. Conclusion: While actions against tobacco were
being developed, a strong framework of knowledge and an extensive practice in the field of tobacco control was built.
This aspect, together with data on tobacco use and lung cancer incidence, suggests that tobacco control measures
implemented in the country are successful.
Key words: legislation as topic; tobacco; smoking/legislation & jurisprudence; Control and sanitary supervision
of tobacco-Derived Products; Brazil
The Project originating this article is supported by faPerJ (young investigator fellowship of our state, faPerJ Process e26/ 102.203/2009) and CnPq
(edital universal, process 478151/2010-1).
1 full researcher from Casa de oswaldo Cruz – fiocruz. Doctorate degree in history of sciences. research developed at the research Department from
Casa de oswaldo Cruz – fiocruz. email: teixeira@fiocruz.br.
2 historian. Master's Degree in history of sciences and health. Doctorate student at the history of sciences and health Graduate school Program at
Casa de oswaldo Cruz - fiocruz. email: jaquestiago@yahoo.com.br.
Correspondence Address: luiz antonio teixeira. avenida Brasil, no 4.036 - sala 400 - Manguinhos. rio de Janeiro (rJ), Brazil. CeP: 21040-361.
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Teixeira LA, Jaques TA
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INTRODUCTION
This article approaches the development of the antitobacco
policy in Brazil, discussing the transformations
in the Brazilian legislation in this field during the last
four decades of the 20th century. although this subject
has already been discussed in several articles designed
by medical doctors, journalists and historians, its
analysis is made relevant to the extent it evaluates these
transformations in light of the changes in Public health
undertaken in the period.
as from the last quarter of the 20 th century, with
the strengthening of the anti-tobacco movement in the
united states, multinational cigarette manufacturers
intensified their action in developing countries. Their
strategy had as basis the notion that these countries had
a great marketing potential as they contemplate large
population numbers and would have more difficulty in
designing more strict anti-tobacco legislations. in this
context, cigarette consumption in the country started to
grow fast, achieving its peak in the mid 1980s. Besides
investments of the industry in production and marketing,
the increased competition in the sector, the control of
prices and the steady growth of the urban population
contributed to this process 1 .
at the moment of both cigarette consumption and
national tobacco production intensification, the country
was found under a dictatorial regime of liberal character
and the health sector was going through a process of
difficulties, determined by the lack of resources and by
the severe crisis that achieved medical welfare, as from
the 1970, to the detriment of initiatives of preventive
character from the Ministry of health. in this context,
the first initiatives appeared, although still timidly,
for the standardization of tobacco commercialization
in the legislative field. although these initiatives were
supported in scientific postulations on the harms of
smoking and even second hand smoking, they did not
obtain the expected results. only with the beginning of
the democratization process and the transformation in
healthcare which led to the sanitary reformation and the
creation of the Brazilian unified health system (sus),
was this situation changed.
in the context of changes and construction of a new
way of thinking that saw health as a citizenship right,
whose provision is a state obligation, the actions of
the public power as to the control of tobacco smoking
started to be quite recognized, leading the country to
a paradoxical position of being one of the largest world
exporters of tobacco and, at the same time, a strong
world leadership regarding the policy for the control of
its production and consumption.
the aims included discussing the first legislative
initiatives of commercialization standardization
Brazilian Journal of Cancerology 2011; 57(3): 295-304
and cigarette advertisement, which were subjects
taken to the Congress in the 1960s; evaluating the
consequences of Public health changes, instituted from
the redemocratization process of he country, in the actions
for tobacco control; and evaluating laws and campaigns
for the control of tobacco products commercialization and
advertisement, commissioned in the 1990s.
METHOD
The present work is characterized as a social history
study. it was designed with basis on the analysis of
documental sources referring to the anti-tobacco legislation
in the country, consulted in the federal senate and Ministry
of health websites; in secondary sources, related to the
development of Public health and reference books written
by medical doctors and journalists who discuss the trajectory
of tobacco use in Brazil. Documents on the trajectory of
actions of medical groups for the control of lung cancer
were also used – several of them made available by the
Brazilian national Cancer institute - inCa, the institution
responsible for the national Program for tobacco Control
(PnCt in Portuguese), since the end of the 1980s. The
temporal limits of the worked sources are between 1980
and 2011. The selection and utilization of these sources
had research, verification and historical interpretation as its
basis. after the critical analysis and crossing of information
with those from various research developed in different
areas of medical knowledge, the objective was to evaluate
the process of transformation of the legal reference on the
utilization of tobacco in the country.
RESULTS AND DISCUSSION
The firsT sTeps of The AnTi-TobAcco LegisLATion
investigations relating health problems to tobacco
use, carried out as of the middle of last century, had an
important role in the change people see the smoking habit.
in the previous decades, some investigations were already
obtaining conclusions in this regard, although these had
little repercussion. in the 1950s, complex epidemiological
studies, done by american and British researchers, became
the starting point for the design of the report on smoking
and health from the Royal College of Physicians, written
in 1962, and the “terry report”, written by the advisory
Committee on smoking and health in the usa in 1964 2 .
These documents demonstrated that the death rate due to
lung cancer was higher among smokers and mentioned
chronic bronchitis and emphysema as the most frequent
diseases among smokers. its disclosure gave breath to
anti-tobacco smoking and transformed the way scientific
communities from several states view tobacco smoking.

in Brazil, the disclosure of these reports within
the medical community reinforced the anti-tobacco
viewpoints related, up to that moment, to religious and
moral aspects mainly. in the 1960s, some tuberculosis
specialists, surprised by the increased number of lung
cancer cases, started to observe a relationship between
smoking and the increase in the number of that disease.
however, these ideas were still very controversial and,
in order to avoid more conflicts, they tried to attain
their considerations on the causes of lung cancer to the
medical community, writing in specialized journals and
maintaining caution as to the viewpoints presented 3 .
in the context of the growth of medical concerns
as to smoking, the first bills for its control were taken
to discussion in the national Congress. in 1964, state
representative eurico de oliveira, elected by the former
state of Guanabara, submitted a project that proposed
the banning of tobacco derivatives advertisement in any
communication media. in the following year, another
project of his suggested the institution of an additional
tax for fighting cancer. still in 1965, Pedro Marao,
federal representative from the state of são Paulo and
ivan luz, elected through Paraná, submitted different
bills, determining the printing of cancer risk warnings on
cigarette packs. Marao also wrote a second bill providing
for the ban of selling cigarettes to teens under 18 years
of age. Before the end of the decade, other five projects
related to the control of tobacco products were submitted
to the Congress. all have been archived 3 .
During the 1970s, a steady increase of bills for tobacco
control in the national Congress could be noticed.
Gonçalves 3 found 79 projects in this decade, against nine
in the previous decade. Thirty five of those provided for
some kind of regulation of cigarette advertisements and
the distribution of gifts from the tobacco companies.
There was also significant concern with the selling of
cigarettes for teens under 18 years old (11 projects) and
with the regulation of smoking in public transportation,
either aerial or terrestrial, as well as in public places 3 .
among the propositions, six demanded sanitary control of
cigarettes produced in Brazil, three suggested the insertion
of warnings about the harms of tobacco on cigarette packs,
four suggested taxes on tobacco products to be destined
to Public health, two proposed the subject of tobacco
and its harms in school curriculum, and lastly, a project
proposed a national Week for tobacco Control 3 .
such a number of projects demonstrates that discussion
regarding this subject has been on in the Congress since
the 1970s. But the fact that none of them was approved
shows how limited the discussion was at that time. in
Legislation and Tobacco Control in Brazil
the middle of a military dictatorship, when economical
liberalism was dominant and the notions of prevention
and even Public health were eclipsed by the medical
welfare of curative character, the possibility of approval
of projects which, besides being out of the scope of the
governmental guidelines for health, put in danger the
interests of big economical forces, had no way of being
implemented. Besides that, at that time, the subject of
tobacco was still defended by groups that saw it with a
moral bias mainly. initially, medical doctors got aligned to
them in order to strengthen their viewpoints; however, the
scientific speech could not count on the social consensus
necessary to become hegemonic yet. hence, tobacco kept
growing and cigarette advertisements kept on selling the
image of smoking associated to success, charm, elegancy
and virility.
The sTrengThening of The AnTi-smoking movemenT in
brAziL
in the 1970s, the harms provoked by tobacco smoking
were consolidated as a health problem for the international
agencies, becoming a constant subject in the World
health assemblies, the highest decision-making body
of the World health organization (Who). in 1970,
the Who Committee of experts wrote a report entitled
“The smoking habit and health” summarizing several
aspects of tobacco smoking and the harms it causes. This
and others reports coming after it brought a number
of recommendations to its Member-states, starting by
the suggestion that governmental projects be created
specifically to fight tobacco smoking, based on permanent
bodies 2 .
The globalization of medical concerns with tobacco
widened initiatives proposing the regulation of its
commercialization and consumption in the country.
in March 1979, a document was created as the
conclusion of works carried out in a seminar on tobacco
smoking, organized by the Brazilian institute for Thorax
investigation, in salvador, Bahia. The then called salvador
letter was written by important names in Pneumology
and tobacco control in the country: José silveira, Jaime
santos neves, José rosemberg, edmundo Blundi,
antonio Pedro Mirra and Mario rigatto. Many of them
were important medical doctors in the struggle against
tuberculosis and were then including in their concerns
the harms to the respiratory tract caused by smoking 3 .
The salvador letter recognized the challenge of the fight
against tobacco smoking, highlighting the economical
deadlock faced by the state, due to the money collected
with tobacco production. Besides that, their authors
did not get intimidated. finding support in the Who
recommendations, they defended the creation of a
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Teixeira LA, Jaques TA
298
“national Committee of multi-institutional character”,
capable of planning and promoting a campaign to flgith
smoking throughout the national territory 4 .
Giving continuation to the initiative of the
pulmonologists that met in salvador, the Brazilian
Cancerology society, still in 1979, put together a wide
group of scientific associations and health-related
institutions, in the city of são Paulo, with the objective
of designing a national Program against smoking. The
program was then coordinated by the Brazilian Medical
association, through a national committee composed
by several national Medical societies. it was also defined
that this commission should send to the Congress a
request for the creation of parliamentary investigation
committee - CPi about smoking and health that should
evoke the approval of new laws about the control of
cigarette advertisement, smoking ban in determined
places, cigarette commercialization, tobacco products
taxation and warnings on the risk of tobacco smoking 2 .
in 1980, the tuberculosis league from the state of
espírito santo sponsored the first Brazilian Conference
to fight tobacco smoking, in Vitória. several medical
doctors who took part in the event in salvador, in the
previous year, attended the conference. Besides the
disclosure of international researches on the subject as well
as Who recommendations, one of the objectives was to
promote the work done by Brazilian medical doctors 3 .
as seen, the medical doctors related to activities against
tuberculosis were the main incentivators of actions for
tobacco regulation in the late 1970s.
Very soon the subject was on the cover of VeJa
magazine, a weekly Brazilian magazine of widespread
circulation. in april 1980, a group of journalists wrote a
general scenario on the subject, informing readers about
the harms of smoking and the way in which tobacco
smoking was being approached in some parts of the
world, especially in the usa. The article highlighted
the importance of tobacco production for the Brazilian
economy, at the time responsible for 35.5% of total iPi
(a tax on industrialized products) collection – twice the
amount collected by the automotive industry – and related
such fact to the then week performance of government
to approve measures for tobacco control in the country 5 .
still in 1980, to celebrate the World Day of health,
the Who launched an international campaign fight
tobacco smoking, with the slogan “tobacco or health”,
and designed the Program of tobacco and health, which
recommended the intensification, or beginning where
there was none yet, of government strategies for the
control of tobacco smoking with emphasis in educational
Brazilian Journal of Cancerology 2011; 57(3): 295-304
measures, particularly in respect to young people, as well
as in the prohibition, restriction or limitation of tobacco
products advertisement 6 .
as part of these happenings, the Ministry of health
tried, in a timid way, to participate in the process of
changes in the legislation on tobacco smoking which
seemed to be approaching. in order to do that, in 1981,
it created the Committee for the studies of smoking
Consequences, with the main objective of designing
reports on the several bills about the subject, presented
at the national Congress. Composed by important
members of the anti-tobacco movement, such as antonio
Pedro Mirra, edmundo Blundi, Jayme santos neves, Jose
rosemberg, José silveira and Mario rigatto, it worked
only for a year 2 . its composition and the short period of
its existence show the difficulties lived by the anti-tobacco
movement in that period. if on one side, its leaderships
could, at times, be heard by the state, the resistance or
lack of consensus as to its viewpoints soon removed them
from the scene.
in the legislative field, still in 1980, the then state
representative italo Conti, elected through the PsD
Party from Paraná, presented a bill proposing that,
every year, august 29 th would be the celebration date of
the “national Day against tobacco smoking” and, in
the preceding week, an educational campaign with the
objective of disseminating the harms caused by tobacco
smoking should be organized. The following year, his
project was approved by the legislative chamber and sent
to the senate. it remained in the senate until 1986, when,
after long discussions, it was voted and approved almost
unanimously, only two votes being registered against
and one absence, and was later sanctioned by President
José sarney on June 11 th of the same year. The federal
law 7,488/86 instituted the date of august 29 th as the
“national Day against tobacco smoking”. This law is
characterized as the first legislation of federal scope related
to the regulation of tobacco smoking in Brazil*.
even before the sanction of the law # 7,488, the
Ministry of health decided to act more strongly as to
the tobacco problem, creating the support Group for
tobacco Control - GaCt in Portuguese, in 1985. The
group was composed by physicians, lawyers, politicians
and representatives of several social instances related to
tobacco control. GaCt was, until the end of the decade,
responsible for the campaigns of the national Day against
tobacco smoking. in november 1986, it organized a
symposium in which a series of documents produced
by the group were presented, among which, a new bill
presented to the then president José sarney during the
* Brazil. law number 7,488 of June 11th, 1986. it instituted the “national Day against tobacco smoking” [cited 2011 Jun 30]. available from: http://
www6.senado.gov.br/legislacao/listaPublicacoes.action?id=130266

celebration of the first national Day against tobacco
smoking. The project would ban the use of “cigarettes,
cigars, cigarillos and pipes in collective, public or private
places destined to work, leisure, health and education, as
well as in collective transportation of any nature”, except
in places specified for smokers, with the exception of
health and education related places, inlcuding restrictions
in their outdoor areas 7 .
The concern with places free of tobacco environmental
pollution was the basis for the proposals at thet ime. it was
intensified as from the 1980s, when studies on the harmful
effects of tobacco smoke on non-smokers accumulated.
in 1986, the us Department of health and the us
national academiy of sciences national research Council
published a report on second hand tobacco showing its
relationship with lung cancer in healthy non-smokers 8 .
This new scientific evidence gave to the anti-tobacco
movement throughout the world an important argument
in the battle against tobacco: tobacco smoking was then a
problem to others and not only to smokers.
the nearly six-year delay for the approval of the
Conti Project and the creation of the support Group
from the Ministry of health show an important aspect
of the process of development of awareness as to tobacco
harms in Brazil. in 1980, when the project was designed,
the medical field was excited with the subject. our
pulmonologists, main characters in this process, created
events and organizations with the objective of placing the
subject of the harms caused by tobaccosmoking in the
Public health agenda. however, the political conditions
in the country and the current institutional possibilities
at the time did not make possible the execution of the
proposed objective. Gathered in medical societies and
other civil organizations and, in research and education
institutions, they could not aggregate enough support to
transform their battle into political action. such objective
could only begin to be achieved when the Ministry of
health itself started to control this process. for such, a
wider transformation of the health sector was necessary; a
transformation that was related to the more general process
of redemocratization that was happening in the country.
in the mid 1980s, with the end of the dictatorship and
the design of a social pact that allowed the entrance of
the first civil president in 21 years, a new group occupied
the important positions in the Ministry of health.
representatives of the medical way of thinking who would
see health in a broader way, giving appropriate value to
primary care and preventive action, led an inflexion in the
guidelines of the Ministry, allowing the tobacco matter
to achieve an important position in the guidelines of our
Public health.
however, besides the efforts of medical groups
devoted to the tobacco subject, the Ministry of health
had its action circumscribed by legal limits. Therefore,
Legislation and Tobacco Control in Brazil
their initiatives as to tobacco restriction at this time
were limited to educational measures, promotion of
august 29 campaigns and the publication of ordinances
that, although had little immediate impact for smoking
cessation, were of great importance for becoming the
basis for subsequent measures of greater efficacy. The
ordinance # 428/GM, for example, banned the use of
tobacco products inside the Ministry, except in places
destined to their consumption. it allowed the creation of
the inter Ministry ordinance # 3,257, of 1988, which
recommended restrictive measures against smoking in
working environments and provided certificates of merit
to companies that had important participation in antitobacco
campaigns in Brazil 9 .
The TobAcco conTroL TAkes shApe
the redemocratization process that happened
during the late 1980s generated important changes in
the institutional and federative order of the country.
The 1988 Constitution would radically transform the
Brazilian health policy, allowing the emergence of a
unified and decentralized health system, the attribution
of a new responsibility to the state regarding this field
and the widening of its scope. its article 196 established:
“health is a right of all and an obligation of the state,
guaranteed through social and economic policies that
aim at the reduction in disease risk and other health
aggravations as well as the universal and egalitarian access
to actions and services for its promotion, protection and
recovery” 10 . in the specific field of tobacco regulation, the
article 220 of the new Constitution gave competence
to the federal sphere to impose restrictions to cigarette,
alcoholic beverage and medication advertisements and
include warnings on the harms coming from their use
whenever necessary – the article was fundamental for
the justification of the constitutionality of further antitobacco
laws.
in the year of its promulgation, the Ministry of
health created the Decree number 490, which forced
the tobacco industry to stamp the following warning on
the package of their products: “The Ministry of health
Warns: smoking is harmful to health” 11 . in the following
year, a Bill written by representative elias Murad aimed
at regulating article 220 of the new constitution. Besides
the regulation of advertisement of cigarettes, alcoholic
beverages and medications, the project also provided for
the banning of the use of cigarettes and other tobacco
products in collective places, either private or public,
except for areas destined to this end, properly isolated and
with sufficient ventilation. The project also highlighted
the ban in government buildings, hospitals and health
centers, classrooms, libraries, closed work environments
and theaters of all kinds 12 .
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Teixeira LA, Jaques TA
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only in 1996 would Murad’s project become a
llaw (law number 9.294 from 1996); however an
inter Ministry Decree, designed in the previous year,
already determined the use of warnings on cigarette
packages as well as the restrictions of tobacco product
advertisements 13 . Due to the new legislation, the
advertisement of tobacco products on tV and the radio
was restricted to the time between 9pm and 6am, and
warning messages alerting to the several harms provoked
by smoking started to be associated to these ads, in
posters, banners, magazines and newspapers and on
cigarette packages. The previous warning “The Ministry
of health Warns: smoking is harmful to health”, which
had been posted on cigarette packages since 1988, had
its second part replaced by the following sentence:
“smoking can cause heart disease and brain stroke”;
“smoking can cause lung cancer, chronic bronchitis and
emphysema”; “smoking during pregnancy can cause
damage to the baby”; “those who smoke have a higher
incidence of stomach ulcer”; “avoid smoking around
children” and “smoking causes several health damages”.
in 1999, the interim Measure # 1,814 allowed the
Ministry of health to define new warnings. The term
“can cause” was replaced by the term “causes”, making
the warnings more direct and emphatic. new themes
were also introduced 14 .
it is important to highlight that, even though the elias
Murad law was an important tool for the widening of
smoking restrictions, a flaw was evidenced since it did not
establish any punishment to the violator smoker and it
did not clearly define the rules as to smoking places and
places that do not have it, allowing the tobacco industry
to design strategies to soften the law enforecement 15 . even
nowadays tobacco has not been completely banned from
closed environments. nowadays in Brazil, states and
towns have been regulating more comprehensive laws like
the elias Murad law, with more strict oversight, followed
by a broad educational campaign, as in the cases of the
sates of são Paulo and rio de Janeiro, in 2009.
becoming more sTricT
at the institutional level, in the context of sanitary
reformation, the competence of the Ministry of health as
to tobacco control was transferred to inCa, which since
then has housed the PnCt.
Besides the more general guideline of reducing the
number of smokers and consequently the morbidity
and mortality related to the consumption of tobacco
derived products in Brazil, the program aimed at reducing
smoking initiation, mainly among young people;
increasing smoking cessation and reducing exposure to
environmental tobacco smoke. The program acted in
the coordination and execution of actions developed in
partnership with the health state and town secretariats
Brazilian Journal of Cancerology 2011; 57(3): 295-304
and several sectors from the organized civil society, above
all the scientific societies and professional regulating
bodies in the healthcare area.
Besides articulating the May 31 st , the World notobacco
Day, instituted by the Who in 1987, and the
august 29 th campaigns, the national Day against tobacco
smoking, created in 1986, the PnCt started to promote
a series of educational actions, such as congresses and
seminars; programs for tobacco free work environments
and educational actions in schools and healthcare centers.
it also promoted programs for smoking cessation, qualified
healthcares professionals in this field and worked in the
diffusion of methods for smoking cessation in several
media. The PnCt followed the sus rationale so that such
programs could be developed throughout the country,
investing in strategies to decentralize their actions.
restrictions to cigarette and other tobacco products
publicity and the use of warnings on their packages and in
advertisement material were slowly becoming, throughout
the 1990s, one of the main PnCt concerns. inCa actions
regarding the program made the institution very influent in
the process of regulating tobacco smoking in the country.
inCa became a national reference for the design of
technical evaluations, used as subsidies for the creation of
policies both in the legislative and economic levels.
in the mid 1990s, the national Coordination for
tobacco Control from inCa, responsible for the PnCt,
already had important international recognition, having
received, in 1994, the tobacco or health medal from
Who. This distinction was the first one done to this kind
of program in latin america. and that made Brazil host
the “World no tobacco Day” that year.
in 1995, inCa ordered an analysis of the content
of the five best sold brands produced in Brazil from a
laboratory of analysis of tobacco products in Canada,
the laBstat 16 . The report of the outcomes received
considerable media coverage in 1996, when it was verified
that the levels of several substances analyzed were high
above the maximum levels allowed in other countries.
inCa designed, then, a document with a series of
recommendations, highlighting the need of more strict
oversight of tobacco products. according to Cavalcante,
“this important action was the springboard for subsequent
advancements as to tobacco derived products control and
oversight in Brazil” 16 .
in December 2000, the law number 10,167 would
significantly knock the tobacco companies. according to
the new legislation, tobacco commercial ads were restricted
to the internal areas of the points of sales only; and besides
that, such ads could not associate the product to the
practice of sports or have the participation of children
and adolescents. That is, tobacco products publicity was
banned from the radio, television, cinema, newspapers,
magazines, printouts, billboads and sportive article outfits.

ads on internet were also banned, as well as indirect ads
known as “merchandising” and ads in stadiums, tracks,
stages or similar places, as well as the distribution of
samples and gifts and the commercialization of tobacco
products in educational and healthcare institutions; and
it also banned the use of these products in airplanes and
other means of public transportation. it was also through
this law that, as of the year 2003, the sponsorship of
cultural and international sports activities by tobacco
companies was banned, which was later changed
defining 2005 as the year for the banning of sponsoring
international sports activities. This last modification was
due to economic interests, revealed by the organization of
the formula 1 GP Brazil, in 2003, shown on television 17 .
The law number 10,617 provoked strong reactions
among tobacco manufacturers, and its constitutionality
was questioned for overlapping the right of advertising
a product, the obligation of warning and clarifying
the harms associated to it. the national industry
Confederation, associated to these interests, petitioned for
a Direct action of inconstitutionality as to the project,
with the objective of totally freeing tobacco publicity 18 ;
but, in spite of all resistance, the process of strengthening
the tobacco legislation and regulation was unavoidable.
in 1999, through the federal law number 9,782,
the national health surveillance agency - anVisa was
created, with the aim of promoting health protection
of the population through sanitary control of products
and services. among its attributions, there is the control
and oversight of cigarettes and other tobacco products.
anVisa would become an instrument of great efficacy
for tobacco control. its authority to work with law
enforcement, issue fines and standardize several aspects
related to tobacco production and consumption enabled it
to have broader range of actions when compared to those
put into practice by the Ministry of health.
in the year of its creation, one of its first resolutions
determined the annual registry of all tobacco products
and the delivery of annual reports from tobacco
manufacturers on the products they commercialized 19 .
in an article published in VeJa, in november 1995 20 ,
thus years before the creation of anVisa, the average
levels of tar and nicotine in the Brazilian cigarettes were
published. The article had raised doubts on the reliability
of the data presented by cigarette manufacturers and
highlighted that the use of the word mild, which should
indicate products of lower levels was being used in one
of the strongest brands sold in the country 20 . alert to
these questions, anVisa published, in March 2001 a
resolution establishing the maximum tar, nicotine and
carbon monoxide levels allowed in the smoke of cigarettes
commercialized in the country 21 , and banning the use of
any adjective on cigarette packages or publicity material,
such as: low level, mild, light, moderate levels and others
Legislation and Tobacco Control in Brazil
that could induce the consumers to misinterpret the levels
of toxic substances contained in the cigarettes.
in May 2001, another rule from anVisa regulated
the printing of images that illustrate the meaning of
the warnings on cigarette packages. The warnings also
started showing the “tobacco Quitline”, a service for
the orientation offered by the Ministry of health 22 . The
characteristics of the images and warnings were determined
by anVisa and technically supported by inCa. one of
the objectives of their use is to fight the social acceptance
of smoking and to break the “positive aura” that had been
created around cigarettes for decades. its justification is
related to the field of cognitive-behavioral psychology,
postulating that one of the factors that can contribute for
smoking cessation is the bad feeling caused by the package
of the product. Besides that, cigarette packages started to
be considered as an important communication vehicle on
the harms caused by smoking, having an educational role,
through strong warnings that aim at braking the impulses
of smokers, making them think before automatically
lighting up their cigarette 16 .
inCa and anVisa replaced the group of images and
warnings in 2004 for stronger images, when compared to
the initial ones, so that the images kept causing impact;
and nowadays (2010), a third group of images of strong
impact started circulating on cigarette packages 14 . as from
2004, packages and publicity of tobacco products suffered
even more interventions. a new anVisa resolution, the
same one that introduced the second group of images,
determined that the warnings should also be posted on all
kinds of publicity of the products. The following sentences
were also included: “sale prohibited to persons under
18 years of age” and “This product contains more than
4,700 toxic substances and nicotine that cause physical
or psychological addiction. There are no safe levels for the
consumption of these substances” 23 .
CONCLUSION
the standardization actions put into practice by
anVisa as well as the actions from PnCt, coordinated
by inCa, have built a strong framework of knowledge and
extensive practice in the field of tobacco control. Besides
the fact that the country is the second largest producer
of tobacco and the biggest exporter of tobacco leaves in
the world, the PnCt characteristics and the regulating
legislative apparatus that was formed made Brazil a
world reference in tobacco control measures. in 1999,
when the World health assembly began to design what
became the first international treaty of public health, the
framework Convention for tobacco Control (fCtC),
a document that proposes a series of measures against
tobacco, Brazil became one of the main leaders in the
process of negotiation of its text, unanimously approved
in 2003, by the World health assembly.
Brazilian Journal of Cancerology 2011; 57(3): 295-304
301

Teixeira LA, Jaques TA
302
The history of the state action for tobacco control in
Brazil is an important advancement if we think that the
smoking prevalence dropped from 35% in 1989 to 16%
in 2006 24 . Besides that, there are indications that the
effect of these actions is being translated into numbers in
the graphs on cancer and other diseases incidence, given
the reduced mortality rate for lung cancer among men
between 30 and 59 years of age from 1980 to 2003 25 . such
data demonstrate that the fight of tobacco in Brazil has
been obtaining positive results, signs of relative success.
CONTRIBUTIONS
luiz antonio teixeira was responsible for the
conception and planning of the research project, in which
the student tiago Jaques participated. tiago alves Jaques
was responsible for researching and obtaining data for
the article. analysis, data interpretation and writing were
performed by luiz teixeira and tiago Jaques altogether.
luiz Jaques was in charge of the critical review.
Declaration of Conflicting Interests: Nothing to declare
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com a redação, os acréscimos e alterações que lhes
introduziram a Lei n° 10.167, de 27 de dezembro de
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de 2001 [Internet]. Brasília; 2004 [citado 2011 jun 30].
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FF8080812B83FEF4012B88ACE38A72D7.htm
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para efeitos cadastrais, de todos os produtos fumígenos,
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monóxido de carbono presentes na corrente primária da
fumaça, para os cigarros comercializados no Brasil [citado
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o=46&data=&dataFim=&ano=&pag=1
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produtos fumígenos derivados do tabaco, conterão
na embalagem e na propaganda, advertência ao
consumidor, sobre os malefícios decorrentes do uso
destes produtos [citado 2011 jun 30]. Disponível em:
http://portal2.saude.gov.br/saudelegis/leg_norma_
espelho_consulta.cfm?id=3700221&highlight=&bkp
=pesqnorma&fonte=0&origem=0&sit=0&assunto=&
qtd=10&tipo_norma=32&numero=104&data=&dat
aFim=&ano=&pag=1
Legislation and Tobacco Control in Brazil
23. Agência Nacional de Vigilância Sanitária (Brasil).
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os produtos fumígenos derivados do tabaco, conterão na
embalagem e na propaganda, advertência ao consumidor,
sobre os malefícios decorrentes do uso destes produtos
[citado 2011 jun 30]. Disponível em: http://portal2.
saude.gov.br/saudelegis/leg_norma_espelho_consulta.cf
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&origem=0&sit=0&assunto=&qtd=10&tipo_norma=3
2&numero=335&data=&dataFim=&ano=&pag=1
24. Iglesias R, Jha P, Pinto M, Costa e Silva VL, Godinho J.
Controle do tabagismo no Brasil [Internet]. Washington
(DC): Banco Internacional para Reconstrução e
Desenvolvimento/ Banco Mundial; c2007 [citado 2011
jun 30]. 119 p. (Documento de discussão – saúde,
nutrição e população). Disponível em: http://portal.
saude.gov.br/portal/arquivos/pdf/Controle%20do%20
Tabagismo%20no%20Brasil.pdf
25. Malta DC, Moura L, Souza MFM, Curado MP, Alencar
AP, Alencar GP. Tendência de mortalidade do câncer de
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S1806-37132007000500008.
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303

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304
Resumo
Introdução: o artigo trata do processo de surgimento e consolidação da política antitabaco no Brasil, discutindo
o desenvolvimento da legislação brasileira nesse campo, entre a década de 1960 e os primeiros anos do século XXi.
Objetivos: Discutir as primeiras iniciativas legislativas de normatização da comercialização e da propaganda de cigarros,
postas em pauta no congresso, na década de 1960; avaliar as consequências das mudanças na saúde Pública, instituídas
a partir do processo de redemocratização do país, nas ações de controle do tabaco e avaliar as leis e campanhas para
controle da comercialização e propaganda de produtos fumígenos postas em marcha nos anos 1990. Método: o trabalho
foi elaborado a partir da análise da legislação e fontes secundárias referentes ao desenvolvimento das ações antitabaco
no país. Resultados: no período estudado observou-se o intenso fortalecimento da legislação relativa ao controle do
tabaco no país. Conclusão: Vis-à-vis ao desenvolvimento das ações contra o tabaco, construiu-se um forte arcabouço
de conhecimentos e uma extensa prática no campo do controle do tabagismo. tal aspecto somado aos dados sobre
uso do tabaco e incidência de câncer de pulmão sugerem o sucesso das medidas antitabaco postas em prática no país.
Palavras-chave: legislação como assunto; tabaco; tabagismo/legislação & jurisprudência; Controle e fiscalização de
Produtos Derivados do tabaco; Brasil
Resumen
Introducción: el artículo describe el proceso de surgimiento y consolidación de la política de control del tabaco en
Brasil, discutiendo el desarrollo de la legislación brasileña en este campo, entre los años 1960 y los primeros años del
siglo XXi. Objetivos: Discutir la normalización legislativa inicial de la comercialización y publicidad de los cigarrillos, en
la agenda del Congreso en la década de 1960; evaluar las consecuencias de los cambios en la salud pública introducidos
durante el proceso de democratización del país en las acciones de control del tabaco, y evaluar las leyes para controlar
la comercialización y publicidad de los productos del tabaco, puestas en marcha en la década de 1990. Método: el
trabajo se basó en el análisis de la legislación y las fuentes secundarias para el desarrollo de las acciones de control del
tabaco en el país. Resultados: en el periodo estudiado se pudo observar un fortalecimiento intenso de la legislación
relativa al control del tabaco en el país. Conclusión: ante el desarrollo de acciones contra el tabaco un marco sólido
de conocimientos y una vasta experiencia en el campo del control del tabaco han sido creados. este aspecto, junto
con datos sobre el consumo de tabaco y la incidencia de cáncer de pulmón sugieren el éxito de las medidas de control
del tabaco implementadas en el país.
Palabras clave: legislación como asunto; tabaco; tabaquismo/legislación & jurisprudencia; Control y fiscalización
de Productos Derivados del tabaco; Brasil
Brazilian Journal of Cancerology 2011; 57(3): 295-304

History
23 Years of Tobacco Control in Brazil
Article submitted on 05/31/11; accepted for publication on 06/16/11
23 Years of Tobacco Control in Brazil: the 1988 Brazilian
Tobacco Control Program Today
23 Anos de Controle do Tabaco no Brasil: a Atualidade do Programa Nacional
de Combate ao Fumo de 1988
23 Años de Control del Tabaco en Brasil: Actualidad del Programa Nacional de
Combate al Tabaquismo de 1988
Luiz carlos romero 1 , vera Luiza da costa e silva 2
Abstract
Introduction: The tobacco epidemic greatly increased in Brazil as of the 1970s; its confrontation, however, was limited
to some medical organizations initiatives. a national Program of tobacco Control was created in the structure of
the Ministry of health in 1985 and, in 1988, its coordination felt the necessity to plan its performance in a wider
horizon. Objective: to analyze the creation, implementation and results of the national Program of tobacco Control,
designed in 1988 by the federal government, providing strategies and goals for tobacco control in the country, within
five major strategic areas: (i) educational actions aimed at health and education professionals, (ii) awareness raising
actions targeted at the general population and groups at risk, (iii) legislative and economic actions (iv) medical and
social actions, and (v) actions on research and information. Method: Qualitative; historical and documental research.
Results: it is evident that the plan allowed important advances in the government performance for tobacco control
in the country, successfully meeting the planned goals, and reducing tobacco smoking and consumption prevalence.
Conclusion: The program established in 1988 anticipated the main strategies that are, today, recommended by the
World health organization. Designing a strategic vision of the problem, creating an appropriate management model
for its development, and adopting a multidisciplinary and decentralized approach were the essential tools for the
successful actions for tobacco control in Brazil.
Key words: smoking/history; smoking/prevention & control; national Program of tobacco Control; Brazil
1 Physician. specialist in Public health. legislative Consultant of the federal senate. email: romero@senado.gov.br.
2 Physician. PhD in Public health. associate Professor at escola nacional de saúde Pública. fundação oswaldo Cruz. email: veradacostaesilva@ensp.fiocruz.br.
Correspondence address: luiz Carlos romero. sQn 209/e/102. Brasíia (Df), Brazil. CeP: 70854-050.
Brazilian Journal of Cancerology 2011; 57(3): 305-314
305

Romero LC, Costa e Silva VL
306
INTRODUÇÃO
a epidemia de tabagismo acelerou-se vertiginosamente
no The tobacco epidemic rose vertiginously in Brazil as
from 1970. Between 1970 and 1986, the number of
cigarettes sold in the domestic market grew 132% - at
a time when the adult population grew only 69% - and
cigarette consumption rose from about 780 units per
capita to more than 1,200. in the mid 1970s, there were
25 million smokers in the country; ten years later, this
number was already 33 millions – a growth of 32% 1 .
The information available from the time about the
prevalence of smokers was very limited and consisted of
the result of a survey carried out by the Pan-american
health organization in eight latin-american cities that
found in são Paulo – the only Brazilian city investigated –
a tobacco prevalence of 54% among men and 20% among
women, in 1972 2 ; and a survey done in 1989 by the
feeding and nutrition national institute (inan), with
the cooperation of the Brazilian institute for Geography
and statistics (iBGe) and the Government Management
Planning institute (iPlan), which revealed a tobacco
prevalence in Brazil of 34.8% among those above 15
years of age 3 .
The first national studies demonstrating the increase,
in the country, of tobacco-related diseases had started
in the late 1970s and, in 1987, the Ministry of health
estimated the occurrence of 80 thousand to 100 thousand
premature deaths due to smoking 1 .
in July 1979, a first national Program against
smoking was designed by 46 entities – medical
associations, university centers, health secretariats and
others – gathered in são Paulo under the umbrella of the
Brazilian Cancerology society; and, in april 1980, the
first Brazilian Conference against tobacco was organized
in Vitória 4 .
in the mid 1980s, actions “against smoking” in Brazil
were incipient and poorly connected, taken on mainly by
a few pioneer physicians leading their associations and
organizations, among which it is important to highlight
the names of José rosemberg and edmundo Blundi, at
the Brazilian society of tuberculosis and Pulmonology;
antonio Pedro Mirra and Thomas szego, at the Brazilian
Medical association; Mario rigatto and aloyzio achutti
at the Brazilian Cardiology society; Jayme zlotnik at the
Paraná Medical association and Jayme santos neves, at the
espirito santo league against tuberculosis, among others.
as to the government action on the control of tobacco
smoking, some states made history for their early and
decisive action, generating facts and conceiving strategies
that afterwards started being employed by other states
and towns and at the national level. it was in the largest
Brazilian Journal of Cancerology 2011; 57(3): 305-314
tobacco producing state in Brazil, rio Grande do sul,
that, as from 1975, the first steps were taken, targeting
collaboration between the government and civil society,
which would initially result in official support to the work
of the rio Grande do sul Medical association in their
campaigns for a state legislation on tobacco and, then, at
the establishment of the state Program against smoking
in the early 1980s 5 .
The other pioneer state in tobacco control was são
Paulo which, with the support of the Brazilian Medical
association and the university of são Paulo, gained
impact on the media and the federal government for
the creation of the embryo of what would become the
national Program for tobacco Control 6 . one of the
first administrative acts targeting tobacco control in
Brazil occurred in this state, with the creation of the
tobacco Control Program at the são Paulo secretariat
of health, through the Decree number 26,199, of 1986,
which instituted a work group to study and propose the
regulation of the state law number 5,384, of 1986, which
banned smoking in government facilities.
The third was the state of Paraná, whose commitment
of the state health secretariat was made official in 1979,
through a resolution that determined the execution of
educational and informative actions about smoking. in
1980, Paraná reached national visibility with the tobacco
strike, which served as example for the first federal law
for tobacco control in the country, sanctioned in 1986,
creating the national Day against tobacco smoking 7 .
The government action at the federal level, however,
only began to be institutional in 1985, with the constitution
of the support Group for tobacco Control in Brazil
(GaCt) and the creation, in 1986, of a national Program
against tobacco smoking (PnCf), as a joint action of
the national Divisions of sanitary Pulmonology (DnPs)
and Chronic-Degenerative Diseases (DnDCD) of the
Ministry of health, financed with resources of the national
Campaigns against tuberculosis and fighting Cancer, soon
followed by the creation of a tobacco Control Program,
initially at regional level, at the Brazilian national Cancer
institute (inCa), in rio de Janeiro. This effort had as its
institutional godfathers the physicians Germano Gerhardt
filho, director of DnPs, Geniberto Paiva Campos, director
of DnDCD and the Minister of health Valdir arcoverde.
The coordination of PnCf would be transferred to inCa/
Ms, in rio de Janeiro, in 1992.
at the legislative level, only as from 1980, laws
banning smoking in some environments started to be
promulgated in the state of Paraná (1980), in the city of
são Paulo, in the state of são Paulo (1981) and the state
of rio Grande do sul (1983) 4 . in 1986, the national
Day against tobacco smoking was instituted by national

law, a fact that marked the reversal of a tendency in our
legislation – up to then completely devoted to protect the
tobacco industry – inaugurating, though still timidly, a
standardization targeting tobacco control as a collective
health problem.
the first federal law for tobacco control in the
country, number 7,488, of June 11 th 1986, determined
that the executive Power, through the Ministry of health,
promoted annually, at the week preceding august 29 th ,
declared as the national Day against tobacco smoking,
a campaign at national level, aiming at warning the
population about the harms caused by tobacco use.
in 1988, the PnCf was well institutionalized at the
structure of the Ministry of health and its coordination
felt the necessity of planning its action in a broader
horizon. a Work Plan for the 1988-2000 period that
“aimed at organizing the government action and the nongovernmental
articulation to control tobacco in Brazil”
was then designed 8 .
This plan – discussed and approved by the GaCt
and technical and financing bodies from the Ministry of
health involved – established, for the first time, short-
and long-term objectives and goals and defined strategies
for governmental and societal actions regarding tobacco
control in Brazil, “aiming at promoting health and
reducing the impact of tobacco-related diseases”.
23 years after this formulation, it is understood that
an evaluation of these results does not only demonstrate
the viewpoint of the group who conceived it and the
Public health scenario that favored its creation and
implementation in the following years but also their
success and the modern status of the goals and strategies
then proposed. it also highlights that the planning of
Public health actions based on evidences constitutes a
fundamental tool for the success of interventions performed
and that the institutionalization of a program with a defined
management proposal favors its implementation.
Therefore, this study has as objective to analyze the
creation, implementation and results of the PnCf,
conceived in 1988 by the federal government, establishing
strategies and goals for tobacco control in the country
within five important fields of action: (i) an educational
action towards healthcare and education professionals;
(ii) an educational action towards population-based risk
groups and the general population; (iii) a legislative action
and in the economic sphere; (iv) a medical and social
action; and (v) a research and information action.
METHODS
tit is a qualitative study, with historical and document
research in webpages and old publications by the PnCf/
Ms and in online publication banks, especially scielo,
23 Years of Tobacco Control in Brazil
using as describers “tabagismo no Brasil” (tobacco
smoking in Brazil), “controle do tabagismo”(tobacco
control), “PnCf”, “história do controle do tabagismo”
(history of tobacco control). The information collected
was then analyzed according to tobacco control policies to
reduce the demand identified in the package MPoWer
of the World health organization (Who) and examined
as to the adhesion to principles designed in framework
Convention for tobacco Control (fCtC) from Who
and its guidelines.
RESULTS AND DISCUSSION
two important goals for tobacco control were established
by the Plan: (i) to reduce the consumption of tobacco
products; and (ii) to reduce tobacco prevalence.
the choice of tobacco product consumption as an
indicator, on top of tobacco prevalence, was due to the
fact that the population-based surveys were still rare and
irregular at the time, and the consumption per capita was
the main information available for the regular monitoring
of the epidemic. The smuggling of cigarettes – important
limiting factor for the employment of this class of indicator,
besides not allowing disaggregation of data per age, gender
and income – was not relevant at the time and its growth
happened as from the early 1990s 9 .
Withn 12 years, that is, up to 2000, the Plan intended to
stabilize – total and per capita – cigarette consumption when
compared to the consumption level of 1988 and reduce the
tobacco prevalence to 30% among adults, and to less than
5% among adolescents and young teens.
for the accomplishment of these goals, five important
fields for strategic actions were established: (i) an educational
action towards healthcare and education professionals; (ii)
an educational action towards population-based risk groups
and the general population; (iii) a legislative action and in
the economic sphere; (iv) a medical and social action; and
(v) a research and information action.
the educational actions targeted both the groups
considered priority for the implementation of the defined
strategies (healthcare and education professionals, legislators,
sanitary authorities and opinion makers) and the population
at risk segments (children, adolescents and young people;
pregnant women and risk patients, secondhand smokers;
workers). Direct educational actions were planned for these
groups; the production and diffusion of theoretical and
scientific information; the integration of education actions
for health in the school curricula, at health services and work
environments; the organization of social communication
campaigns; and the sensitization and mobilization of opinion
makers.
the legislative action aimed at encouraging the
production, by the federal, state and town legislative powers,
of laws that were identified as necessary, forwarding bills,
acting with legislators and offering them information,
Brazilian Journal of Cancerology 2011; 57(3): 305-314
307

Romero LC, Costa e Silva VL
308
technical support and assistance. The priorities in this area
were to obtain national laws (i) banning the use of tobacco
in close public places; (ii) prohibiting publicity of tobacco
products and the sponsorship of cultural and sports events
by tobacco producers and (iii) demanding the presence of
warnings on tobacco packages.
in the economical sphere, the Plan intended to obtain
the formulation of a government policy, responsibility of
the Ministry of health, which “meets the interests of the
population health, without compromising tax revenues and
employment”. here the main objectives were: (i) to increase
taxes on tobacco products up to a minimum of 80% of the
selling price and (ii) to remove the price of cigarettes from
the calculation of cost-of-living indices.
The social and medical action was concentrated on
the encouragement to the implementation of “smoking
cessation programs” by both governmental and nongovernmental
organizations. The plan also provided for
the encouragement and financing of studies and surveys
destined to the production of epidemiological information
of interest for the diagnosis, follow up and evaluation of the
governmental action as well as the problem evolution. a
technical cooperation with international bodies would also be
pursued, aiming at the national scientific and technological
development in the field of tobacco control.
an innovative and strategic feature that was configured
in this plan – and that was adequate to the creation, at
that time, of the Brazilian unified health system (sus)
– was the promotion for the creation and broadening of
programs at both state and town levels and with nongovernmental
organizations, with the understanding that it
was at these levels that the program would provoke impact
in the population, always with the help and support of the
community and several organizations. The program was
decentralized and involved hundreds of towns through the
promotion of regular trainings at the state and town levels,
and the use of this management model was configured as
essential to its development.
another perspective that was already configured in
this plan was the one of multi-sectors, with the planning
of involvement of several ministries, which would become
effective in the following decades, with the creation of the
inter-Ministerial Commission of negotiation of fCtC and
the organization of the civil society, which also occurred.
The policy that was being designed for tobacco control in
Brazil adopted, as its guidelines, the Who recommendations
of 1979, established at the 33 rd World health assembly, in
1980 10 , besides those in the salvador letter, of 1979 11 , in
which a group of physicians, who had gathered in a seminar,
“suggests fundamental measures against tobacco” to be
implemented in the country.
the advent of the fCtC, in May 2003 12 , and the
formulation of the MPoWer strategy – Who Measures
Plan to reverse the tobacco epidemic -, in 2008 13 , allows
appreciation of the strategies and goals of the PnCf
Brazilian Journal of Cancerology 2011; 57(3): 305-314
1988-2000 with other eyes, recognizing its coherence and
modernity.
frame 1 shows the correlation between the dispositions
of the framework Convention and the corresponding
measures currently recommended by Who (MPoWer
Measures Plan) and the goals established by the Work Plan
for the Period 1988-2000 of the PnCf (1988-2000).
Through this comparison, it is evident that, back in 1988,
the policy for tobacco control formulated by GaCt and by
the coordination of the PnCf of the Ministry of health
already anticipated – with some points that would be
reviewed according to further research that changed the
paradigm of non-smoker protection – guidelines, goals and
strategies that, later on, would be recommended by Who
and consolidated at the fCtC.
the results obtained in the country, with the
implementation of this policy, seem to confirm its effectivity
(frame 2).
a difference that calls attention between the PnCf
1988 policy and the fCtC/MPoWer (2003/2008) is the
strategy adopted to protect the population against tobacco
smoke. Goal 11 of the PnCf 1988 was that, before 1990
there shall be a federal law banning the use of tobacco in
closed public places (in special schools, health centers and
public transportation) and establishing separate areas for
smokers and non-smokers at work and food consumption
environments. This strategy is not aligned with the current
knowledge that any technology of ventilation and airconditioning
currently available can eliminate the particulate
substances of smoke and reduce exposure to tobacco
environmental pollution to safe levels 14 , and that “the
completely free-tobacco environments are the only proved
way of properly protecting people as to the harmful effects
of secondhand smoking” 13 . it was, nonetheless, coherent
with what was known then, since studies on the impact of
tobacco pollution on secondhand smoker´s health was only
beginning 15 .
The PnCf goal was achieved in 1996 with the approval,
by the national Congress, of the law number 9,294, of
1996, which banned smoking in closed environments, but
permitted the creation of “fumódromos”, [designated places
for smoking] currently one of the most important sanitary
subjects occupying the agenda of the federal legislative
Power. it is worth noticing that, in 1996, the PnCf was
already struggling for “tobacco smoke free environments”
without the establishment of areas for smokers; however,
both influence and interference of the tobacco industry was
stronger, and it became clear in the construction of the bill
that was approved that year by the Brazilian parliament 16 .
The goal of increasing taxes on cigarettes to 80% of
the consumer price was not achieved. nonetheless, data
from the internal revenue service show that there is an
approximation to that: taxes corresponded to 71.6% of the
price of a cigarette package, in 2007; 72.2% in 2008; and
76,3% in 2009 9 . anyway and unfortunately, this policy was

MPOWER/FCTC (2003/2008) PNCF (1988-2000)
M – Monitor tobacco use and prevention
policies (CQCT, Article 20)
P – Protect the population against
tobacco smoke (FCTC, Article 8)
O – Offer help for smoke cessation
(FCTC, Article 14)
only reflected in the actual increase of prices as from 2009,
since Brazilian cigarettes are still among the cheapest in the
world, making them accessible, especially to young adults
and the low income population.
as to the implementation of cessation programs, whose
objective was to be available, in at least, every city with more
than a million inhabitants before the year 2000, the goal, was
apparently achieved: up to June 2010, 1,594 health units of
the sus network, in 715 towns, maintained these programs.
Besides that, the government maintains a call center that
provides assistance on how to quit smoking, through free
calls. This is an activity that grows in importance in our
country, both as a state and a private action. it is worth
reporting that the country already has more former-smokers
than smokers: 26 millions against 24.6 millions 17 .
from 1985 to the present days, several written, spoken
and tV media campaigns have been shown regularly, more
or less intensely, at national and regional levels. as of 1988,
warning messages are mandatory on cigarette packages and in
23 Years of Tobacco Control in Brazil
Chart 1. Correlation between the measures recommended by the Measures Plan (from WHO) to reverse tobacco epidemic (MPOWER) coming
from the FCTC and the goals established by the Work Plan for the 1998-2000 period of the PNCF (1988-2000)
W – Warn on the danger of tobacco
(FCTC, Articles 11 and 12))
E – Enforce the publicity, promotion and
sponsorship bans (FCTC, Article 13)
R – Increase taxes on tobacco (FCTC,
Article 6)
Goal 16 – Produce statistical and epidemiological information of
interest for diagnosis, follow up and evaluation of the government
action and evolution of the problem
Goal 11 – Before 1990, there shall be a federal law banning the
use of tobacco in closed public places (especially schools, health
centers and public transportation) and establishing separate areas
for smokers and non-smokers in work and food consumption
environments
Goal 15 – Before the year 2000, all the federate units and cities with
more than a million inhabitants will have to have smoking cessation
programs
Goal 5 to 10 – Develop an educational action to healthcare and
education professionals; diffuse scientific information to healthcare
and education professionals, legislators, sanitary authorities, health
institutions; develop an educational action directed to the general
population and priority groups (children, adolescents and young
adults, pregnant women, workers, risk patients and secondhand
smokers) at schools, health services, community organizations and
work environments; carry out social communication campaigns
Goal 12b – Before 1995 there must be a federal law demanding the
presence of warnings on cigarette packages, tobacco packages and
other tobacco derived products, as well as in all publicity material
Goal 12 a – Before 1995, there shall be a federal law banning
promotion, advertisement, direct and indirect publicity, support
and sponsorship of cultural and sports events by producers,
manufacturers, industries and sales people of tobacco products
Goal 13 – progressively increase taxes of tobacco products up to, at
least 80% of selling price, up to year 2000
2002, images started to illustrate these warnings, and access
to information on the harms of cigarettes became universal.
recent research results show that 75% of current smokers
think about quitting smoking due to these policies 18 . as a
consequence of these information campaigns and warning
images, the information available shows that 96.1% of people
who are 15 years old or above believe that smoking can cause
serious diseases; 91.4% know that cigarette smoke can cause
diseases and 77% refer as having been informed about it
through television or radio 18 .
The banning of publicity and sponsorship was reached
in 2000, a result of several legislative propositions of both
parliamentary and executive initiatives and after a long and
difficult processing, also with strong opposition lobby by
the tobacco industry 19 . The publicity of tobacco products
is nowadays banned from the media, with the exception
of that done in points of sale, and it has been intensely
broadened since then, just like institutional publicity and
social corporate responsibility. as a result, 31.3% of the
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309

Romero LC, Costa e Silva VL
310
Chart 2. Resultis achieved regarding tobacco control in Brazil, according to recommended measures by the Measures Plan [from WHO]
to Reverse Smoking Epidemic (MPOWER) from FCTC and the goals established by the Work Plan for the 1998-2000 period of the PNCF
(1988-2000)
MPOWER/FCTC (2003/2008) PNCF (1988-2000) Current situation
M – Monitor the use of tobacco and
prevention policies (FCTC, Article 20)
P – Protect the population against
tobacco smoke (FCTC, Article 8)
O – Offer help for smoke cessation
(FCTC, Article 14)
W – Warn on the danger of tobacco
(FCTC, Articles 11 and 12)
E – Enforce the publicity, promotion and
sponsorship bans (FCTC, Article 13)
R – Increase taxes on tobacco (FCTC,
Article 6)
Brazilian Journal of Cancerology 2011; 57(3): 305-314
Goal 16 – statistical and
epidemiological information
Goal 11 – National Law for
Tobacco free environments
Goal 15 – programs for
smoking cessati
Goals 5 to 10 - Information
Goal 12b - Warnings
Goal 12a – Banning of
promotion, advertisement
and sponsorship
Goal 13 - taxation
Existence of enough statistical and
epidemiological information to
monitor the government action and
the control situation
Current law (1996) bans smoking
in public or private collective
environments (government offices,
health centers, educacional
facilities, libraries, cinemas,
theaters, work environments and
public transportation), but allows
“fumódromos”, that is, areas destined
exclusively to smokers “properly
isolated and with convenient airing”.
Several state and town laws ban
smoking in collective environments.
The extinction of “fumódromos” is the
subject of a federal bill
Exisitence of a free program in the
public health system as of 2004.
Tobacco Quitline made available freely
since 2002. Growing and pent-up
demand
Surveys inform high knowledge rates
on “the harms of smoking” among
all population segments. Federal
Constitution of 1988 determines the
presence of warnings with images
“that illustrate its meaning” as of 2001
The Federal Constitution from 1988
determines that publicity “will be
subjected to legal restrictions”.
Publicity restricted to points of sales;
promotion and sponsorship banned.
(Law number 9,294, of 1996).
Restriction/prohibition of publicity/
promotion in points of sales is
the subject of a bill at the Federal
Legislative
Taxes correspond between 72% and
76% of the price to consumers (2007
to 2009)

Brazilian population above 15 years of age say they notice
publicity of cigarettes where they are sold and 21.3% in
other places and in sports events 17-18 .
The information available demonstrates the success
of the Brazilian program for tobacco control and the
achievement of the main goals defined in 1988.
23 Years of Tobacco Control in Brazil
The official data show a significant and sustained fall
of both cigarette consumption (Graph 1) – even when
considering cigarette smuggling, whose growth increased in
importance in the early 1990s, - and tobacco prevalence. in
more recent years, this fall has been better noticed among men,
with women keeping stable consumption (table 1 and 2).
Graph 1. Legal and total consumption per adult (units) and actual price index of cigarettes (December 93 – 100)
Source: iglesias et al. (2007) 9
Table 1. Tobacco Prevalence (%) among adults between 1989 and 2010, per gender, according to population studies. Brazil
Year Survey
Total
Prevalence (%)
Men Women
1989 PNSN3 34.8(*) 40.3 26.2
2003 PMS20 18.1(**) 22.5 14.4
2002/3003 INCA21 18.5(*) 22.8 15.2
2008 PETab/IBGE22 17.2(*) 21.6 13.1
(*) 15 years old and +; (**) 18 years old and +
Source: ViGitel/Ms23 Table 2. Tobacco Prevalence among adults (18 years of age and above ), per gender, in 26 capitals and Federal District. Brazil, 2006-2010
Year Total Men Women
2006 16.2 20.2 12.7
2007 16.6 21.3 12.5
2008 16.1 20.5 12.4
2009 15.5 19.0 12.5
2010
(*) 15 years old and +; (**) 18 years old and +
Source: ViGitel/Ms
15.1 17.9 12.7
23
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Romero LC, Costa e Silva VL
312
independent studies confirm this fact 24 and its impact
in the reduction of mortality associated to smoking 25 ,
making this program one of the biggest success of
prevention and health promotion in the country.
CONCLUSION
The 1988 PnCf was an advance in the planning of one
of the main actions of prevention and control of diseases
of the Brazilian government and allowed guidance for the
construction of a permanent project of national scope, with
well documented and actual impact at the level of health of
our population. The management model of program can
serve as example to other programs for health promotion in
the country, given its insertion within the sus rationale and
the pioneer approach in the use of the multi-sector policy for
the control of risk factors.
The series of effective conquests, from the formulation of
the PnCf in 1988, resulted in a significant fall of tobacco
consumption and prevalence of smokers in the country,
within all age groups and genders.
however, two decades later, some challenges persist,
among which the need to adopt a policy of regular increase
in taxes and prices; the banning of smoking in closed public
places, without areas designated to smokers; the prohibition
of institutional publicity, of social corporate responsibility and
in points of sale; the broadening of access to treatment for
tobacco users and the strengthening of strategies targeting
public information in more vulnerable groups, that is,
through warnings on cigarette packages, either through
educational programs and social communications.
new areas that have not been contemplated by the
1988 program, such as the regulation of tobacco products,
smuggling control and the support to alternatives to tobacco
cultivation, should be the target of growing government
support and constitute the current priorities for tobacco
control in Brazil.
finally, the 1988 program gave place to a much more
comprehensive program, based on the fCtC, from Who,
that the country will have to honor as a way of advancing on
its compromise with Public health.
CONTRIBUTIONS
Both authors contributed to the conception and planning
of the article; the acquisition, analysis and interpretation of
information and the writing of the material.
Declaration of Conflicting Interestss: Nothing to Declare
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Resumo
Introdução: a epidemia de tabagismo acelerou-se grandemente no Brasil, a partir da década de 1970; seu enfrentamento,
no entanto, limitava-se a iniciativas de algumas organizações médicas. o Programa nacional de Combate ao fumo foi
criado na estrutura do Ministério da saúde em 1985 e, em 1988, sua coordenação sentiu necessidade de planejar sua
atuação num horizonte mais amplo. Objetivo: analisar a criação, implementação e resultados do Programa nacional
de Combate ao fumo, concebido em 1988 pelo governo federal, estabelecendo estratégias e metas para o controle do
tabagismo no país, em cinco grandes campos de atuação: (i) ação educativa junto a profissionais de saúde e educação;
(ii) ação educativa junto a grupos populacionais de risco e à população em geral; (iii) ação legislativa e na esfera
econômica; (iv) ação médico-social; e (v) ação de pesquisa e informação. Método: estudo qualitativo com pesquisa
histórica e documental. Resultados: evidencia-se que o programa permitiu avanços importantes na atuação do governo
para o controle do tabagismo no país, atingiu as metas estabelecidas e resultou na redução do consumo de tabaco e
da prevalência de tabagismo. Conclusão: o programa estabelecido em 1988 já contemplava as principais estratégias
que, hoje, viriam a ser recomendadas pela organização Mundial da saúde. ao delinear uma visão estratégica das ações
de controle, criar um modelo de gestão adequado ao seu desenvolvimento e adotar um enfoque multidisciplinar e
descentralizador foram elementos essenciais para o sucesso das ações de controle do tabagismo no Brasil.
Palavras-chave: tabagismo/história; tabagismo/prevenção e controle; Programa nacional de Controle do tabagismo; Brasil
Resumen
Introducción: la epidemia de tabaquismo aceleró grandemente en Brasil en la década de 1970; su confrontación, sin
embargo, era limitada a unas pocas iniciativas de organizaciones médicas. el Programa nacional contra el tabaco fue
creado en la estructura del Ministerio de la salud en 1985 y, en 1988, su coordinación sentía necesidad que planear en
un horizonte más amplio. Objetivos: analizar la creación, implementación y resultados del Programa nacional contra
el tabaquismo, aprobado en 1988 por el gobierno federal, proporcionando los objetivos y metas para el control del
tabaco en el país en cinco grandes áreas estratégicas de acción: (i) actividades educativas para los profesionales salud
y educación, (ii) actividades educativas con la población en general y los grupos de alto riesgo, (iii) acción legislativa
y en la esfera económica, (iv) acción médica y social, y (v) actividades de investigación e información. Método:
estudio cualitativo; investigación histórica y documental. Resultados: en todas las áreas hubo importantes avances
en las medidas adoptadas por el gobierno, cumplimiento de las metas y reducción de la prevalencia de tabaquismo
y del consumo per capita de tabaco. Conclusiones: el Plan de 1988 ya contenía las principales estrategias hoy día
recomendadas por la organización Mundial de la salud. Por adoptar una visión estratégica en la planificación en
salud, crear un modelo de gestión adecuado a su desarrollo e incluir un enfoque multidisciplinario y descentralizado,
fueran elementos esenciales para el éxito de las acciones de control del tabaquismo en Brasil.
Palabras clave: tabaquismo/historia; tabaquismo/prevención y control; Programa nacional de Control del
tabaquismo; Brasil
Brazilian Journal of Cancerology 2011; 57(3): 305-314

Original Article
Air Quality in São Paulo after the Smoke-Free Law
Article received on 3/28/11; accepted for publication on 5/24/11
Air Quality in Bars of São Paulo/Brazil before and after the
Smoke-Free Law in Indoor Places
Qualidade do Ar em Bares de São Paulo/Brasil antes e depois da Lei de Ambientes
Fechados Livres de Fumo
La Calidad del Aire en los Bares de São Paulo/Brasil antes y después de la Ley
Libre de Humo en Lugares Cerrados
mônica Andreis 1 , Jessica elf 2 , paula Johns 3 , Adriana carvalho 4 , Jie Yuan 5 ,
benjamin Apelberg 6
Abstract
Introduction: secondhand smoke is currently considered the main pollutant in indoor environments, with no safe
levels of exposure. Objective: The present study aims to quantify levels of air nicotine in bars in são Paulo, Brazil,
before and after the state law that bans smoking in indoor places. Method: The study was conducted in partnership
between the alliance for the Control of tobacco use - Brazil, and the Johns hopkins Bloomberg school of Public
health – usa. air nicotine was measured using passive air monitors containing a filter treated with sodium bisulfate.
The quantity of air nicotine absorbed by the filters was measured in the laboratory at Johns hopkins university. The
study was conducted in 16 bars and the total amount of valid samples was 72. Results: on average, a 72% reduction in
air nicotine was found in the surveyed establishments after the smoking ban in indoor places in the state of sao Paulo
was adopted. This indicates improvement in air quality within these environments and a decreased risk of exposure
to secondhand smoke for both clients and workers. Conclusion: The results of this study provide local evidence for
the effectiveness of such policies and support the need for federal legislation guaranteeing 100% smoke-free indoor
environments to all Brazilians.
Key words: tobacco; nicotine; air Quality Control; tobacco smoke Pollution; Public health
1 Psychologist, MD, Vice-Director of aCt (alliance for the Control of tobacco use); author to whom correspondence should be addressed: monica.
andreis@actbr.org.br.
2 research Program Manager, MPh. e-mail: jelf@jhsph.edu.
3 sociologist, MD, Director of aCt. e-mail: paula.johns@actbr.org.br.
4 lawyer, specialized in labor law. e-mail: adriana.carvalho@actbr.org.br.
5 environmental/occupational health, MsPh. e-mail: jyuan@jhsph.edu.
6 epidemiologist, PhD. e-mail: bapelber@jhsph.edu.
aCt-alliance for the Control of tobacco use (andreis, Johns and Carvalho). r. Batataes, 602, cj.31, são Paulo (sP), Brazil. 01423-010
Johns hopkins Bloomberg school of Public health (elf, yuan and apelberg), 627 n. Washington street, 2nd floor, Baltimore, MD, usa, 21205
Brazilian Journal of Cancerology 2011; 57(3): 315-320
315

Andreis M, Elf J, Johns P, Carvalho A, Jie Y, Apelberg B
316
INTRODUCTION
secondhand smoke (shs) is currently considered the
main pollutant in indoor environments, with no safe levels
of exposure 1 . of about 4,800 constituents identified in
shs, at least 250 are toxic, and at least 50 compounds
have “sufficient evidence for carcinogenicity” as defined by
the international agency for research on Cancer - iarC,
with eleven proven carcinogens for humans 2-3 . nicotine,
the addictive substance in cigarette smoke, is toxic when
inhaled, causing excessive stress on both circulatory and
nervous systems, and has been associated with increased
susceptibility to cancer development 4 .
Pollutants in tobacco smoke disperse homogeneously
in the environment, and separation of smokers and
nonsmokers in indoor places does not eliminate the
risk of exposure to toxic components of smoke, even
if ventilation systems or air renovation is used 5-8 . Based
on scientific evidence regarding the health risks related
to secondhand smoke exposure, public education
campaigns and the adoption of effective measures to
protect people from shs exposure have become a public
health priority. furthermore, article 8 of the framework
Convention on tobacco Control (fCtC), a global public
health treaty developed under the auspices of the World
health organization (Who), requires that signatory
countries promote effective action to protect people from
secondhand smoke and recommends a smoking ban in
indoor public and work places, among others 9 .
in Brazil, it is estimated that 200,000 deaths occur
annually due to active smoking, and at least 7 deaths
daily are related to secondhand smoke exposure 10 . Despite
having ratified the fCtC treaty, Brazil has not yet adopted
a national 100% smoke-free policy. under the current
national law, act 9,296/1996, smoking rooms are allowed,
which is not in accordance with article 8 of the fCtC.
With about 40 million inhabitants, the state of são
Paulo took an important step towards reducing the impact
caused by exposure to secondhand smoke by banning the
consumption of tobacco products in collective indoor
places. The “Lei Antifumo” [antismoking law] in são
Paulo, as it is known, was approved in april 2009, signed
in May 2009 and enforced as of 7 th august 2009 11 .
recently, a study was published demonstrating the impact
of the smoking ban in indoor places in the city of são
Paulo. The carbon monoxide concentration was measured
in restaurants, bars, night clubs and similar venues and in
their workers, and a significant reduction was verified 12 .
in order to measure improvements in indoor air quality
after law enforcement and provide additional evidence of
effectiveness, bars in the capital of são Paulo were chosen
to be monitored by a study conducted in partnership
between the nGo alliance for the Control of tobacco
use - Brazil, and the Johns hopkins Bloomberg school of
Brazilian Journal of Cancerology 2011; 57(3): 315-320
Public health - usa. This present study aims to quantify
levels of air nicotine in bars in são Paulo before and after
the law that bans smoking in indoor places was adopted.
METHOD
air nicotine was measured using passive air monitors
containing a filter treated with sodium bisulfate (figure 1).
The monitors were placed in bars and kept there for
seven consecutive days (figure 2). The first phase of data
collection occurred from June 3 to July 30, 2009 (prior
to the smoke-free law enforcement in são Paulo), and
the second phase from november 12 to December 23,
2009 (after the enforcement, which occurred on august 7 ).
in addition to the monitors, for each establishment,
an observational questionnaire was completed, which
included general information such as opening hours, use
of ventilation or heating systems, and the accurate location
of the monitors in the environment.
The quantity of air nicotine absorbed by the filters was
measured in the laboratory at Johns hopkins university.
The concentration of air nicotine is considered a good
indicator of shs because it can be easily identified and
quantified and is highly specific, which makes it an
objective parameter of secondhand smoke exposure.
Figure 1. Nicotine monitor based on sodium bisulfate treated filter
Figure 2. Air nicotine monitor hung in a bar in São Paulo, Brazil

follow-ups were conducted to verify monitor location
and condition, and after seven days the monitors
were collected. two monitors were installed for each
establishment and were hung at different locations in the
serving area of the establishment. to ensure measurement
accuracy, 10% duplicates and 10% field blanks were
deployed for quality control purpose.
The study was conducted in 16 bars located in the
western region of são Paulo (Capital) in Vila Madalena,
a neighborhood known for its large concentration of
bars and restaurants. sampling locations were selected
through contact with aGeaC, the association of
Gastronomy, entertainment, art and Culture of Vila
Madalena, which pointed out the bars available for the
research. after obtaining consent from the establishment’s
representatives, observational data was collected at each
location and air nicotine monitors were placed.
in total, 78 samples were collected. as six of them
had to be discarded because they were damaged, the total
amount of valid samples was 72. having the building as
the unit of analysis, descriptive statistics were generated
and levels of air nicotine were compared using the stata
11 statistical software (stata Corporation).
RESULTS
on average, a 72% reduction in air nicotine was found
in the surveyed establishments after the smoking ban in
indoor places in são Paulo state was adopted. Percent
reduction ranged from 6% to 94%, with a median of 73%
(p

Andreis M, Elf J, Johns P, Carvalho A, Jie Y, Apelberg B
318
as the Brazilian federal law of 1996 14 , people are still
exposed to high levels of tobacco smoke. These exposure
levels demonstrate the need for comprehensive smoking
bans, as opposed to partial bans in indoor places, to fully
protect workers and the general public. follow-up air
nicotine concentrations found in the sampled bars in
são Paulo after the implementation of the smoke-free law
demonstrate the effectiveness of such policies and reinforce
why they have been internationally recognized as one of
the most effective and inexpensive ways to protect people's
health. not only are smoke-free policies effective, as
demonstrated by this study, but have also been supported
by the public. a survey conducted by the state government
one month post-enforcement of the smoke-free law in são
Paulo reported that 94% of the state of são Paulo citizens
support the measure, and 87% among smokers. among
people over 45 years of age, the proportion of those in
support of the new law reaches 95% 15 . similar studies in
other countries, such as Mexico, also show that there is
popular support for smoke-free policies, with these types
of feelings generally increasing post-implementation of
the policy 16 .
a survey conducted with 60 bars and restaurants
owners in the city of são Paulo after one year of the law
implementation reveals that 82% agree with the law, and
95% report there was either hire increase or no dismissals.
in addition, governmental data reveals high compliance
with the law since its implementation: over 99% of the
establishments inspected 17-18 . results of this policy in são
Paulo mirror results in other areas of the world. successful
policy implementation and reduction of shs levels have
been found in Mexico, Guatemala, and uruguay, among
others 16, 19-20 .
CONCLUSIONS
in order to protect workers and the general public
from the harmful effects of shs, it is critical that a
100% smoke-free policy, such as the one adopted in the
state of são state, be enacted at the national level. such
policy is scientifically incontestable and has wide-ranging
public support, lacking only political will to achieve it.
a comprehensive smoking ban is the only way to ensure
protection from shs exposure, especially for professionals
in the hospitality sector, such as waiters, who are most at
risk in their place of work. arguments against the adoption
of 100% smoke-free indoor places lack rationality and
credibility and are, most of times, clearly associated with
the commercial interests related to tobacco consumption.
The results of this study provide local evidence for the
effectiveness of such policies and support the need for
federal legislation guaranteeing 100% smoke-free indoor
environments to all Brazilians.
Brazilian Journal of Cancerology 2011; 57(3): 315-320
ACKNOWLEDGEMENTS
Clarissa homsi, Marina seelig and raquel topfstedt,
for your contribution during the survey design and data
collection period.
Part of this research (monitors and lab analysis) was
supported by a grant from Pfizer foundation. note: The
funding organization had no role in the outcome of this
study or preparation of the article.
CONTRIBUTIONS
Mônica andreis worked with the design, planning,
data collection and interpretation of the research project,
as well as with the final writing of the paper; Jessica
elf worked with the design, planning, data analysis,
interpretation and the final revision of the paper; Paula
Johns worked with the design, planning of the research
project and the final revision of the paper; adriana
Carvalho worked with the design, planning, data
collection and interpretation of the research project, as
well as with the final revision of the paper; Jie yuan worked
with the data analysis and interpretation; Benjamin
apelberg worked with the design, planning, data analysis,
interpretation and the final revision of the paper.
Conflict of Interest: None
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CE, Valentin LS, et al. The effect of São Paulo's smokefree
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em ambientes fechados de uso coletivo em todo Estado
de São Paulo. [Notícia]: Lei Antifumo completa 1 ano
com 99,7% de adesão. A lei antifumo paulista completa
um ano em vigor neste sábado, 7 de agosto, com 99,78%
de adesão por parte dos estabelecimentos e total apoio
da população por intermédio de denúncias feitas pela
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php?id=183
19. Barnoya J, Arvizu M, Jones MR, Hernandez JC, Breysse
PN, Navas-Acien A. Secondhand smoke exposure in
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20. Blanco-Marquizo A, Goja B, Peruga A, Jones MR, Yuan J,
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Andreis M, Elf J, Johns P, Carvalho A, Jie Y, Apelberg B
320
Resumo
Introdução: o fumo passivo é atualmente considerado o principal poluente em ambientes internos, sem nível seguro
de exposição. Objetivo: o presente estudo visa a quantificar os níveis de nicotina no ar em bares de são Paulo, Brasil,
antes e depois da lei estadual que proíbe o fumo em locais fechados. Método: o estudo foi realizado em parceria
entre a onG aliança de Controle do tabagismo - Brasil, e a Johns hopkins Bloomberg school of Public health -
eua. a nicotina no ar foi medida através de monitores passivos contendo um filtro tratado com bissulfato de sódio.
a quantidade de nicotina no ar absorvida pelos filtros foi medida no laboratório da universidade Johns hopkins.
o estudo foi realizado em 16 bares e a quantidade total de amostras válidas foi de 72. Resultados: em média, uma
redução de 72% da nicotina no ar foi encontrada nos estabelecimentos pesquisados após a proibição de fumar em locais
fechados no estado de são Paulo. isso indica uma melhora na qualidade do ar nesses ambientes e uma diminuição
do risco de exposição ao fumo passivo por clientes e trabalhadores. Conclusão: os resultados deste estudo oferecem
evidências locais da eficácia de tais políticas e apoio à necessidade de uma legislação federal que garanta ambientes
fechados 100% livres de fumo a todos os brasileiros.
Palavras-chave: tabaco; nicotina; Controle da Qualidade do ar; Poluição por fumaça de tabaco; saúde Pública
Resumen
Introducción: el humo de tabaco es actualmente considerado el principal contaminante de ambientes interiores, sin
niveles seguros de exposición. Objetivo: el presente estudio tiene como objetivo cuantificar los niveles de nicotina
del aire en los bares de são Paulo, Brasil, antes y después de la ley estatal que prohíbe fumar en lugares cerrados.
Método: el estudio se llevó a cabo en colaboración entre la alianza para el Control del tabaquismo - Brasil, y la Johns
hopkins Bloomberg school of Public health - ee.uu. la nicotina del aire se midió mediante monitores pasivos de
aire que contiene un filtro tratado con bisulfato de sodio. la cantidad de nicotina absorbida por el aire de los filtros
se midió en el laboratorio de la universidad Johns hopkins. el estudio fue realizado en 16 bares y la cantidad total
de muestras válidas fue de 72. Resultados: en promedio, una reducción de 72% de la nicotina en el aire se observó
en los establecimientos después de la prohibición de fumar en lugares cerrados en são Paulo. esto indica una mejora
en la calidad del aire dentro de estos ambientes y un menor riesgo de exposición al humo de segunda mano para los
clientes y trabajadores. Conclusión: los resultados de este estudio proporcionan evidencias locales de la eficacia de
esas políticas y apoyan la necesidad de una legislación federal que garantice ambientes cerrados 100% libres de humo
a todos los brasileños.
Palabras clave: tabaco; nicotina; Control de Calidad del aire; Contaminación por humo de tabaco; salud Pública
Brazilian Journal of Cancerology 2011; 57(3): 315-320

Original Article
Tobacco and Health-Related University Students
Article submitted on 02/14/11; accepted for publication on 04/26/11
Tobacco and Health-Related University Students in the City of
Rio de Janeiro
O Tabagismo no Contexto dos Futuros Profissionais de Saúde do Rio de Janeiro
El Tabaquismo en el Contexto de Futuros Profesionales de la Salud de Rio de
Janeiro
André salem szklo 1 , mariana miranda Autran sampaio 2 , Luís felipe Leite martins 3 ,
elaine masson fernandes 4 , Liz maria de Almeida 5
Abstract
Introduction: a strategy to reduce tobacco-related deaths is to have skilled healthcare professionals who may get
involved in tobacco prevention and cessation counseling. Objective: to evaluate the importance of tobacco smoking
among health-related university students in the city of rio de Janeiro. Method: a Census of students attending the
3rd year of both public and private Medicine, Dental and Pharmacy courses as well students attending the 3rd year of
public nursing courses was conducted in 2006/2007 in rio de Janeiro. a total of 1,525 students participated. Results:
Cigarette smoking prevalence was 14.6%, whereas 5.7% reported smoking other tobacco products. almost 70% were
occasional smokers and around 34% of smokers stated having smoked tobacco products inside university buildings.
More than 90% believed that healthcare professionals should receive formal training in smoking cessation approaches
and advise individuals to quit, but roughly 30% did not consider healthcare professionals as role models. More than
85% were taught about the dangers of smoking during their courses and, in a lower proportion, about its secondhand
effects. however, approximately 80% have not yet received any formal training in smoking cessation by their
3rd year at university. Conclusion: Monitoring tobacco prevalence among students must be a priority at university,
mainly because of its high prevalence of occasional smokers. The monitoring of the law that prohibits smoking in
enclosed places could create barriers against tobacco use. it is also important that both health and education sectors
work together to evaluate whether issues such as influence of healthcare professionals upon their patients and formal
training are taught after 3 rd year or not.
Key words: smoking; Professional role; Professional training; epidemiologic surveillance
1 Chemical engineer. PhD in Public health from escola nacional de saúde Pública (ens P/fiocruz). Cancer Control analyst of the
epidemiology Division at the Brazilian national Cancer institute (inCa)
2 Psychologist. PhD in Group health from instituto de Medicina social (iMs) of the universidade estadual do rio de Janeiro (uerJ).
Cancer Control analyst of the epidemiology Division at inCa.
3 statistician. PhD in Group health from instituto de estudos em saúde Coletiva (iesC) of the universidade federal do rio de Janeiro
(ufrJ). Cancer Control analyst of the epidemiology Division at inCa
4 nutritionist from universidade federal fluminense (uff). Cancer Control analyst of the epidemiology Division at the Brazilian
national Cancer institute (inCa)
5 Physician. PhD in Pathology from universidade de são Paulo (usP). Manager of the epidemiology Division at inCa.
Correspondence Address: andré salem szklo. rua Marquês de Pombal, nº 125/7º andar – Centro. rio de Janeiro (rJ), Brazil. Ce
P:20230-240. Email: aszklo@inca.gov.br
Brazilian Journal of Cancerology 2011; 57(3): 321-327
321

Szklo AS, Sampaio MMA, Martins LFL, Fernandes EM, Almeida LM
322
INTRODUCTION
The use of tobacco is considered the second leading
cause of death in the world by the World health
organization (Who) 1 and can be avoided. it is associated
with mortality due to several kinds of cancer (lung, mouth,
larynx, pharynx, esophagus, stomach, pancreas, bladder,
kidney, cervix and acute myeloid leukemia), chronic
obstructive pulmonary disease (CoPD), heart disease,
arterial hypertension and stroke 2-4 . Besides the smoker
being more subjected to mortality due to all these diseases
when compared to non-smokers, the simple fact that a
person can be secondhandly exposed to tobacco smoke
per se also contributes for the appearance of diseases of
the cardiovascular system, heart disease and lung cancer 1 .
for these reasons, the Who identifies tobacco use as a
risk factor against life that has to be banned with high
priority at world level 1 .
in order to control tobacco in a broad way, the Who
proposes several strategies, among which we highlight
tobacco 1 surveillance and monitoring 5 . the Global
tobacco surveillance system (Gtss), developed in
19995, has been implemented in most Who Member
states, using a standardized protocol. The studies that
compose the Gtss are: Global youth tobacco survey
(Gyts), with students from 13 to 15 years old; Global
school Personnal survey (GsPs), which focus on people
who work in schools; Global adult tobacco survey
(Gats), with adults who are 15 years old or above; and
Global health Professional students survey (GhPss),
with students from the third undergraduate course year
at the healthcare area.
as for the GhPss especifically, the Who chose the
courses of Medicine, nursing, Dentistry and Pharmacy to
integrate it, using as criteria the fact they prepare future
opinion makers within the society, especially with regards
to patient assistance. several studies have already pointed
out that healthcare professionals can play an essential
role in the reduction of tobacco use 6 . even a simple and
brief counseling can significantly increase the smoking
cessation rate6. hence, one of the strategies to reduce
tobacco-related deaths is to encourage the involvement
of healthcare professionals in the counseling for tobacco
prevention and cessation 5 . to do so, a good educational
background of these professionals is necessary. Therefore,
the analysis of outcomes obtained after the the Brazilian
version of this Gtss component was implemented is
important to guide the actions for tobacco control in the
country and will be the focus of this article.
The objective of this study was, therefore, to evaluate
the importance of tobacco smoking in the context of
healthcare university students in rio de Janeiro.
Brazilian Journal of Cancerology 2011; 57(3):321-327
METHODS
the GhPss is called, in Brazil, tobacco Profile
among university students of Brazil: tobacco smoking
surveillance Project among healthcare university
students. The data analyzed in this study is a census of
the students from the third year of undergraduate courses
of Medicine, wiether public or private (n=7), Dentistry
(n=6) and Pharmacy (n=7) and public courses of nursing
(n=3) in the city of rio de Janeiro, between 2006 and
2007. The global response rate in rio de Janeiro was
76.5%. a total of 1,525 students participated in it.
The standard questionnaire from which the analyzed
responses were used in this article is available online 7 . in
the Brazilian version, some specific questions of regional
interest were introduced addressing subjects such as
knowledge about the effects of second hand smoking and
specific legislation on smoking bans in closed environments,
definition of the cigarette type smoked and characterization
of the nicotine dependence degree of the smoker. The
criteria used to measure the prevalence of cigarette smokers
and those of other tobacco derived products, respectively,
was having smoked it at least one day in the previous 30
days of the research. The tobacco products considered were:
snuff, cigar, cigarillo, narguille, etc.
according to the course and gender, the prevalence
of cigarette smokers and users of other tobacco products
was calculated. The proportions of occasional users, as
well as the one for consumption of tobacco products
in the university building were evaluated according to
gender. Besides that, information about the students was
analyzed according to their course, their beliefs as to the
education received and knowledge acquired during the
course, the effects of direct and secondhand smoking,
the importance of prevention and the formal training on
cessation approaches. Due to the fact that the data come
from a census, occasional differences in the percentages
of responses on the aforementioned subjects were directly
interpreted.
The project was approved by the research ethics
Committee (CeP) from the Brazilian national Cancer
institute (inCa) (protocol number 013/06).
RESULTS
The prevalence of cigarette smokers was 14.6% while
that for users of other tobacco products was smaller, namely,
5.7%. This pattern occurreded regardless of the course
analyzed and the students’ gender (table 1). it is still noticed
that, on average, for any kind of tobacco product smoked,
the proportion of male smokers was higher when compared
to females (table 1).

The majority of cigarette smokers were occasional
smokers (68.2%), of which 69.0% are women and 66.7%
are men. among the students who smoked cigarettes and
used other tobacco derived products, 34.3% used the
university building to this end, the percentage of male
students being higher (37.4%) when compared to female
students (32.1%).
regardless of the course, more than 90% of the students
believed that healthcare professionals should receive training
on cessation techniques and should routinely advise their
patients to quit smoking. however, on average, 33% did
not consider healthcare professionals as “behavior models”
for their patients and the general public (table2).
More than 85% had heard about the effects of smoking
during their course and, in smaller proportion, the effects
of secondhand smoking or its consequences in specific
subgroups, such as children, young teens and pregnant
women, regardless of the course (table 3). however, on
average, almost 80% of the students did not receive any
type of formal training on the approaches on how to quit
smoking up to the third year, varying from 68.0% at the
Medical school to 88.5% at the Pharmacy course (table 3).
Tobacco and Health-Related University Students
DISCUSSION
The monitoring of tobacco prevalence among students
should be focus of the university, especially if one considers
the high proportion of users, yet occasional ones, found
among the investigated students, when compared to the
general population 8 . The promotion of smoking cessation
should be designed having as its target the smoker profile,
according to his dependence level and motivation to
quit smoking 6,9 . The actions available from the public
system range from motivational campaigns, distribution
of self-help leaflets with cognitive-behavioral guidance
and warnings on cigarette packages, to phone counseling,
through the tobacco Quitline 9 . The university can use
this wide already existing network or even propose other
creative ways directed to achieving this specific population.
Besides being targets of the cessation promotion,
it is necessary that undergraduate students, as future
healthcare professionals, be prepared so they can include
the minimum approach to the smoker for cessation
in their assistance routines. the main focus of this
approach is motivation, consisting in discussing beliefs
Table 1. Prevalence of cigarette smokers and users of other tobacco products, according to undergraduate course and gender.
“Tobacco Surveillance Survey among Healthcare students” in the city of Rio de Janeiro (2006/2007)
Course
Cigarette smokers Users of other tobacco derived products
Geral Female Male Geral Female Male
Medicine 16.7% 14.4% 19.4% 5.3% 3.4% 7.4%
Nursing 8.3% 7.6% 15.4% 4.7% 4.5% 7.3%
Dentistry 20.2% 18.5% 24.7% 10.8% 7.8% 17.4%
Pharmacy 5.4% 5.7% 4.9% 1.6% 1.3% 1.2%
Total 14.6% 12.6% 18.2% 5.7% 4.1% 8.1%
Table 2. Belief of university students about the educational background and role of healthcare professionals, per undergraduate course.
“Tobacco Surveillance Survey among Healthcare students” in the city of Rio de Janeiro (2006/2007)
Course
Should healthcare
professionals receive
specific training about
the cessation methods?
Should healthcare
professionals routinely
advise their patients to
quit smoking?
Are healthcare
professionals “behavior
models” for their
patients and the
general public?
Medicine 94.4% 98.2% 66.3%
Nursing 95.7% 96.5% 65.7%
Dentistry 91.6% 97.5% 74.2%
Pharmacy 96.3% 97.5% 61.3%
Total 94.3% 97.8% 67.0%
Brazilian Journal of Cancerology 2011; 57(3): 321-327
323

Szklo AS, Sampaio MMA, Martins LFL, Fernandes EM, Almeida LM
324
Table 3. Information received by the students during class, per undergraduate course. “tobacco surveillance survey among healthcare
students” in the city of Rio de Janeiro (2006/2007)
Course
Brazilian Journal of Cancerology 2011; 57(3):321-327
Heard about the
effects of tobacco
on health in some
class
Received, in some
class, some kind of
information on the
effects to health
of secondhand
environmental
exposure to
tobacco
Learned about
the importance
of preventing
the initiation
and tobacco
consumption
among children,
young teens and
pregnant women
Received some
kind of formal
training on the
approaches to
quit smoking to
be used with their
patients
Medicine 97.8% 85.3% 73.3% 21.2%
Nursing 91.9% 87.6% 82.7% 32.0%
Dentistry 90.8% 74.6% 64.1% 22.1%
Pharmacy 87.0% 69.6% 56.8% 11.5%
Total 94.2% 81.5% 70.7% 21.7%
and thoughts generated by chemical dependence, work
their psychological effects and conditionings associated
to smoking and training of individual abilities. since
2004, the service network of the Brazilian unified health
system (sus) for low and medium complexities also has
intensive treatment for smokers who have a high degree
of dependence9. Thus, it is indispensable that future
professionals be prepared for this kind of assistance.
it is important to highlight, however, that 80% of the
students reported not having received formal training
about approaches on how to quit smoking to be used with
their patients. nevertheless, it is necessary to evaluate how
the influence of professionals on patients and their formal
training are present in the curricula after the third year or
if they are not included yet.
it is worth mentioning, still, that some information
should already be disseminated, regardless of the course.
for example, the warning images on cigarette packages
were included in 2001. These were substituted for more
impact causing images in 2004, which were in circulation
at the time of the research. as from 2009, they were
replaced by other still more aversive warnings, which are
important to increase the sensitization of future healthcare
professionals with regards to this subject 10 .
the Who, since 2005, has been concentrating
efforts for discussing the considerable role that healthcare
professionals have in the battle against tobacco epidemics 11 .
it is possible that its credibility before the smoker-patient
contributes for the treatment efficacy or the message that
is being transmitted 12 . Besides that, the influence that a
student who does not smoke can have in the prevention
of tobacco initiation by adolescents is highlighted in
several studies 13-15 . such fact can be probably explained
by the aspiration of young teens who want to behave
like adults 16-17 . in Brazil, in particular, this impact can be
even higher if it is considered that the average initiation
age is below 188, which reinforces the concern with the
finding that only one third of university students from
the healthcare area of rio de Janeiro considered that
healthcare professionals “are behavior models”.
Besides having represented a great advance in tobacco
control at the time, the federal law number 9,294/96 18 ,
which bans smoking in closed collective environments,
still allows reserved areas for smoking in collective
environments. Many university students report having
consumed tobacco products at the university building,
even though on average, more than 80% reported having
received information about the effects of secondhand
smoking on health. it is possible that either the university
students were smoking in reserved areas or the law was
not being enforced. in this case, non-smokers could be
exposed, including university hospital patients, reinforcing
the need for oversight. it can be highlighted that, for
making the use of smoked tobacco products in collective
environments more difficult, the law ends up decreasing
its prevalence 19 , although the primary objective of the
law is not this one.
as of 2009, the state of rio de Janeiro, as well as several
other Brazilian states and towns, conscious of the need
to protect their population and the risks of secondhand
smoking, approved the law number 5,517 20 , which
established collective use environments which are 100%
smoke free. however, it is still necessary to approve a
national legislation that completely bans smoking in
closed collective environments, protecting the population
against the risks of exposure to environmental tobacco

smoke. The Ministry of health has been working intensely
to approve the Bill number 315/2008 21 , which establishes
this measure.
it is worth mentioning that all the responses obtained
in this study were reported by the students directly, that
is, they were not measured and/or confirmed afterwards.
Besides that, it is possible that the students have received
information coming from outside the university
environment (for example: warning images on cigarette
packages) and attribute the knowledge they acquired to the
course taken. it is also plausible that the students want to
correspond to social pressures 22 against tobacco, reporting
smaller consumption of these products, causing the under
estimation of the prevalences. however, the fact that the
questionnaires are self-filled minimizes this fact. one
cannot discard, therefore, the possibility of information
bias 23 in the interpretation of the results.
a positive aspect of the findings is the fact that they are
inserted in a wider international surveillance system, based
on a standardized methodology (similar questionnaire and
collection model). Thus, it is possible to compare them
among the several countries, so that it allows a deeper
understanding of the problem. in a recent publication 24 ,
in which data from rio de Janeiro were included, the
prevalence of cigarette consumption among medical
school students, from 29 investigated places in the same
period, ranged from 1.3% to 47.0%, while in the 18
places where nursing students were evaluated, it ranged
from 0.5% to 41.5%.
the data were presented to some courses of the
healthcare area in rio de Janeiro. it is worth noticing
that, during the research, a sample of nursing students
from private courses in rio de Janeiro was also used and
after the confidence intervals (Ci 95%) for their answers
were obtained, the considerations raised by this article
remained unaltered (data not shown). even so, not all
the courses that could interfere with tobacco cessation
were investigated, such as Psychology, for example.
Generalization of these results should be done, however,
very cautiously when one tries to evaluate the effect of
the actions for tobacco control on students from other
cities and/or courses. it is necessary to consider how
similar political perspectives for tobacco control, social
demographic and cultural profiles, and curricula are.
new studies are also necessary, since the surveillance
system should take into account the dynamics inherent
to the Brazilian tobacco industry strategies and to
policies and actions for tobacco control that have been
developed in the country. The monitoring of new products
created by the industry, as well as the incorporation of
anti-tobacco policies targeting priority groups to the
curricula of university courses, could be, for example,
Tobacco and Health-Related University Students
evaluated in futher investigations. it would also be
interesting to evaluate the feasibility of expanding the
study entitled Tobacco Profile in Brazilian Undergraduate
Students: Tobacco Surveillance Project among Healthcare
Undergraduate Students to periodically represent the
national territory as a whole.
CONCLUSION
Monitoring tobacco smoking among students should
be the university focus, especially if the high prevalence of
occasional users is considered. The oversight of the law that
bans tobacco smoking in closed collective environments,
which serves, above all, to protect people from secondhand
exposure to smoke, could also make the use of this product
more difficult and decrease its prevalence. in addition, it
is necessary to evaluate if themes such as the influence
of professionals on their patients and formal training are
present in the curricula after the third year or if they are not
included yet. a partnership between the areas of health and
education is essential for the preparation of professionals
according to the necessities of the healthcare systems
this study was financed by inCa and by
resources coming from the Pan-american health
organization, Who regional office [sDe-toB-102/
XK/06-07/995].
ACKNOWLEDGEMENTS
We thank all the technicians of the inCa epidemiology
Division who helped in data collection for the “tobacco
surveillance survey among healthcare university
students” performed in rio de Janeiro in 2006/2007. to
the course coordinators, employees, students from the
participating universities and international Gtss partners
who made this study possible.
CONTRIBUTIONS
a. s. szklo and M. M. a. sampaio made the
calculations and built the tables, discussed the results
and analyzed those with the team. They wrote the body
of the article, having worked on it up to its final copy;
l.f. Martins participated in the discussion of results,
having collaborated with its writing up to its final copy. e.
Masson participated in data collection, results discussion,
having collaborated with the writing of the article up to
its final copy; l.M. almeida coordinated the work of
data collection, participated in the discussion of results,
having collaborated with the writing of the article up to
its final copy.
Declaration of Conflicting Interests: Nothing to Declare.
Brazilian Journal of Cancerology 2011; 57(3): 321-327
325

Szklo AS, Sampaio MMA, Martins LFL, Fernandes EM, Almeida LM
326
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Tobacco and Health-Related University Students
Resumo
Introdução: uma estratégia para reduzir mortes relacionadas ao tabaco é uma boa formação dos profissionais de
saúde, os quais poderão se envolver no aconselhamento da prevenção e cessação do tabagismo. Objetivos: avaliar a
importância do tabagismo no contexto dos universitários da área de saúde no rio de Janeiro. Método: Censo dos
estudantes do terceiro ano da graduação dos cursos públicos e privados de medicina, odontologia e farmácia e dos
cursos públicos de enfermagem da cidade do rio de Janeiro (2006/2007). Participaram 1.525 estudantes. Resultados:
a prevalência de fumantes foi 14,6%; a de usuários de outros produtos de tabaco, 5,7%. Quase 70% eram fumantes
ocasionais. entre usuários de qualquer produto de tabaco, 34,3% o consumiram no prédio da universidade. Mais de
90% acreditavam que profissionais de saúde deveriam receber treinamento sobre técnicas de cessação e aconselhar
rotineiramente seus pacientes a pararem de fumar, mas cerca de 30% não os consideravam “modelo de comportamento”.
Mais de 85% ouviram falar sobre efeitos do fumo durante o curso e, em menor proporção, sobre as consequencias do
fumo passivo. entretanto, cerca de 80% não receberam treinamento formal até o terceiro ano. Conclusão: Monitorar a
prevalência de estudantes fumantes deve ser foco da universidade, considerando-se, especialmente, a elevada proporção
de usuários ocasionais. a fiscalização da lei que proíbe fumar tabaco em ambientes coletivos fechados poderia reduzir a
utilização desse produto. É preciso também avaliar, em uma colaboração saúde/educação, se temas como influência de
profissionais sobre pacientes e treinamento formal integram os currículos após o terceiro ano ou não estão incluídos.
Palavras-chave: tabagismo; Papel Profissional; Capacitação Profissional; Vigilância epidemiológica
Resumen
Introducción: Para reducir las muertes relacionadas al tabaco es necesario una buena formación de profesionales de
salud que puedan intervenir en el asesoramiento a la prevención y cesamiento del tabaquismo. Objetivos: evaluar la
importancia del tabaquismo en el contexto de universitarios del área de la salud en rio de Janeiro. Método: Censo de
universitarios del tercer año de carreras públicas y privadas de medicina, odontología y farmacia y de carreras públicas
de enfermería en la ciudad de rio de Janeiro (2006-2007). Participaron 1.525 estudiantes. Resultados: la prevalencia
de fumadores fue 14,6%; la de usuarios de otros productos de tabaco, 5,7%. Casi un 70% eran fumadores ocasionales.
entre los usuarios de cualquier producto de tabaco, 34,3% lo consumieron en el edificio de la universidad. Más de 90%
creían que profesionales de salud deberían recibir capacitación sobre técnicas de cesación y aconsejar rutinariamente
sus pacientes a pararen de fumar, pero cerca de 30% no los consideraban "modelo de comportamiento". Más de 85%
escucharon sobre efectos del fumo durante su carrera y, en menor proporción, sobre las consecuencias del tabaquismo
pasivo. sin embargo, cerca de 80% no recibieron capacitación formal hasta el tercer año. Conclusión: Monitorizar
la prevalencia de estudiantes fumadores debe ser un foco de la universidad, especialmente por la elevada proporción
de usuarios ocasionales. la fiscalización de la ley que prohíbe fumar tabaco en ambientes colectivos cerrados podría
reducir el uso de ese producto. es necesario también evaluar, a través de una colaboración salud/educación, si los
temas tales como influencia de profesionales sobre pacientes y entrenamiento formal integran los currículos tras el
tercer año o si no están incluidos.
Palabras clave: tabaquismo; rol Profesional; Capacitación Profesional; Vigilancia epidemiológica
Brazilian Journal of Cancerology 2011; 57(3): 321-327
327

Original Article
Quality of Life of Smokers
Article submitted on 02/02/11; accepted for publication on 05/13/11
Quality of Life of Smokers Seeking Help to Quit Through
Telephone Counseling
Qualidade de Vida em Tabagistas que Buscaram Auxílio para Deixar de Fumar
por meio de Aconselhamento Telefônico
Calidad de Vida en los Fumadores que Buscan Ayuda para Dejar de Fumar a
través de Asesoramiento Telefónico
Taís de campos moreira 1 , Luciana rizzeri figueiró 2 , maristela ferigolo 3 , simone fernandes 4 , melaine czerminski Larré 5 ,
helena maria Tannhauser barros 6
Abstract
Introduction: several factors may interfere with quality of life, including problems related to the use of substances
such as tobacco, which consequently affect life satisfaction. The effects of smoking that affect the quality of life serve
to alert smoker and also to motivate the person to quit and maintain abstinence. Objective: to evaluate the quality
of life of smokers who sought telephone service for information and advice about drugs by applying WhoQol-
Bref. Method: Cross sectional study with users of tobacco and other psychoactive substances who called to a toll-free
phone number between november/2009 and December/2010. smokers answered a questionnaire covering data on
social and economic features, tobacco consumption (quantity, frequency, diagnosis and severity of dependence) and
the WhoQol-Bref was also applied. Results: 105 smokers were included in the study. The social and psychological
domains of WhoQol-Bref in smokers showed statistically lower values as to the reference population (p=0.023 and
p=0.001, respectively). it was observed that tobacco users had lower scores than non-dependents in all WhoQol-Bref
domains, although there were no statistically significant differences between groups. all domains correlated positively
and significantly with global domain, but not with the intensity of nicotine dependence. Conclusion: smokers have
lower levels of quality of life when compared to nonsmokers, which could be directly related to dissatisfaction with
various aspects of life including happiness and well-being.
Key words: Quality of life; tobacco; smoking; telemedicine
1 speech Therapist. Phd student in health sciences by universidade federal de Ciências da saúde de Porto alegre (ufCsPa). Departament of
Pharmacology. serviço nacional de orientação e informação sobre a Prevenção do uso indevido de Drogas – ViVaVoz, ufCsPa. Porto alegre (rs),
Brasil. Emails: taiscmoreira@hotmail.com, tais.moreira@bol.com.br.
2 Biochemical doctor. Master in health sciences by ufCsPa. Departament of Pharmacology. ViVaVoz, ufCsPa. Porto alegre (rs), Brasil. Email:
lucianarizzieri@yahoo.com.br.
3 Pharmacist. Phd in Medical sciences. Departament of Pharmacology. Coordinador of ViVaVoz, ufCsPa. Porto alegre (rs), Brasil. Email: mari@ufcspa.edu.br.
4 Psicologist. Phd student in health sciences by ufCsPa. Departament of Pharmacology. ViVaVoz, ufCsPa. Porto alegre (rs), Brasil.
Email: simone_psicol@yahoo.com.br.
5 Graduanda em fonoaudiologia pela ufCs Pa. Departament of Pharmacology. ViVaVoz, ufCs Pa. Porto alegre (rs), Brasil. Email: melaine_cl@hotmail.com.
6 Phd in neuropsycopharmacology. full professor of Pharmacology at ufCsPa. Departament of Pharmacology. Coordinador of ViVaVoz, ufCsPa.
Porto alegre (rs), Brasil. Email: helenbar@ufcspa.edu.br.
Correspondence Address: taís de Campos Moreira. rua sarmento leite, 245 - 3º andar. farmacologia - sala 316. Porto alegre (rs ), Brasil. Ce P: 90050-170.
Brazilian Journal of Cancerology 2011; 57(3): 329-335
329

Moreira TC, Figueiró LR, Ferigolo M, Fernandes S, Larré MC, Barros HMT
330
INTRODUCTION
one of the concepts of quality of life is to value
broader parameters instead of the control of physical or
psychological symptoms, the decrease of mortality or
increase of life expectancy 1 only. Quality of life is related
to one of the basic human desires, which is to live well
and feel good. several factors may interfere with this
quality, among them the problems arising from the use
of substances such as tobacco, which consequently affect
life satisfaction 2 .
the number of individuals who make use of
psychoactive substances is increasing, in our country
there are currently 10.1% of tobacco dependents 3 . in
this sense there is a new possibility of research focusing
on the influence on the quality of life caused by the effect
of drug use. among all substances, tobacco dependence
is associated with a greater predisposition to disease and
disability, resulting in decreased health and quality of
life of the general population 4 . smoking is associated
with high morbidity and mortality, accounting for
approximately 5 million deaths a year and it is considered
by the World health organization (Who) 5 the leading
cause of preventable death and the fastest one growing
worldwide. about 90% of lung cancer cases in the
world are attributable to smoking, this association is well
established, and the cancers of the larynx and esophagus 4
can also be highlighted.
in recent years, there has been an increase in the
number of research that measures the quality of life in
smokers and a common thread found in these studies was
the best quality of life of non-smokers when compared
to smokers 6-7 . With regard to smoking cessation, several
studies have verified its association with improved quality
of life 6-7 and this result can be used as a way to motivate
smokers to achieve abstinence 7 .
Quality of life has been increasingly seen as a
prerequisite for the overall health of individuals, including
satisfaction, happiness and well-being, so all the variables
that interfere with this aspect are important for health
professionals, since they interfere with the treatment of
any disease, including nicotine dependence. The effects
of smoking that affect quality of life and the possibility
of using these effects to warn the user of its damages and
to motivate them to consumption cessation and remain
abstinent, justify the interest for the subject. Thus, the
objective of this study was to evaluate the quality of life
through the World Health Organization Quality of Life
Instrument (WhoQol-Bref) in smokers who sought a
telemarketing service for information and guidance on
drugs, called ViVaVoz.
METHOD
a cross-sectional study was conducted with users of
tobacco and other psychoactive substances. Data collection
Brazilian Journal of Cancerology 2011; 57(3): 329-335
took place between november 2009 and December 2010
through reactive phone calls to the call center of the
national service of Guidelines and information about
Drug abuse - ViVaVoz 8-10 . this phone counseling
service offers free, anonymous telephone counseling and
open to the Brazilian population in general. it provides
guidance and information on the characteristics of
psychoactive drugs, their action in the body and also on
prevention of misuse 9 . socioeconomic features and data
on substances consumption (amount, period, dependence
and frequency) were collected as well as the application
of the WhoQol-Bref questionnaire 11 . The shortened
version of WhoQol-Bref is validated in Portuguese 12
and well used in studies in the Brazilian population 13 .
The questionnaire consists of 26 items divided into four
domains (physical, psychological, social relationships
and environment) in which responses are recorded with
individual scales of five points each 11 . The fagerström test
for nicotine dependence (ftnD) was applied to evaluate
the intensity of dependence. The instrument consists of six
questions related to smoking, allowing the classification
of dependence from very mild to very high 14 . The total
score is calculated by the sum obtained on each question,
ranging between 0 and 10 points, the higher the score,
the stronger the dependence.
telephone interaction and the application of
questionnaires were carried out by undergraduate
academics in health and education, previously selected
and trained as the Medical Education for the Prevention
and Treatment of Alcohol Use Disorders 8,10 interdisciplinary
model. for the application of the WhoQol-Bref 11 :
theoretical and practical training with lecture (8h) and
application of the questionnaire in pairs were held. The
data were evaluated and discussed at a later stage. after
this process, the students were systematically evaluated
and supervised throughout the call center service 9 .
We sampled all Brazilian tobacco users, aged between 18
and 60 years who called the ViVaVoz service during the
collection period and who agreed to participate in the study,
after informed consent. Those who demonstrated inability
to adequately answer to the treatment protocol and to the
WhoQol-Bref or who were under the effect of drugs
were excluded. incomplete protocols were also excluded.
the interviews were conducted by telephone,
following a digital guide of the protocols regarding: 1.
socioeconomic data; 2. amount of substance consumed
on average per day and Quality of life (WhoQol-Bref).
answers to calls were standard to all users. to ensure
ethical procedures, a verbal consent form was applied
to all participants, to obtain permission to use the data.
anonymity of those who used the telephone service was
guaranteed. The study was approved by the research
ethics Committee (CeP) of the federal university of
health sciences of Porto alegre (ufCsPa) (09/532).

DATA AnALYsis
a total of 105 subjects was included in study.
initially, univariate descriptive analysis of socioeconomic
characteristics was performed, in which variables were
ranked by frequency and percentage and quantitative
variables by mean and standard deviation. for calculations
of the WhoQol-Bref questionnaire Who references 15
were used.
specific questions regarding substances consumption,
such as time of use and quantity used, were asked at the
beginning. following, criteria for dependence diagnosis
were assessed. as the National Household Survey on Drug
Abuse (asDh) suggests, a user is considered dependent
when fitting at least two of the following criteria within
12 months: a) have spent much of their time to get drugs,
use them or to recover from its effects; b) have used in
amounts or frequency greater than intended; c) tolerance
(the need to use more amounts of the drug to produce
the same effect), d) have been in situations of physical risk
under effect or soon after drug effects (e.g., driving, using
machinery etc.); e) have had personal problems caused by
drugs (such as with family, work, police, of emotional or
psychological nature); f) expressed a desire to lessen or quit
the use of certain drugs. two or more positive responses
were used as the cutoff point for dependence assumption 16 .
in order to analyze the WhoQol-Bref scores
among smokers, the t test for a sample was carried out by
comparing the scores of smokers with the scores of a sample
of non-users of tobacco or other drugs that made calls to
the service. Bivariate analyzes were performed through
the student's t test. Correlation between the domains of
scale and between domains and nicotine dependence was
performed by using Pearson's correlation. P values 0.2 for all correlations). among those with low-
Quality of Life of Smokers
intensity dependence, the environment domain score was
higher in men than in women (13.0 +2.4 and 10.6 +3.1,
respectively, p = 0.02).
table 2 shows the results of the scores of WohQol-
Bref domains of the studied sample, compared to
average population of nonsmokers who called the
service. Psychological and social relations domains were
significantly lower when compared to the reference
population (p

Moreira TC, Figueiró LR, Ferigolo M, Fernandes S, Larré MC, Barros HMT
332
Pearson correlation was carried out among domains
(physical, psychological, social and environmental) and
the between the overall domain of quality of life. all
areas correlated positively and significantly with global
domain (p

similarly to the study of Pereira et al. 17 , there is an
association between the domains evaluated by the scale and
the overall score of quality of life, demonstrating that changes
in one or more domains may involve changes in the overall
quality of life. The difference between this study and Pereira's 17
is that there is a strong association, then it is possible to believe
that the contribution of the four domains altogether to measure
the quality of life is greater than the contribution of 36% found
by the author.
The treatment of smoking is usually initiated by heavy
smokers, i.e., more dependent and who have smoked for
a longer period of time 20-21 , thus they may have a health
problem related to smoking that is known to interfere with the
quality of life. The study corroborates the information on the
characteristics of smokers seeking treatment, and the fact that
there is no difference in the quality of life may be due to the
lack of questions that are more specific to the problems faced by
smokers. in addition, smokers may be reluctant to recognize a
health problem before it has reached a higher degree of severity.
study limitations are mainly related to the association
of tobacco with other drugs, which can interfere with the
increased anxiety and depression, as well with other related
health problems that further undermine quality of life. items
of anxiety and depression were not assessed in this sample and
it was not possible to verify whether the problems were related
exclusively to the use of tobacco or other substances consumed.
Moreover, the number of individuals who were
included in the study could have been larger in order
to give greater significance to the results, as well as the
sample could have included individuals who consume
tobacco exclusively.
another limitation refers to the fact that the telephone
contact does not allow biological confirmation of drug
use, as well as being a self-report of the client.
CONCLUSION
smokers have lower indices of quality of life when
compared to non-smokers, which would be directly
related to dissatisfaction with various aspects of life,
including happiness and well-being. The measure of
quality of life is an important way to measure therapeutic
results, mainly in drug users, in which many variables
interfere with treatment, such as severity of dependence,
psychiatric symptoms and social, familiar, physical and
psychological situations.
the quality of life of smokers, especially in the
psychological domain, can be hampered by the occurrence
of tumors, because it is quite likely to develop depressive
states and anxiety related to the reality of living with
cancer. Thereafter, it would be interesting to relate, in
subsequent studies, the existence of mood disorders (such
as anxiety and depression) that may worsen the smoker’s
quality of life.
ACKNOWLEDGEMENTS
Quality of Life of Smokers
The authors thank CaPes (Coordination for the
improvement of higher level Personnel) for the Ph.D
research scholarship – tCM; CnPq for the hMtB-1c
productivity scholarship, the collaboration of the national
secretariat on drug policies (senaD), and ViVaVoz
consultants.
CONTRIBUTIONS
taís de Campos Moreira and luciana rizzeri figueiró
contributed to the conception and planning of the study,
the collection, analysis and interpretation of data, as
well as the writing, critical revision and final approval
of the version; Maristela ferigolo, simon fernandes
and helena Mt Barros contributed to the analysis and
interpretation of data, as well as the writing, critical review
and final approval of the version; Melanie Czerminski
larré contributed to the conception and planning of the
study, in obtaining, organizing data and final approval
of the version.
Declaration of Conflicting Interests: Nothing to Declare.
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Quality of Life of Smokers
Resumo
Introdução: Diversos fatores podem interferir na qualidade de vida, entre eles os problemas advindos do uso de
substâncias, como o tabaco, que por consequência afetam a satisfação com a vida. os efeitos do tabagismo, que
interferem na qualidade de vida, servem para alertar o tabagista, bem como motivá-lo a parar e manter a abstinência.
Objetivo: avaliar a qualidade de vida por meio do WhoQol-Bref em tabagistas que procuraram um serviço de
teleatendimento para informações e orientações sobre drogas. Método: estudo transversal com usuários de tabaco
e outras substâncias psicoativas que ligaram para o ViVaVoz no período de novembro/2009 a dezembro/2010.
foram coletadas características socioeconômicas, dados de consumo do tabaco (quantidade, frequência, diagnóstico e
intensidade de dependência) além da aplicação do questionário WhoQol-Bref. Resultados: 105 fumantes foram
incluídos no estudo. os domínios psicológicos e de relações sociais do WhoQol-Bref em tabagistas apresentaram
valores estatisticamente menores em relação à população de referência (p=0,023 e p=0,001, respectivamente).
observou-se que dependentes de tabaco apresentavam escores inferiores a não dependentes em todos os domínios do
WhoQol-Bref, embora não tenham diferenças estatisticamente significativas entre os grupos. todos os domínios
se correlacionaram positiva e significativamente com o domínio global, mas não com a intensidade de dependência.
Conclusão: tabagistas apresentam índices inferiores de qualidade de vida, quando comparados a indivíduos não
fumantes, o que estaria diretamente relacionado à insatisfação com vários domínios da vida incluindo felicidade e
bem-estar.
Palavras-chave: Qualidade de Vida; tabaco; tabagismo; telemedicina
Resumen
Introducción: Varios factores pueden interferir con la calidad de vida, incluidos los problemas derivados de la utilización
de sustancias como el tabaco, que por lo tanto afectan la satisfacción de la vida. los efectos del tabaquismo que afectan
a la calidad de vida sirven para alertar a los fumadores, así como motivar a dejar de fumar y mantener la abstinencia.
Objetivo: evaluar la calidad de vida por medio del WhoQol-Bref en los fumadores que buscaban un servicio
telefónico de información y asesoramiento acerca de las drogas. Método: estudio transversal con los usuarios de tabaco
y otras sustancias psicoactivas que llamaron a “ViVaVoz” entre noviembre/2009 – Diciembre/2010. se recogieron
datos socioeconómicos, el consumo de tabaco (cantidad, frecuencia, el diagnóstico y severidad de la dependencia),
además de la aplicación del cuestionario WhoQol-Bref. Resultados: se incluyeron 105 fumadores en el estudio.
las áreas del WhoQol-Bref sociales y psicológicos en los fumadores presentaron valores estadísticamente más bajos
para la población de referencia (p=0,023 y p=0,001, respectivamente). se observó que los consumidores dependientes
de tabaco tenían puntuaciones más bajas que los no dependientes en todas las áreas del WhoQol-Bref, aunque no
hayan diferencias estadísticamente significativas entre los grupos. todos los dominios se correlacionaron positivamente
y significativamente con el dominio global, pero no con la intensidad de la dependencia. Conclusión: los fumadores
tienen niveles más bajos de calidad de vida en comparación con los no fumadores, lo que puede estar directamente
relacionado con la insatisfacción con los diversos aspectos de la vida, incluyendo la felicidad y el bienestar.
Palabras clave: Calidad de Vida; tabaco; tabaquismo; telemedicina
Brazilian Journal of Cancerology 2011; 57(3): 329-335
335

Original Article
Tobacco Quitline in Brazil
Article submitted on 04/12/11; accepted for publication on 07/06/11
Tobacco Quitline in Brazil: an Additional Information Source to
the Population
Disque Saúde Pare de Fumar no Brasil: uma Fonte de Informação a mais para
a População
Línea de Salud para Dejar de Fumar en Brasil: una Fuente de Información para
la Población
cristina de Abreu perez 1 , claudia Teresa pinheiro 2 , stella bialous 3 , valéria cunha 4 , Tânia maria cavalcante 5
Abstract
Introduction: The tobacco Quitline is an important service of telephone counseling for population-based smoking
cessation, as well as a population-based source of elucidation about the harms of tobacco use. Objective: The purpose
of this study is to describe the profile of persons who called the tobacco Quitline, to carry out a descriptive analysis of
this service and to discuss the growing number of calls, relating them to some political measures. Method: Between
January and December 2009, data collected from both ‘Ouvidor SUS’ and ‘Web Report’ systems were analyzed. The
number of calls and distribution according to social and demographic characteristics, such as gender, marital status,
education, age and reason for calling were compiled. Their smoking status was also identified, whether they are smokers,
ex-smokers or have never used tobacco before, and also if it is their first time calling the service. Results: tobacco
represented 23% of all calls received, becoming the second most sought after subject, only after diseases and health
information. among individuals who called the tobacco Quitline, 79% were smokers and 80% said it was their first
call. as to age, young teens between 12 and 24 years-old represent almost half of the population looking for the service
and among all callers, 56% were male and 49% were single. Conclusion: The Quitline is an important source of
information about smoking, however it is necessary to conduct a survey regarding the effectiveness of smoking cessation.
Key words: tobacco use Disorder; tobacco use Cessation; smoking; epidemiology, Descriptive
1 Cristina Perez de abreu. Psychologist of the Brazilian national Cancer institute (inCa). Master's candidate at Professional Master's Degree
Course in Policy and Management of science, national school of Public health sergio arouca (ensP) / fiocruz. Email: cperez@inca.gov.br.
2 Claudia teresa Pinheiro. nurse at inCa. Email: cpinheiro@inca.gov.br.
3 stella Bialous. tobacco Policy international. san francisco - California, usa. Email:stella@bialous.com.
4 Valeria Cunha. Manager of the Division of tobacco Control of inCa and Msc in Public health by the institute for the study of Collective
health (iesC) / ufrJ. Email: valeriac@inca.gov.br.
5 tania Maria Cavalcante. executive secretary of the national Commission for implementation of inCa's framework Convention on tobacco
Control and Master in Public health by ensP/fiocruz. Email: tcavalcante@inca.gov.br.
Brazilian Journal of Cancerology 2011; 57(3): 337-344
337

Perez CA, Pinheiro CT, Bialous S, Cunha V, Cavalcante TM
338
INTRODUCTION
in Brazil, public policies for tobacco control are quite
advanced when compared to other developing countries;
however, there is still much to be done, given the large
number of smokers, around 24 million, who continue to
be addicted to nicotine 1 .
The Brazilian national Cancer institute (inCa)/
Ministry of health (Ms) has developed, for over 20
years, the tobacco Control and other Cancer risk
factors Program, aiming to prevent and control cancer
in a comprehensive and broad way. actions range from
solar protection, encouraging healthy eating and physical
activity, to tobacco control 2 .
as part of this program, in May 2001, during the
celebration of World no tobacco Day, the Brazilian
Minister of health launched the tobacco Quitline, which
is accessed through free calls from anywhere in Brazil. The
tobacco Quitline was thus born from the service platform
of the existing health line, which had received calls from
all over the country on various health issues since 1997,
and which was already recording a growing demand for
information regarding smoking.
The tobacco Quitline, a major component of the
national Program for tobacco Control, is coordinated
by inCa and developed in partnership with the General
ombudsman Department of the secretariat for strategic
and Participatory Management of the Mh.
in february 2002, tobacco industries were required to
insert warnings with pictures and the tobacco Quitline
phone number on all tobacco products, giving greater
visibility to the program, thus increasing the number of calls 3 .
scientific evidence shows that quitlines, as the
telephone services for quitting smoking assistance are
known worldwide, are an effective tool to increase the
number of attempts of smoking cessation, help smokers
quit smoking, as well as assist in the reversion of relapses 3-4 .
The quitlines have low cost to their providers. for
smokers, they are free, easily accessible and a popular
smoking cessation service. they provide support to
smokers wishing to quit smoking with confidentiality
and anonymity 5 . The counseling service through the
phone provides several features that other services do not
have, such as access to care without displacement, access
to treatment for communities where there are no units
that offer formal treatment to quit smoking, access to
treatment whenever it is possible for the citizen without
prior appointments 6-7 , and for smokers who live in rural
areas 8 .
The tobacco Quitline is physically located in Brasilia
and its platform service operates from 7 am to 7 pm from
Monday to friday. at evenings or weekends and holidays,
Brazilian Journal of Cancerology 2011; 57(3): 337-344
all information is available by a recording in the audio
response unit.
at the beginning of the service in 2001, all people who
called received human service. Currently, when someone
calls the tobacco Quitline, they hear a recording with
the option to get information on how to quit smoking
or help someone quit smoking, the benefits of quitting
smoking, symptoms resulting from smoking cessation or
they can simply speak directly with one of the attendants.
in addition to this information, it is possible to get general
information related to smoking such as economics,
legislation and prevention aspects.
The purpose of this article is to describe the profile of
individuals who sought the tobacco Quitline, to make a
descriptive analysis of the service and discuss the evolution
on the number of calls, relating them to policy measures.
METHOD
Data were collected from the “ouvidorsus” and “Web
report” systems of the Mh which are available on its
website 9 . These data, routinely collected by the technical
staff of the sus General ombudsman Department,
are referred to inCa by monthly reports, in which
the number of calls and their distribution according
to social and demographic data such as gender, marital
status, education, age and subject sought 9 can be found.
Questions about smoking status, whether the person is
currently a smoker, a former smoker or never smoked and
if it is the first time they are calling the service were also
collected and analyzed.
first, we described and analyzed the evolution through
time and the influence of some policy measures adopted
in the period between the release of the tobacco Quitline,
in May 2001, and December 2009 on the total number
of calls.
second, social and demographic data and status
of tobacco users between the months of January and
December 2009 were described and analyzed. These
data were collected through a questionnaire completed
during the telephone service. users were asked to answer
questions after the receipt of the information sought by
them.
RESULTS AND DISCUSSION
evoLUTion TroUgh Time
The framework Convention for tobacco Control
(fCtC), the first public health treaty negotiated under the
auspices of the World health organization (Who), of
which Brazil is a signatory as from 2003, in its article 14,
which talks about measures on demand reduction related
to dependency and smoking cessation, recommends in its

guidelines that signatory countries should offer quitlines
service as support for smoking cessation 10 .
in the international literature, a distinction is made
between two types of services that provide care for
smoking cessation by phone: proactive quitlines and
reactive quitlines 11 . The Brazilian tobacco Quitline fits the
second definition because it is a service that answers users'
phone calls, but doesn't make return calls 4 . in the context
of the media, mass anti-smoking campaigns – quitlines
- represent the merging of public health approaches that
aim to produce changes in population through clinical
approaches 12 .
in the first year of operation, the tobacco Quitline
received 30,851 calls, in the second year, there were
198,964 calls and, in the third year, the number of
calls rose to 211,073. in 2009 there were 1,236,892
calls, fact which means that smoking represents 23%
of all calls received by the health line of Mh, placing
it as the second most sought subject after diseases and
advice on health 9 .
During the period described, the diffusion of the
service occurred through the package of tobacco products
and through tobacco control campaigns using posters,
leaflets, billboards and some inserts in the media. it was
observed that since images of health warnings and the
tobacco Quitline number were inserted in the packages
of tobacco products, the number of calls increased twofold
or even threefold at some moment (figure 1).
it is clear, then, that cigarette packages remain an
important source of dissemination and they should be
kept for this purpose even when the health warnings are
replaced.
1000000
100000
10000
1000
100
10
1
May/01
Sep/01
Launch of the Tobacco
Quitline
Jan/02
Introduc�on of images
with 0800 number in packs
Introduc�on
of recorded
messages
May/02
Sep/02
Jan/03
May/03
Sep/03
Jan/04
May/04
Sep/04
Jan/05
May/05
Sep/05
Tobacco Quitline in Brazil
on the other hand, the large increase in number of
calls, after the introduction of service number on packages
of tobacco products, generated a series of problems such
as line congestion, which caused many losses of access,
because the service platform was constantly busy. That
was the reason for the introduction of electronic services
in order to unburden the attendants and provide the best
care to the population. however, these results show that
Brazil, as one of the pioneers in inserting the health line
number on cigarette packs, created a new global model
for increasing access to these services, a model that has
been replicated internationally 13 -14 .
in this sense, it can also be seen in figure 1 that, with
the implementation of the recorded messages, there was an
increase on the number of people served, up to 726,195
calls received in January 2005, relieving the human service
and avoiding busy lines. so there was a pent-up demand
of people non-served that was resolved.
two other factors stand out in figure 1, firstly, the
blocking of cell phone calls in June 2004; and, in 2005,
when the number of calls fell dramatically, a major factor
so that the Mh had to rethink the measure and go back
to accept connections from cell phones, despite their high
cost. The second factor that caused the drop of phone
calls was the need to change the number of the tobacco
Quitline in early 2006 to make the unification of all Mh
numbers for free treatment possible.
finally, although the Brazilian service does not offer
return calls, since its launch, there is great demand
showing that the population is interested in the smoking
issue and it is encouraged to seek information.
Blocking of
cellular calls
Change in the Tobacco
Quitline number
Jan/06
May/06
Sep/06
Jan/07
May/07
Sep/07
Jan/08
May/08
Sep/08
Jan/09
May/09
Sep/09
Figure 1. Evolution of the number of calls received per month, registered by the Tobacco Quitline, from May 2001 to December 2009
Source: ouvidorsus/Mh system.
Brazilian Journal of Cancerology 2011; 57(3): 337-344
339

Perez CA, Pinheiro CT, Bialous S, Cunha V, Cavalcante TM
340
sociAL AnD DemogrAphic profiLe
of the 1,236,892 calls received in 2009 by the tobacco
Quitline, 708,316 people, or 57.2%, agreed to answer
the research on the social and demographic profile. as
shown in figure 2, the vast majority, i.e., 79% of users
that sought the service, was, at the time of the call, a
smoker; 15% had never smoked; and 6% were former
smokers, demonstrating the high demand for the service
by smokers.
15%
6%
79%
Brazilian Journal of Cancerology 2011; 57(3): 337-344
smoker
never smoked
ex-smoker
Figure 2. Distribution of the number of calls regarding smoking status
among individuals who called in 2009 (n = 708,316)
Source: ouvidorsus/Mh system.
in 2009, similar to previous years, the main sources
of difussion of the tobacco Quitline number reported
by respondents were cigarette packs (33.6%), posters
(21.5%), television (20.6%) and others (24.3%) 8 .
among the people who responded to the
questionnaire, 80% said it was their first call, 56%
were male and 49% were single, 29% married, 12%
cohabiting, 7% divorced and 3% widowed. as for age,
it was noticed that young people between 12-24 years
old accounted for almost half the population who
sought care, as shown in figure 3.
100%
80%
60%
40%
20%
0%
8,2%
50
years old
Figure 3. Distribution, as to age, of individuals who called the Tobacco
Quitline in 2009, (n = 708,316)
Source: ouvidorsus/Mh system.
When analyzing their educational background
(figure 4), it is perceived that the largest demand to
the service was made by individuals with complete
elementary and high school education, which
amounted 71% of the surveyed population.
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
16%
43%
Illiterate Elementary
School
28%
High
Schooll
7% 6%
Higher
Education
Postgraduate
Education
Figure 4. Distribution, as to educational background, of individuals
who called the Tobacco Quitline in 2009, (n = 708,316)
Source: ouvidorsus/Mh system.
The profile of individuals who sought the tobacco
Quitline is comprised by young smokers, who have
finished high school and are single. These data are in line
with one of the objectives of the national Program for
tobacco Control, which is to prevent tobacco initiation
that occurs mostly among young teens 2 , as well as
educating them about the harm caused by tobacco use
and reducing exposure to secondhand smoking 15 .
finally, among the subjects requested by citizens to
the tobacco Quitline, 41% of the callers were seeking
information about treatment for smoking cessation. This
option includes advice to quit smoking or to help someone
quit smoking, or on medication and alternative methods
or other methods of quitting smoking and also advice on
the grounds of the treatment of smokers.
The second most popular subject brought by citizens
(30%) calling the tobacco Quitline was prevention. here
is included information on how not to start smoking again,
that is, how to prevent relapse, as well as the benefits that
the individual gets when quitting smoking. international
experience confirms that most people who called were
seeking assistance to quit smoking or remain abstinent,
but this type of program also offers other services such
as information to the public and health professionals, as
part of a proposal for dissemination of information on
the harms of smoking, among others 11,16-17 .
of the total number of individuals calling the tobacco
Quitline, 35,382 people requested human service without
hearing any recording and 152,730 people heard some
recording and then requested human service.
legislation relating to smoking cessation programs,
especifically the ordinance 1035 of 2004 18 , which expands
access to smoking approach and treatment in the network
of Basic and average Complexity Care of the Brazilian
health Care system (sus), and determines that medicines

and materials to support the treatment of smokers be made
available to the population, was the third most popular
subject, corresponding to 17%.
Given that the tobacco Quitline serves the entire
country, it was possible to make a survey on the
distribution of calls by state, identifying that southeastern
states represent 48% of total calls and that, especially, the
northern states have little representativeness, as presented
in figure 5.
it is important to note that the Brazilian states
which most sought treatment were são Paulo and rio
de Janeiro. on the other hand, the northern states
had low demand and may indicate a need for greater
dissemination of the service. it is noteworthy that the
northern states of Brazil did not have high demand, but
there lies the state with the highest prevalence of smokers
in Brazil, acre, with 22% 1 .
CONCLUSION
Given the number of calls received by the tobacco
Quitline, it is clear that some policy measures affected the
number of incoming calls. for example, a large increase in
the number of calls received was due to the introduction
of this service number on cigarette packages and the
introduction of recorded messages.
other measures seem to be responsible for the decrease
in the number of calls such as the blocking of cell phone
calls and the change of the service number. Therefore, such
measures should be evaluated before, so that, if they are
%
25
20
15
10
5
0
22.9
12.2
11.1
6.7
5.2 5.2 4.9 4.1 4.0
Tobacco Quitline in Brazil
really necessary, the service can be prepared to receive an
increase in calls and that, if its number has to be changed,
strategies be designed so that people become aware of this
change in advance and are not affected by unavailability
of the service.
The tobacco Quitline proved to be an important
source of information on smoking for the Brazilian
population, with a high demand since its launch. it is
therefore an important tool within the national Policy
for tobacco Control that should be improved and, if
possible, become proactive, thus enabling monitoring of
smokers who decide to quit smoking or being a source
of motivation for cessation by those who still continue
to smoke.
it is also necessary to conduct an effectiveness survey
to evaluate if smokers who sought the tobacco Quitline
actually quit smoking and remain abstinent.
ACKNOWLEDGEMENTS
to the sus/Mh ombudsman team, responsible for
compiling and organizing the data collected for this
article; to Mariana Marques de Pinho, who between 2002
and 2008 was part of the coordination of this service
in inCa; to staff members ricardo henrique Meireles
(Conprev / inca), Cristiane Gallardo Vianna (ConiCQ
/ inca) and felipe lacerda Mendes (ConiCQ / inca),
who participated in the preparation of the database of
the tobacco Quitline, as well as to all employees of the
Division of tobacco Control / Conprev who took part
in its updates.
2.9 2.6 2.3 2.1 2.1 1.8 1.7 1.5 1.4 1.2 1.0 0.9
0.7 0.5 0.5 0.3 0.2 0.1
SP RJ MG RS BA PE GO PA PR CE SC DF ES MA PB RN AL MT PI TO SE MA RO AM AP AC RR
Figure 5. Distribution according to the percentage of calls, by State, to the Tobacco Quitline in 2009
Source: ouvidorsus/Mh system.
Brazilian Journal of Cancerology 2011; 57(3): 337-344
341

Perez CA, Pinheiro CT, Bialous S, Cunha V, Cavalcante TM
342
CONTRIBUTIONS
C. a. Perez participated in the design, research project
planning; collection, analysis and interpretation of data,
writing and critical review. other authors participated in
the collection, analysis and interpretation of data, writing
and critical review.
Declaration of Conflicting Interests: Nothing to Declare
REFERENCES
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[citado 2011 jul 14]. Disponível em: http://www.inca.gov.
br/inca/Arquivos/publicacoes/tabagismo.pdf
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Câncer: modelo lógico e avaliação [Internet]. 2a ed. Rio
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asp?item=programa&link=programa_de_tabagismo.pdf
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[cited 2011 Jul 14]. Available from: http://www.14wctoh.
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Disease Prevention and Health Promotion, Office on
Smoking and Health, Final Edition; 2004 [cited 2011
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quit_smoking/cessation/quitlines/pdfs/quitlines.pdf
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quitlines: an underrecognized intervention success story.
Am Psychol. 2010 May-Jun;65(4):252-61.
7. World Health Organization. Policy recommendations for
smoking cessation and treatment of tobacco dependence.
[Geneva]: WHO; 2003.
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Pierce JP. The demographics of help-seeking for smoking
cessation in California and the role of the California
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Estratégica e Participativa. Departamento de Ouvidoria-
Geral do SUS. Relatório temático: tabagismo [Internet].
2010 [citado 2011 jul 14]. 46 p. Disponível em:http://
portal.saude.gov.br/portal/arquivos/pdf/relatorio_
tabagismo_2009.pdf
10. WHO Framework Convention on Tobacco Control.
Guidelines for implementation of article 14 of the WHO
FCTC (Demand reduction measures concerning tobacco
dependence and cessation) [Internet]. [cited 2011 Jul 14].
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fctc/Guidelines.pdf
11. Zhu SH. Telephone quitlines for smoking cessation. In:
Shopland DR, Burns DM, Amacher RH, Ruppert W,
editors. Population based smoking cessation: proceedings
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the general population [Internet]. [Bethesda (MD)]:
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Cancer Institute; [2000] [cited 2011 Jul 14]. Chapter
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Available from: http://cancercontrol.cancer.gov/tcrb/
monographs/12/Chapter_8.pdf
12. Wakefield M, Borland R. Saved by the bell: the role
of telephone helpline services in the context of massmedia
anti-smoking campaigns. Tob Control. 2000
Jun;9(2):117-9.
13. Pictorial warning labels by country and jurisdiction:
campaign for tobacco-free kids [Internet]. 2011 May
[cited 2011 Jul 14]. Available from: http://www.
tobaccofreecenter.org/files/pdfs/en/WL_examples_
en.pdf
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[cited 2011 Jul 14]. Available from: http://www.
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en.pdf
15. Tobacco quitlines: at a glance [Internet]. [Washington
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INTPHAAG/Resources/AAGTobaccoQuitlines.pdf
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facts: an overview of the NAQC 2009 Annual Survey of
Quitlines [Internet]. 2009 [cited 2011 Jul 14]. Available
from: http://www.naquitline.org/resource/resmgr/
QL_About_Facts/2009-Survey_All-Quitline-Fac.pdf
17. Carroll T, Rock B. Generating Quitline calls during
Australia's National Tobacco Campaign: effects of
television advertisement execution and programme
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18. Brasil. Ministério da Saúde. Portaria n. 1035/GM, de
31 de maio de 2004 [citado 2011 jul 14]. Disponível
em: http://dtr2001.saude.gov.br/sas/PORTARIAS/
Port2004/GM/GM-1035.htm

Tobacco Quitline in Brazil
Resumo
Introdução: o Disque saúde Pare de fumar é um serviço de aconselhamento para a cessação de fumar por meio do
telefone e uma fonte de esclarecimento da população sobre os malefícios do tabagismo. Objetivo: Descrever o perfil
dos indivíduos que procuraram o Disque saúde Pare de fumar, fazer uma análise descritiva do serviço e discutir a
evolução do número de chamadas, relacionando-as às medidas políticas. Métodos: entre os meses de janeiro a dezembro
de 2009, os dados foram coletados nos sistemas ouvidorsus e Web Report. levantou-se o número de ligações e sua
distribuição de acordo com dados sociodemográficos como gênero, estado civil, escolaridade, faixa etária e assunto
procurado. também foi identificado o status do tabagismo dos indivíduos: fumante, ex-fumante ou nunca fumou e
se é a primeira vez que está ligando para o serviço. Resultados: o tabagismo representou 23% de todas as ligações
recebidas, posicionando-o como segundo assunto mais procurado depois de doenças e orientações sobre saúde.
entre os indivíduos que telefonaram para o Disque saúde Pare de fumar, 79% eram fumantes e 80% informaram
ter ligado pela primeira vez. Quanto à faixa etária, os jovens, entre 12 a 24 anos de idade, representam quase metade
da população que procura pelo atendimento e, entre todas as pessoas que ligaram, 56% eram do sexo masculino e
49% eram solteiros. Conclusão: o Disque saúde Pare de fumar mostrou-se uma importante fonte de informações,
entretanto faz-se necessário realizar uma pesquisa de efetividade quanto à cessação de fumar.
Palavras-chave: transtorno por uso de tabaco; abandono do uso de tabaco; tabagismo; epidemiologia Descritiva
Resumen
Introducción: el teléfono de atención ciudadana: “Pare de fumar” es un importante servicio de consejo a la población
para el cese de fumar a través del teléfono, así como una fuente de aclaración a la población acerca del tabaquismo.
Objetivo: el objetivo de este artículo fue describir el perfil de los individuos que buscaron el teléfono de atención
ciudadana: “Pare de fumar”, realizar un análisis descriptivo del teléfono de atención ciudadana: “Pare de fumar” y
discutir la evolución del número de llamadas, relacionándolas a algunas medidas políticas. Método: entre los meses
de enero a diciembre de 2009 se analizaron los datos recolectados a través de los sistemas ouvidor sus y Web report.
Con esos levantamientos fue posible describir el perfil de los individuos que buscaron la atención en cuanto al número
de llamadas y la distribución en consonancia con datos socio demográficos como género, estado civil, escolaridad,
franja etaria y asunto buscado. estos datos fueron recogidos a través de un cuestionario hecho por teléfono. fueron
también realizadas preguntas sobre el status del tabaquismo como si actualmente es fumador, ex-fumador o nunca
fumó y si es la primera que llama al servicio. Resultados: el tabaquismo representó 23% de todas llamadas recibidas,
lo que lo clasifica como el segundo asunto más buscado después de enfermedades y orientaciones sobre salud. entre
las personas que llaman para la línea de salud para dejar de fumar, 79% eran fumadores y 80% reportó haber llamado
por primera vez. en cuanto a la franja etaria mostró que los jóvenes de entre 12 y 24 años de edad representan casi la
mitad de la población que busca cuidar y entre todas las personas que llamaron el 56% eran hombres y el 49% eran
solteros. Conclusión: el teléfono resultó ser una importante fuente de información sobre el tabaquismo, sin embargo,
es necesario llevar a cabo un estudio sobre la eficacia de dejar de fumar entre los fumadores que se llaman.
Palabras clave: trastorno por uso de tabaco; Cese del uso de tabaco; tabaquismo; epidemiología Descriptiva
Brazilian Journal of Cancerology 2011; 57(3): 337-344
343

Original Article
Anxiety, Depression and motivation in smokers
Article submitted on 2/28/11; accepted for publication on 5/25/11
Evaluation of the Level of Anxiety, Depression and Motivation of
Smokers Seeking Treatment for Smoking Cessation in the Federal
District
Avaliação do Grau de Ansiedade, Depressão e Motivação dos Fumantes que
Procuraram Tratamento para Deixar de Fumar no Distrito Federal
Evaluación del Grado de la Ansiedad, de la Depresión y de la Motivación de los
Fumadores que Solicitan Tratamiento para Dejar de Fumar en el Distrito Federal
maria suélita de Lima 1 , carlos Alberto de Assis viegas 2
Abstract
Introduction: anxiety, depression and low motivation can interfere with successful treatment of smoking. Objective:
to evaluate the level of anxiety, depression and motivation of smokers enrolled in cessation programs in the federal
District. Method: a cross-sectional study involving 1,233 smokers enrolled at 19 reference Centers. instruments:
Hospital Anxiety and Depression Scale, motivation (richmond test), and forms with social and demographic data. for
data analysis, where appropriate, the Student t test, chi-square and Spearman correlation were used. Results: Women
had higher level of anxiety (p

Lima MS, Viegas CAA
346
INTRODUCTION
although the harmful effects of tobacco use are quite
known, according to the Brazilian institute of Geography
and statistics (iBGe), in Brazil, in 2008 , the percentage
of smokers was 17.5% among people aged 15 or above,
which corresponded to the contingent of 25 million
people. in the federal District, the percentage of smokers
found was 13.4% 1 .
among the reasons smokers report to continue
smoking is the relief of anxiety and depression symptoms.
furthermore, it is known that anxiety is associated with
increased risk of relapse during smoking cessation, and
depressive symptoms are significant predictors of lapses
and premature relapses 2 . it is observed that many people
who meet diagnostic criteria for mental disorders do
not seek treatment for this condition, which makes it
important to investigate the relationship between mental
illness and smoking 3 . Thus, a closer look at the issues
related to anxiety and depression of smokers undergoing
treatment for smoking cessation, as well as the provision
of concurrent treatment, may become an important step
to help them cope with nicotine abstinence 4 .
another important point in this process is motivation,
which is an indispensable condition to initiate treatment,
and its absence practically eliminates the hope of
abstinence. The knowledge of the characteristics associated
with the motivation for quitting and smoking cessatiom
are important because they enable the identification of
groups with higher and lower probabilities to smoking
cessation and, thereby, adapt approach strategies 5 .
Therefore, the objective of this study was to evaluate
the levels of anxiety, depression and motivation in patients
seeking treatment to quit smoking in reference Centers
of smoking treatment in the federal District.
METHODS
a cross-sectional study was carried out with 1233
patients from 19 reference Centers of smoking treatment
in the federal District. The data were collected in the
period from february to september 2009, by professionals
who give assistance and who were previously trained by
the researchers. The survey was conducted after approval
of the research ethics Committee of the foundation for
teaching and research of health sciences (fePeCs)
ses/Df (letter no 256/09. CeP/ses), based on the
resolution 196/96 Cns/Ms, which provides for “research
involving human beings”. all patients in the study signed
a free and informed consent and filled out a form when
they entered the smoking cessation program. information
concerning the levels of anxiety and depression were
Brazilian Journal of Cancerology 2011; 57(3): 345-353
measured with the hospital anxiety and Depression
scale (haDs). for each item, 0, 1, 2 or 3 points can be
given - the odd questions evaluate the level of anxiety
(haDs-a) and the even ones the level of depression
(haDs-D). zigmond and snaith 6 cut-offs were adopted,
recommended for both situations: from 0-7 points:
unlikely, 8-11 points: possible (questionable or doubtful)
and 12-21: likely. at the beginning, haDs was designed
to identify symptoms of anxiety and depression in clinical
hospital not psychiatric patients, and subsequently used
in non-hospitalized patients without diagnosed diseases 7 .
We opted for this scale because of its easy handling and
fast execution, which enables it to be used either by the
patient or interviewer.
Motivation was measured by the richmond test,
and cut-offs suggested by the author 8 were adopted: 0-6:
low motivation, 7-9: moderate motivation and 10: high
motivation. social and demographic data were obtained
from the “outpatient smoking Cessation Clinic form”.
Data were analyzed through the statistical Package for
social sciences (sPss), version 17,0, using student's t
test or chi-square test and spearman correlation whenever
appropriate for the comparison of variables; the level of
significance was 5% (p. 0.05).
RESULTS
a total of 1,233 patient sheets from various health
units of federal District was searched. in table 1 sociodemographic
and economic data from the sample are
presented, and it is noticed that most patients, 65%,
were females. age ranged from 19 to 77 years old, 44±11
years on average. age at smoking initiation was between
5 and 40 years old, 16±4.7 years on average; and, in 70%
of the sample, the age at smoking initiation was under
20 years old.
as to family income, patients who received less than
one minimum wage are equivalent to 13%, those with
incomes from 1 to 2 MW, totalize 15%; 2-4 MW - 10%,
4-6 MW - 3%, 6-8 MW - 2%, and 8 MW or above - 4%.
as to education, it is noticed that among most patients
surveyed 43% finished elementary school, 37% finished
high school and just slightly more than 11% have higher
education. it was also observed that 6% of patients are
not literate.
table 2 shows the levels of depression in the
population studied and their distribution within the
analyzed variables. it is possible to see that women are
statistically significantly (p

Table 1. Distribution of population as to sociodemographic and economic variables
Gender
Age group
Age range at smoking
initiation
Income range in
minimum wage
Educational background
Anxiety, Depression and motivation in smokers
Studied factor n %
groups, although a tendency to be more depressed can be
observed in the population ranging from 41 to 50 years
old. Probable depressed patients’ average age was 45±12
years. When comparing the age at smoking initiation and
the level of depression, it was found that the relationship
between them was significant (p = 0.025), and from this
data, it si possible to extract that patients with a probable
level of depression started smoking at an average age of
15±5 years.
regarding family income, there is statistically
significantly higher depression probability among the ones
in the least favored groups (p = 0.001). similarly, smokers
with lower educational background had significantly (p
= 0.003) more chances of depression than those with
higher education. as to the amount of tobacco consumed
daily and scale of depression, no statistically significant
association (p> 0.05) was found.
in table 3, there are variables related to the level of
anxiety, and it can be verified that the level of anxiety
Male 427 34.6
Female 806 65.4
Under 30 years old 165 13.4
31 to 40 y 250 20.3
41 to 50 y 432 35
51 to 60 y 278 22.5
61 y and above 108 8.8
Under 10 years 97 7.9
11 to 20 y 949 77
21 to 30 y 100 8.1
Above 30 y 20 1.6
Not reported 66 5.4
Less than 1 MW 161 13.1
1 to 1.99 MW 190 15.4
2 to 3.99 MW 119 9.6
4 to 5.99 MW 42 3.4
6 to 7.99 MW 27 2.2
8 MW or above 54 4.4
Not reported 640 51.9
Illiterate 76 6.2
Elementary 531 43.1
High school 459 37.2
Higher education 143 11.6
Not reported 24 1.9
among men and women showed significant difference
(p

Lima MS, Viegas CAA
348
Table 2. Level of depression as to sociodemographic variables
Gender
Age range
Income
range in
minimum
wages
Educational
background
Age at the
smoking
onset
Amount
of tobacco
(cigarettes)
a day
also compared. in table 4, it is observed that the level of
motivation varies with the patient’s gender. Motivation is
different between men and women, and this difference is
significant (p = 0.006). Chances that a man be classified
with low motivation are twice higher than in women.
Motivation had no significant correlation with age
range (p = 0.607), educational background (p = 0.408),
age at smoking initiation (p = 0.510), family income
(p = 0.116); amount of tobacco smoked a day (p =
0.077); and the anxiety (p = 0.072) and depression
scales (p = 0.293).
Brazilian Journal of Cancerology 2011; 57(3): 345-353
Depression Scale (HAD)
Unlikely Possible Likely
n n n
Total
n
Chi-square
test (p-value)
Male 248 108 60 416
Female 334 237 213 784 0.000
Total 582 345 273 1,200
Under 30 y 85 47 30 162
31 to 40 104 89 52 245
41 to 50
51 to 60
201
134
113
75
106
59
420
268
0.066
61 and above 58 21 26 105
Total 582 345 273 1,200
Under 1 MW 60 46 52 158
1 to 1.99 MW 86 56 41 183
2 to 3.99 MW 64 29 25 118
4 to 5.99 MW 25 10 6 41 0.001
6 to 7.99 MW 18 5 4 27
8 MW or above 37 12 4 53
Total 290 158 132 580
Illiterate 24 27 19 70
Elementary 238 146 136 520
High school 231 126 92 449
Higher educ. 80 41 18 139
Total 573 340 265 1,178
Under 10 y 41 32 22 95
11 to 20 y 435 264 225 924
21 to 30 y 61 24 12 97
Above 30 y 6 8 6 20
Total 543 328 265 1,136
Less than 20 359 204 161 724
More than 20 137 93 69 299
Total 496 297 230 1,023
DISCUSSION
0.003
0.025
0.519
tobacco smoking is a disease of complex treatment.
Most smokers show peculiar characteristics and are often
among specific populations that demand differentiated
attention. a careful evaluation of patients seeking
treatment is of primordial importance to suit the various
strategies for treatment.
in this sample, 59% of patients quit smoking at the
end of the fourth session of treatment, 34% of patients
were classified with likely level for anxiety and 28% with

Table 3. Level of anxiety as to sociodemographic variables
Gender
Age range
Income
range in
minimum
wages
Educational
background
Age at the
smoking
initiation
Amount
of tobacco
(cigarettes)
a day
Anxiety scale (HAD)
Unlikely Possible Likely
Total
n n n n
Male 192 130 93 415
Female 192 268 327 787
Total 384 398 420 1,202
Under 30 y 54 59 50 163
31 to 40 67 76 102 245
41 to 50 124 146 152 422
51 to 60 89 90 89 268
61 and above 50 27 27 104
Total 384 398 420 1,202
Under 1 MW 37 58 65 160
1 to 1.99 MW 61 58 64 183
2 to 3.99 MW 33 43 43 119
4 to 5.99 MW 16 13 12 41
6 to 7.99 MW 14 8 5 27
8 MW or above 21 21 10 52
Total 182 201 199 582
Illiterate 16 18 36 70
Elementary 155 167 200 522
High school 157 148 144 449
Higher educ. 48 58 33 139
Total 376 391 413 1,180
Under 10 y 28 26 41 95
11 to 20 y 282 317 327 926
21 to 30 y 43 28 26 97
Above 30 y 5 9 6 20
Total 358 380 400 1,138
Less than 20 231 252 242 725
More than 20 96 90 114 300
likely level for depression. Motivation was high in 51%
of cases. regarding anxiety and depression, this rate is is
considered high when compared to other studies, such as
Mc Clave et al., who found 14.9% of patients diagnosed
with anxiety and 20.3% with diagnosis of depression.
Women showed levels of anxiety and depression higher
than men, as already noticed by other authors, whose
findings show that it’s nearly twice as high when compared
to men 10 . another relevant fact was that women are more
motivated to quit smoking than men, although it is known
that men have higher rates of cessation than women in
the smoking cessation treatment. The probable levels of
Total 327 342 356 1,025
Anxiety, Depression and motivation in smokers
Chisquare
test
(p-value)
0.000
0.008
0.039
0.001
0.057
0.253
depression and anxiety were also more prevalent in female
patients and in those with lower education. inasmuch as
psychiatric comorbidities are related to the worst indices
of smoking cessation, this fact reinforces the data shown
in the study by ferguson et al. 11 , in which some successful
predictors of smoking abstinence were found, such as:
male gender, higher education level, higher motivation,
absence of psychiatric comorbidity symptoms and less
depression symptoms.
The relationship between tobacco and poverty was,
as a vicious cycle, has already been well documented. in
most countries there is an association between smoking,
Brazilian Journal of Cancerology 2011; 57(3): 345-353
349

Lima MS, Viegas CAA
350
Table 4. Level of anxiety as to sociodemographic variables
Gender
Age range
Income
range in
minimum
wage
Educational
background
Amount of
tobbaco
a day
(cigarettes)
Age range
at smoking
initiation
Depression
scale (HAD)
Anxiety scale
(HAD)
Brazilian Journal of Cancerology 2011; 57(3): 345-353
Motivation (Richmond test)
Low Moderate High
Total
n n n n
Male 32 183 204 419
Female 29 334 426 789
Total 61 517 630 1,208
Under 30 y 7 73 82 162
31 to 40 y 13 103 129 245
41 t0 50 y 16 187 223 426
51 to 60 y 16 116 138 270
61 and above 9 38 58 105
Total 61 517 630 1,208
Less than 1 MW 7 67 86 160
1 to 1.99 MW 8 74 102 184
2 to 3.9 MW 10 53 56 119
4 to 5.99 MW 4 14 23 41
6 to 7.99 Mw 3 15 9 27
8 MW or above 3 31 19 53
Total 35 254 295 584
Illiterate 4 32 34 70
Elementary 26 211 283 520
High school 21 196 236 453
Higher education 9 71 61 141
Total 60 510 614 1,184
Less than 20
cigarretes
30 323 374 727
More than 20
cigarettes
21 118 163 302
Total 51 441 537 1,029
Under 10 y 5 32 59 96
11 to 20 y 47 406 477 930
21 to 30 y 5 41 52 98
30 y and above 1 6 13 20
Total 58 485 601 1,144
Unlikely 24 245 313 582
Likely 18 143 184 345
Probable 18 125 128 271
Total 60 513 625 1,198
Unlikely 22 153 209 384
Likely 11 186 201 398
Probable 26 175 217 418
Total 59 514 627 1,200
Chisquare
test
(p-value)
0.006
0.607
0.039
0.408
0.077
0.510
0.293
0.072

low income and low educational level. in Brazil, among
groups of individuals with low level of education, the
likelihood of their becoming smokers is five times higher
than individuals who have graduated from university 12 . it
is also known that depressive disorders are more common
in women and in people with lower incomes and lower
level of education 13 .in this study, in addition to smoking,
patients with lower income and lower education also had
a higher likelihood for anxiety and depression. Cigarette
smoking is associated with the possibility of pleasure and
anxiety relief, as exemplified by rondina et al. 14 : some
depressed smokers may use smoking to relieve their
negative feelings.
in this study, the smoking initiation age confirms
data in the literature: the majority started smoking
in adolescence, a phase of life when group influences,
rebellion and self-assurance are present. These findings
coincide with the studies by levy et al. 15 and Pedersen 16 , in
what regards the strong association between the smoking
initiation in adolescence and the subsequent appearance
of symptoms of depression. These authors also found a
strong association between the smoking initiation age and
anxiety. smoking in adolescence seems to be a starting
point for further psychopathologies, because this phase
of life is a period of higher neural vulnerability to the
effects of nicotine on the synaptic function and brain
development 17 .
as to the data in this study, a tendency between the
likely level of anxiety and smoking initiation age (p =
0.057) was observed. another detail that draws attention
was the absence of significant difference between amount
of tobacco per day and the levels of anxiety and depression,
which differs from literature. a study by Kang and lee. 18 in
Korea identified the presence of depression among 31.3% of
people who smoked two packs or more a day and, among
18.7% of those who smoked, less than half a pack a day.
This same study showed index of depression among nonsmokers
of 17.8%, which was lower than the one found
among those who smoked less than half a pack or more than
two packs a day. other studies have shown that anxious and
depressed patients tend to increase tobacco consumption as
self-medication to minimize the symptoms 17-18 .
Patients suffering from likely anxiety and depression
were aged between 41 and 50 years old. This data is
corroborated by another study, in which the average age
was 46 years old, which can also be an indicative of a
period in life cycle characterized by important hormonal
changes and, especifically in the case of women, the
imminence of menopause 19 .
as previously mentioned, half of the smokers in this
sample showed high level of motivation, regardless of the
levels of anxiety and depression, but when we compared
Anxiety, Depression and motivation in smokers
the variables of this study to the level of motivation in the
three levels of richmond scale, there are some differences
to be considered such as the moderate level of motivation
presented by 84% of smokers who started smoking at ages
from 11 to 20 years, in 41% of smokers with elementary
education only and in 73.% of those who smoked up to
20 cigarettes a day. We found low levels of motivation
in 44% of patients with likely level of anxiety and 30%
with likely level of depression. in a study by Melo et al. 20 ,
when comparing the motivational stages with anxiety and
depression, attention is drawn to the fact that the higher
scores of anxiety and depression, the less motivation and
adherence to treatment. our results were not consistent
with this study, since no correlation was found between
motivation and high levels anxiety and depression (p =
0.072 and p = 0.293).
The fact that the patients surveyed were seeking a place
for treatment in one of the reference Centers may have
influenced the information related to motivation and this
can be considered a factor liable to cause confusion in this
variable. another limitation of this study is that, when a
test is applied, it refers only to that specific moment the
person is living, and it may be under the influence of
transitory situations and facts.
CONCLUSION
The study data suggest that about 30% of smokers
who sought treatment at the reference Centers in the
federal District showed likely levels of anxiety and
depression. among these, 50% were highly motivated to
quit smoking. Women showed the highest likely levels of
anxiety and depression; however, as for men, motivation
for cessation is highlighted.
from these results, attention is drawn to the need of
evaluating the motivation of patients and the preparation
of the health care staff for early recognition of psychiatric
comorbidities through the early detection of signs and
symptoms, which can define a more appropriate treatment
for smoking, thus increasing the rate of success.
ACKNOWLEDGEMENTS
to Dr. Celso antonio rodrigues da silva for the
incentive to accomplish this work through his contagious
enthusiasm as the head of the tobbaco Control Program
in the federal District.
CONTRIBUTIONS
Maria lima suelita contributed to data collection,
analysis and interpretation; Carlos alberto de assisViegas
contributed to the final writing and editing.
Brazilian Journal of Cancerology 2011; 57(3): 345-353
351

Lima MS, Viegas CAA
352
Declaration of Conflicting Interests: Nothing to Declare.
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um círculo vicioso: a convenção quadro de controle do
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13. Lima MS. Epidemiologia e impacto social. Rev Bras
Psiquiatr. 1999;21 supl 1: SI1-5.
14. Rondina RC, Gorayeb RS, Botelho C. A dinâmica
psicológica do tabagismo: o papel de características
de personalidade, psicopatologia, fatores genéticos e
neurobiológicos no comportamento de fumar tabaco.
Cuiabá: Entrelinhas; 2004.
15. Levy AS, Anna LM, Westein BS, Reamy SB, Reyner CJ,
Syed T, et al. Comunication about smoking between
depressed adolescents and their parents. Nicotine Tob
Res. 2010 Mar;12(3):191-7.
16. Pedersen W, Soest T. Smoking, nicotine dependence
and mental health among young adults: a 13- year
population-based longitudinal study. Addiction. 2009
Jan;104(1):129-37.
17. Lemos T, Gigliotti AP. Transtornos psiquiátricos e
tabagismo. In: Viegas CAA, coord. Tabagismo do
diagnóstico à saúde pública. São Paulo: Atheneu; c2007.
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KS. Sintomas de ansiedade em tabagistas no início
do tratamento. Revista de Psicologia da IMED.
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Anxiety, Depression and motivation in smokers
Resumo
Introdução: ansiedade, depressão e baixa motivação podem interferir no sucesso do tratamento do tabagismo. Objetivo:
avaliar o grau de ansiedade, depressão e motivação dos fumantes atendidos no Distrito federal. Método: estudo
transversal, envolvendo 1.233 fumantes atendidos em 19 Centros de referência. instrumentos utilizados: Hospital
Anxiety and Depression Scale, teste de motivação de richmond e ficha com dados sociodemográficos. Para análise
dos dados, foi utilizado, quando pertinente, teste t de Student, qui-quadrado e correlação de spearman. Resultados:
Mulheres apresentaram maiores graus de ansiedade (p

Original Article
Tobacco Smoking and Body Composition
Article submitted on 02/02/11; accepted for publication on 05/26/11
Impact of Tobacco and Alcohol on the Body Composition of Youth
Impacto do Tabagismo e Álcool sobre a Composição Corporal de Jovens
Impacto del Tabaquismo y el Alcohol en la Composición Corporal en la Juventud
ellencristina da silva batista 1 , Tatiana do nascimento campos 2 , flávia Xavier valente 3 , sílvia eloiza priore 4 , sylvia do carmo castro franceschini 5 ,
céphora maria sabarense 6 , maria do carmo gouveia peluzio 7
Abstract
Introdution: The early onset of smoking and alcohol consumption, whether or not associated with excess weight are
considered modifiable risk factors for chronic diseases such as cardiovascular diseases and cancer. When occurring
concomitantly, they increase the likelihood of developing these diseases. Objectives: Given these assumptions, this
study aimed to evaluate the influence of smoking and alcohol consumption on body composition of young people.
Method: a cross-sectional, analytical and descriptive study with 68 volunteers, among smokers and non-smokers,
between 18 and 26 years of age, from three universities, four elementary schools, two high schools and two technical
courses in the town of Viçosa, MG, Brazil. Results: among the body composition measures, BMi, waist circumference
and waist-hip ratio were higher among male smokers (p

Batista ES, Campos TN, Valente FX, Priore SE, Franceschini SCC, Sabarense CM, Peluzio MCG
356
INTRODUCTION
tobacco smoking is considered today a global Public
health problem and the strongest preventable isolated
cause of diseases and premature deaths in the world,
accounting for 5 million deaths a year. if the current pattern
of consumption remains the same, 10 million deaths are
expected a year in 2020, 70% of them in developing
countries. in Brazil, data from the Pan american health
organization (oPas), point out to 200 thousand deaths
a year due to tobacco smoking 1 .
tobbaco initiation usually occurs in adolescence,
between 13 and 14 years old on average. The earlier the
initiation, the more severe the addiction to associated
problems 2 . tobacco smoking in adolescence has been
associated to parental, friend, and older siblings smoking,
low performance in school, school dropout and paid
work 3 . among the reasons for adolescent cigarette
experimentation, the most common one was “curiosity”.
other reasons shown were the nicotine effect (pleasure and
relaxation) and friends’ influence 4 .
inappropriate feeding in this period, characterized by
the massive consumption of sugar and fats, associated to
low consumption of fruits and greenery and the long period
dedicated to low intensity activities, such as watching
television, using the computer and playing video games,
contributes to the gaining of weight among adolecents 5 .
Considering that many unsolved questions as to the effect
of tobacco over body weight, there are increasing evidences
that smoking is favorable to a major accumulation of visceral
fats and resistance to insulin, and, as a result, it increases the
risk of metabolic syndrome and type 2 diabetes 5 .
as much as it is for tobacco, the early initiation of
alcohol consumption is one of the most relevant predictors
of health, social, cultural and economic problems.
Consumption before the age of 16 significantly raises the
risk of excessive alcohol consumption at adult age, for both
genders. young adults constitute the population group with
the most serious problems concerning alcoholic beverages 6 .
accordingly to slaterry et al., the consumption of grams
of alcohol per week and the number of cigarettes smoked a
day were significantly associated to total body fat and body
fat distribution through the waist/hip circumference ratio
in young men and women 7 .
as we face these assumptions, this study aims at
evaluating the influence of tobacco smoking and alcoholic
beverage consumption in the body composition of young
adults.
METHOD
a transversal, analytics and descriptive study was
developed with volunteers between 18 and 26 years old
from three colleges, four schools, two pre-college courses
Brazilian Journal of Cancerology 2011; 57(3): 355-363
and two technical courses in the city of Viçosa, MG,
Brazil.
The volunteers were selected through the filling out
of a form with questions about cigarettes consumption.
individuals were considered smokers if they stated
smoking, at least, a cigarette a day during the last 30
days before filling out the form and, non-smokers, those
who have never tried a cigarette before. a person was
considered a former smoker if he smoked for a long period,
and these were excluded from the research.
also, those who stated having experimented a cigarette
at least once; who had cardiovascular problems, thyroid
alterations, diabetes, cancer, hypertension, feeding allergy
or intestinal malabsorption syndrome; pregnant women
and nursing, were excluded. individuals who were making
regular and recent use of multivitamins (during the last
six months) were also excluded.
The evaluations were individually done and led by only
one qualified professional. The research was conducted
after approval of the research ethics Committee from
Viçosa federal university (ufV), Viçosa (MG), Brazil,
in 2005, in accordance with the resolution 196/96 about
“research involving human Beings”, from the health
Council of the Ministry of health. all participants signed
a free and clear informed Consent before their inclusion
on the sample.
The volunteers were divided in two groups: smokers
(34) and non-smokers (34). for each selected smoker, a
non-smoker of the same age and gender was chosen by
lot, once there was a pairing by gender and age, totalizing
68 participants.
the information about smoking was obtained
through a questionnaire. for the management of the
variables about tobacco smoking, the following measures
were taken into consideration: the number of cigarettes
smoked a day, the date of smoking initiation to calculate
the time of consumption. The consumption of alcoholic
beverages was also evaluated through a questionnaire and
its classification was done in quarters based on quantity
(quarter i: if consumption was between 80 and 1,750 ml,
and quarter ii, between 1,750 ml and 5,400 ml; quarter
iii: between 5,400 and 6,750ml and quarter iV: between
6,750ml and 29,400ml and on the weekly frequency.
Weight and height were obtained according to
techniques proposed by Jellife 8 and the body mass index
(BMi) was calculated. The proposed anthropometric
reference for BMi/age from the World health organization
(Who, 2007) 9 was used for individuals between 18 and
19 years old and, for adults, the adopted BMi was from
Who (1998) 10 .
The percentage of body fat was evaluated by the skin
folds (triceps, biceps, subscapular and suprailiac), according
to heyward and stolarczyk 11 technique. Calculation of the
body fat percentage was done according to the classification

proposed by lohman 12 . Central body fats (Cf) and
peripheral fats (Pf) were calculated as from the sum of all
subscapular and suprailiac folds (central fat) and biceps
and triceps (peripheral). The relationship between central
and peripheral fats (Cf/Pf) was obtained by dividing the
central fat (Cf) by the peripheral fat (Pf) 13 .
Waist circumference (WaC) and waist/hip ratio
(Whr), which was obtained by dividing the waist
circumference and the hip circumference, were based on
recommended cut-off points (Who, 1998) 10 .
for the statistical analysis, the sPss for Windows
program (release 8.0 Chicago, il, usa) was used.
for the numerical variables, average (a), standard
deviation (sD), median (M) were presented. for
the comparison of two independent groups, Mann
Whitney test was used, once the variables did not pass
through regular distribution. for the comparison of
two dependent groups, the paired t test was applied. to
check the correlation between two variables, Pearson or
spearman correlation was used, according to the linear
characteristics between them 14 . 5% was considered as
the level of statistical significance.
Tobacco Smoking and Body Composition
Table 1. Classification of the anthropometric parameters and of body composition of young smokers and non-smokers, according to gender.
Viçosa (MG), 2005.
BMI (a)
Parameter and
classification
RESULTS
2.019 questionnaires were answered, 93.3% (1,883)
of which were valid. among these questionnaires, it
could be observed that 72.9% (1,372) adolescents had
never smoked; 21.1% (397) have smoked a cigarette just
once; 2.4% (45) were former smokers and 3.6% (69)
were smokers.
out of the total number of smokers detected, 30.6%
(28) didn’t want or could not take part due to business
or travel. it was not possible to contact 5 individuals and
2 of them presented a criterion of exclusion. Therefore,
49.3% (34) smokers took part in the study.
Between the smoker and non-smoker group,
distribution by gender was 50% women and 50% men
and average age (20.53, sD=2.0) and median (21.0) was
the same for both groups.
as for tobacco smoking, it could be observed that
participants smoked between 7.44 ±5.03 cigarettes a
day; they had been smokers for about 4.66 ±2.94 years;
tried a cigarette when they were 13.38 ±2.06 years old
and initiated smoking when they were 15.94±2,36 years
old. no statistically significant difference (0.94) between
genders for the above variables was observed.
By analyzing the anthropometric parameters and
body composition (table 1), it could be observed that the
frequency of overweight and increased waist circumference
was higher among smokers rather than among non-smokers.
Women who smoke (n=17) showed a higher percentage of
body fat than men and the latter showed higher overweight
figures considering the BMi and high waist circumference.
according to table 2, the group of smokers had higher
average with significant difference for BMi, WaC and
Whr when compared to the non-smoker group. When
evaluated by gender, (table 3), male smokers had higher
Smoker Non-Smoker
Total Female Male Total Female Male
% (n) % (n) % (n) % (n) % (n) % (n)
Low weight 5.9 (2) 11.8 (2) - 14.7 (5) 5.9 (1) 23.5 (4)
Eutrophy 70.06 (24) 82.3 (14) 58.8 (10) 82.4 (28) 88.2 (15) 76.5 (13)
Overweight
% Body Fat
23.5 (8) 5.9 (1) 41.2(8) 2.9 (1) 5.9 (1) -
Elevated 11.7 (4) 23.5 (4) - 14.7 (5) 23.5 (4) 5.9 (1)
Acceptable 55.9 (19) 52.9 (9) 58.8 (10) 44.1 (14) 64.7 (11) 23.5 (4)
Ideal
Waist Circunference (WaC)
29.4 (11) 23.5 (4) 41.2 (7) 41.2 (14) 11.8 (2) 76.5 (12)
High 5.9 (2) 5.9 (1) 5.9 (1) - - -
Adequate
Waist/Hip (WHR) Ratio
94.1 (32) 94.1 (16) 94.1 (16) 100.0 (34) 100.0 (17) 100.0 (17)
High - - - - - -
Adequate 100.0 (34) 100.0 (17) 100.0 (17) 100.0 (34) 100.0 (17) 100.0 (17)
(a) for adolescents, BMi was considered for their age.
Brazilian Journal of Cancerology 2011; 57(3): 355-363
357

Batista ES, Campos TN, Valente FX, Priore SE, Franceschini SCC, Sabarense CM, Peluzio MCG
358
weight, BMi, WaC, Whr and significant peripheral fat
rather than non-smokers of the same gender.
according to table 4, smokers of both genders
consumed alcoholic beverages more frequently and in
higher quantity than non-smokers. among smokers,
individuals of both genders consumed alcoholic beverages
more frequently per day and per week (p

Anthropometry
and body
composition
Quarter I
M +
SD
Md
M +
SD
Md
P
Quarter II
M +
SD
Md
M +
SD
Md
P
Tobacco Smoking and Body Composition
Table 4. Consumption of alcoholic beverages among young smoker and non-smoker individuals, according to gender. Viçosa (MG), 2005
Frequency of
alcoholic beverages
consumption
Weight (kg)
bmi (kg/cm 2 )
Wac
hip
circunference
Whr
central fat %**
peripheral fat**
central fat
pf/cf r (d)
55.02
+ 7.63
20.56
+ 2.01
69.00
+ 4.99
0.73+
0.02
24.27
+ 6.14
20.33
+ 5.82
27.25
+ 8.62
1.35 +
0.22
58.35
21.21
70
0.74
26.4
22
22
1.34
Smoker Non-Smoker
Total Female Male Total Female Male
% (n) % (n) % (n) % (n) % (n) % (n)
Does not consume 5.9 (2) 11.8 (2) - 29.4 (9) 17.6 (3) 35.3 (6)
Consumes 94.1 (32) 88.2 (15) 100.0 (17) (25) 82.4 (14) 64.7 (11)
< 1 per week 17.6(6) 13.3 (2) 23.5 (4) (13) 64.3 (9) 36.4 (4)
1 per week 23.5(8) 40.0 (6) 11.7 (2) (5) 7.1 (1) 36.4 (4)
twice a week 26.5(9) 33.4 (5) 17.6 (4) (5) 21.5 (3) 18.2 (2)
3 to 4 times a week 29.4(10) 13.3 (2) 47.1 (8) (2) 7.1 (1) 9.1(1)
Quantity M + SD M + SD M + SD M + SD M + SD M + SD
Litersc onsumed a
day (1) (2) (3) 1.43 + 1.24 1.15 + 1.16 1.82 + 1.25 0.30 + 0.62 0.39 + 0.75 0.23 + 0.47
Liters consumed a
week (1) (2) (3) 5.18 + 5.78 2.15 + 2.68 5.16 + 6.91 6.64 + 1.63 2.09 + 0.51 0.42 + 0.12
for a comparison between smokers and non smokers groups, p- value originated from Wilcoxon test. for the comparison among female individuals, smokers or
non smokers, as well as for male smokers or non smokers, p-value came from Wilcoxon test.
(1) p non smokers
(2) p female non smoker
(3)p male non smoker.
for the comparison between male and female smokers, p-value came from Mann Whitney test, and for non smokers as well.
Table 5. Anthropometry and body composition of young smoker and non-smoker participants, according to the quarter consumption of
alcoholic beverage per week.Viçosa (MG), 2005
67.28+
12.25
23.61
+3. 27
78.21 +
9.14
0.81 +
0.04
19.80 +
7.51
18.94 +
8.23
29.66 +
12.30
1.62 +
0.43
67.7 0.042*
23.28 0.057
77.75 0.030*
0.81 0.001*
9.66 0.194
18.5 0.463
26.5 0.714
1.44 0.172
59.67 +
9.19
21.58 +
2.44
75.52 +
6.71
0.77 +
0.05
21.52 +
7.33
20.43 +
7.88
27.82 +
11.07
1.37 +
0.21
59.37
21.3
71.75
0.77
21.2
21
25.5
1.34
70.85 +
13.84
24.62 +
3.53
80.65
+10.31
0.82 +
0.05
20.06 +
7.64
17.70 +
7.30
30.8 +
12.13
1.80 +
0.48
68.47 0.038*
24.62 0.020*
79.5 0.038*
0.82 0.015*
19.08 0.639
18 0.429
26.5 0.539
1.92 0.012*
* p-value originated from the Wilcoxon test.
24 individuals were evaluated, and those who did not drink alcoholic beverages or rarely did it were excluded
(d) central and periferical fat ratio
Quarter IV
M +
SD
61.82 +
10.46
22.23 +
2.75
74.54 +
7.74
94.21 +
6.55
0.78 +
0.05
21.10 +
7.40
19.61 +
7.50
28.58 +
11.28
1.47 +
0.28
Md
59.6
21.7
73.5
96
0.78
20.7
20
26
1.4
M +
SD
671.42
+ 15.78
24.79 +
4.2
80.00
+12.45
94.21+
8.76
0.81 +
0.06
20.33 +
7.81
18.33 +
8.60
30.50
+12.56
1.79 +
0.61
Md
Brazilian Journal of Cancerology 2011; 57(3): 355-363
p
71.6 0.12
25.1 0.16
76 0.39
96 0.42
0.8 0.35
20.2 0.84
18 0.64
26.5 0.67
1.75 0.24
359

Batista ES, Campos TN, Valente FX, Priore SE, Franceschini SCC, Sabarense CM, Peluzio MCG
360
stomach, pancreas, liver, kidney, bladder, cervix and
leukemia), in addition to respiratory and cardiovascular
diseases. as a carcinogen, tobacco either in cell induction
(mutagenic effects) or cell proliferation 16-19 .
in this study, only 3.6% of contacted adolescents
were smokers and 2.4% were former smokers. studies
of prevalence of smokers and former smokers at that age
range in this population are still unknown. This data
would be important to foresee the future dissemination
of tobacco smoking and analyze the results of big antitobacco
campaigns adopted by the government in this
analyzed population 15 .
according to the household survey about risky
Behaviors and referred Morbidity of Diseases and nontransmissible
aggravations, carried out in 2002 and 2003,
with people between 15 year-old or above, living in 15
Brazilian capitals and in the federal District, prevalence
of tobacco smoking varied between 12.9% and 25.2% in
the analyzed cities. Men presented higher prevalence than
women in all capitals 17,19 .
the number of smoked cigarettes a day showed
a positive correlation with higher weight and fat
concentration in the abdominal area. the number
of smoked cigarettes a day and length of time of
addiction are associated to higher values of Whr
and weight of adult smokers, and Whr increases
progressively with the number of smoked cigarettes
a day 20-21 . obesity and smoking have a highlighted
position in Public health of western countries as
avoidable causes of cancer 17 .
Presence of higher BMi, WaC and Whr in the
smoker group was found only among males. freedman et
al. found a higher BMi and higher prevalence of obesity
in adolescent smokers rather than non-smokers of both
genders 5,21 . in this study, the smoker group had women
who were underweight (n=2) and even in a small number,
might have influenced the results above; whereas, for
men, the same group did not present any underweight
individual.
The explanation for the difference of the central fat
distribution in smokers has not been well established yet.
some authors suggest that differences related to sexual
hormones may provide a feasible biological explanation 21 .
These authors suggest that tobacco may have an anti
estrogenic effect and or increase the levels of androgens,
resulting in high androgen/estrogen ratio favors the
deposition of fats in the abdominal area.
han et al. 22 observed, in adult men only, that higher
than expected WaC for BMi is associated to smoking. for
freedman et al. 21 , the high values of BMi and body weight
found in young male smokers could be related to the short
time and lower number of cigarettes smoked if compared
to adults, and there may be limitation of nicotine action
on energy expenditure.
Brazilian Journal of Cancerology 2011; 57(3): 355-363
in case this pattern of body fat remained in these male
individuals, between the age of 35 and 40, it could have
been aggravated due to the drop of testosterone level,
contributing to the increase of abdominal adiposity and
as a consequence, to the emergence of aggravations such
as cancer and cardiovascular diseases 17 .
The higher accumulation of fat in the abdominal
region and high weight in smokers reflect subjacent
differences to lifestyle between smokers and non-smokers,
such as food intake, alcoholic beverages consumption,
physical activity and educational level 23-24 .
in this study, there was a statistically significant
difference in the amount of alcoholic beverages consumed
by young smokers comparing to non-smokers per day
and per week, which can become a confusing factor to
interpret the higher BMi and higher concentration of
abdominal fat among smokers.
lahti-Koski et al. observed positive association
between high consumption of alcoholic beverages with
BMi23. smokers who drank 80ml or more of alcoholic
beverages a day already presented higher Whr for the
consumption of less than 80 ml a day.
horta et al. 25 confirmed a positive association and
correlation between smoking and alcoholism, and a
tendency of alcohol-dependants to initiate smoking
earlier, keep smoking for a longer period a higher number
of cigarettes.
CONCLUSION
smoking and the consumption of alcoholic beverages
among young men have a positive correlation with the
levels of WaC, characterizing an inappropriate lifestyle
that, if maintained, may result throughout life in several
types of chronic diseases, like cardiovascular, pulmonary
and many types of cancer.
on account of the context presented, the importance
of the prevention of these diseases programs is highlighted,
such as control of tobacco use, as well as the reduction
of alcohol consumption, especially during adolescence,
searching for the effective elimination or reduction of the
main risk factors associated to cancer and to several other
chronic non-transmissible diseases.
AKNOWLEGEMENTS
to the Coordination for improvement of higher level
Personnel (CaPes), for the master degree scholarship
concession.
CONTRIBUTIONS
ellencristina da silva Batista took part in the
conception, planning of the research project; data

collection, analysis and interpretation; writing and
critical review. tatiana do nascimento Campos and flávia
Xavier Valente took part in data collection, analysis and
interpretation, writing and critical review. sílvia eloiza
Priore took part in coorientation, conception, planning of
the research project; writing and critical review. sílvia do
Carmo Castro franceschini participated on data analysis
and interpretation, writing and critical review. Maria do
Carmo Gouveia Peluzio took part in students’ orientation;
conception, research project planning; data analysis and
interpretation; writing and critical review.
Declaration of Conflicting Interests: Nothing to Declare.
REFERENCES
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361

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362
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Tobacco Smoking and Body Composition
Resumo
Introdução: a precocidade no início do tabagismo e consumo de bebida alcoólica, associados ou não ao excesso de
peso, são considerados fatores de risco modificáveis para doenças crônicas, como as cardiovasculares e o câncer. Quando
ocorrem concomitantemente, elevam a probabilidade de desenvolvimento dessas doenças. Objetivos: Diante desses
pressupostos, objetivou-se avaliar a influência do tabagismo e do consumo de bebida alcoólica sobre a composição
corporal de jovens. Método: estudo transversal, analítico e descritivo com 68 voluntários, fumantes e não fumantes,
entre 18 a 26 anos, de três instituições de ensino superior, quatro de ensino médio, dois cursos pré-vestibulares e
dois cursos técnicos do município de Viçosa (MG), Brasil. Resultados: entre as medidas de composição corporal,
o índice de massa corpórea, circunferência da cintura e relação cintura/quadril foram maiores entre os fumantes do
sexo masculino (p

Original Article
Movies and its Implication for Youth Smoking
Article submitted on 3/29/11; accepted for publication on 06/07/11
Ratings for Popular Movies in Brazil and their Implications for
Youth Tobacco Smoking
A Classificação Indicativa de Filmes de Popularidade nos Cinemas Brasileiros
e sua Implicação para o Tabagismo entre Jovens
La Clasificación de las Películas Más Taquilladas en Brasil y su implicación en el
Tabaquismo entre Jóvenes
rosa vargas 1 , James Thrasher 2 , James sargent 3
Abstract
Introduction: The majority of smokers begin using tobacco products before the age of 18. intense exposure to images of
smoking and tobacco consumption in movies contribute to youth tobacco initiation, and it is important to reduce this
exposure. Objective: The present study aimed to compare the ratings attributed to the same popular movies across the
Brazilian and american rating systems, as well as to determine the amount of tobacco imagery in foreign movies that
were rated as appropriate for adolescents. Method: lists of the top-grossing 100 films from 2002 through 2009 were
examined for both Brazil and the united states, and 412 films were identified as popular in both countries. for each
film, the amount of smoking imagery and country-specific rating were determined. rating systems for each country
were harmonized into four categories: children; younger adolescent; older adolescent; adult. The amount of imagery
exposure of tobacco products and consumption was determined for each rating category. Results: The Brazilian system
generally rated the same movie more suitable for a younger audience. Movies rated for younger audiences in Brazil
have a higher amount of smoking imagery when compared to the same group in the united states. Conclusion: The
prevalence of tobacco imagery is high in popular movies that the Brazilian system has rated for adolescents. There are
differences in movie ratings between both countries. Movie rating systems could reduce youth exposure to tobacco
imagery by considering them inappropriate.
Key words: tobacco; Motion Pictures as topic; tobacco-Derived Products Publicity; adolescent Behavior
¹Psychologist. specialization in Mental health. national Cancer institute (inCa). rio de Janeiro (rJ), Brazil. Email: rvargas@inca.gov.br
²Psychologist. M.a. (anthropology). M.s. (epidemiology). Ph.D. (health Behavior). national institute of Public health. Cuernavaca, Mexico.
university of south Carolina. Columbia, south Carolina, usa. Email: thrasher@mailbox.sc.edu
³Pediatrician Doctor. MD. norris Cotton Cancer institute. Dartmouth university. Dartmouth, new hampshire, usa. Email: James.D.sargent @ Dartmouth.edu
Correspondence Address: rosa Vargas. inCa. rua rezende, 128/302 - rio de Janeiro (rJ), Brazil.
Brazilian Journal of Cancerology 2011; 57(3): 365-377
365

Vargas R, Thrasher J, Sargent J
366
INTRODUCTION
in 2008, the national Cancer institute (nCi) published
the monograph "The role of Media in Promoting and
reducing tobacco use”, the nineteenth volume of a series
of studies about tobacco Control, which considers that
"cigarettes are a product of the mass media age; the art and the
science of mass communications and mass marketing were
fundamental to the growth of tobacco use in the last century”.
even a brief exposure to any tobacco advertising can influence
the behavior of adolescents (young people between 10 and
19 years) i , and their perception about smoking, both as to
initiation and to the possibility of becoming regular smokers¹.
Movies are included in the scope of the mass means of
communication, and the total number of scientific evidence
from studies performed combined with high theoretical
plausibility from the perspective of social influences indicates
a causal relationship between exposure to tobacco depictions
in movies, and teenagers smoking initiation¹.
The established relationship of addiction to nicotine,
substance present in tobacco products, does not mean that
pharmacological factors alone determine the smoking habit.
Besides the additive component there are psychosocial,
economic, legislative, religious, family and individual
factors as well as whether access to these products is easy or
not, among others, that interfere with smoking initiation
and experimentation and also with those who continue
or quit smoking. added to this are the efforts of the
tobacco industry in brands development, promotion and
advertising of products that contribute to a construction of
positive smoking imagery that interferes with the initiation
probability 1-2 .
it has been long that the relationship between the cinema
and the tobacco industry can be noted, which was considered
by companies a perfect space for the promotion of products,
and identified as a mean for the construction of social rules
regarding tobacco smoking, a fact that can be proven by
contracts agreements between the tobacco industry and the
cinema industry³. for the tobacco industry, movies are a good
opportunity to transform a deadly product in a desirable ideal
of glamour, modernity and success, since these depictions are
rarely realistic, omitting the true smoking consequences 4 .
Viewers are affected by the stories they see when they
identify themselves with the film plot and characters. The
exposure to depictions interferes with the construction of
thoughts and intentions about smoking, positive expectations
and favorable attitudes regarding smoking 1,5-6 .
Watching tobacco depictions in movies are related to
experimentation of tobacco products by adolescents and
Brazilian Journal of Cancerology 2011; 57(3): 365-377
smoking initiation, also interfering with the possibility of
becoming smokers when adults, which would make them
vulnerable to morbidity and mortality caused by tobacco
smoking. these conclusions result from studies with
different methodological approaches, through representative
longitudinal and experimental studies, in which other factors
related to smoking initiation were controlled 1,7-10 .
There is a dose-response relationship to the exposure
to these depictions in movies. The greater the exposure of
adolescents and young adults, the higher is the chance they
become smokers. adolescents who have high exposure to
these depictions, when compared to those with low exposure,
are about three times more likely to try tobacco products
and to become smokers, even after controlling factors such
as: living with parents and friends who smoke, exposure to
cigarette advertisements, academic performance, and socio
and demographic factor, among others 9-11 .
one of the ways to reduce the exposure of adolescents to
tobacco depictions in movies is to consider this issue when
evaluating movies for their rating, assigning classification as
recommended for those above 18 years of age for movies
released comprising this content 12 .
every day, 100.000 young adults start smoking globally
and it is at the youngest age groups that nicotine chemical
dependence is established. Between adult smokers, 80% to
90% initiated smoking during adolescence and two thirds
became daily and regular smokers before turning 18 years old.
By the early age of experimentation and initiation, smoking is
considered a pediatric disease and the symptoms of nicotine
chemical dependence can be observed even in the early stages
of use. for these reasons, any increasing experimentation for
this population group is alarming and unwanted 13-14 .
The exposure of adolescents to tobacco depictions in
movies contributes to the initiation of these groups to
smoking and guides us to an important reflection about this
kind of exposure in movies shown for adolescents in movie
theaters aiming their reduction.
The present study aims to compare the indicative ratings
attributed in Brazil and in the united states to popular
movies in these countries and reflect about the number
of tobacco depictions, found in foreign movies rated as
appropriate for teenagers.
METHOD
a documental research was performed in blockbuster
movies in movie theaters in Brazil, between the years 2002
to 2009. a list with 100 foreign movies that have had the
highest income between 2002 and 2009 in Brazilian movie
i in this article, the word "adolescent” is following the World health organization definition: young people between 10 and 19 years old [cited 2011 feb 25].
available from: http://www.who.int/topics/adolescent_health/en/

theaters was obtained in Portal filme B ii , considering the
total number of movie theaters in the country.
Then, from a list of movies with the highest income
in the u.s., previously encoded as part of another
Project 7-8 , the movies included in both samples were
identified (n = 412) (seeappendix).
the correlation study between watching tobacco
depictions in movies and smoking initiation by teenagers
are extensively documented in international scientific
publications; and, to perform these studies, counting
methods of tobacco depictions in movies were validated
as well as the related exposure of these teenagers
to them 7-8,15-16 . Data of depiction content from the
412 movies considered in this sample were previously
encoded in past studies 7-8 in two ways: firstly, the total
time in which any tobacco product, packaging, or smoke
emanating from a tobacco product is shown was recorded.
This provided an indication of total exposure time to
these tobacco depictions, as done in previous research
correlating the exposure to those depictions in movies to
attitudes and behavior as to smoking 15-16 . Then the movies
were encoded by the occurrences amount of tobacco
consumption depictions. a "tobacco consumption
occurrence” was defined as: each time a character, whether
or not protagonist, carried or used tobacco in a scene, or
when the tobacco use was shown at the background of
the scene (for example, when "extras" are smoking in a
bar scene). The occurrences were counted regardless of
the duration of the scene or the amount of times they
happened during the same scene. exposure of young
adults to these scenes has already been associated, in a
previous study, both to smoking initiation and the increase
in tobacco use among young adults in the united states 8,17 .
the indicative rating gradations assigned in the
united states and in Brazil for movies were identified
(see appendix). for comparison purposes iii , the indicative
ratings between the two countries were compiled as follow:
children - when indicative rating is l (free) in Brazil
and 10 years old (not recommended for those under
10 years of age) and in the united states is G (General
audiences) and PG (Parental Guidance suggested); early
adolescence - indicative rating in Brazil is 12 years old
(not recommended for children under 12 years old) and 14
years old (not recommended for children under 14 years
old) and in usa, PG-13 (Parents strongly Cautioned);
late adolescence - the indicative classification is 16 years
old (not recommended for children under 16 years old) in
Brazil; adults– the indicative classification is 18 years old
movies and its Implication for Youth Smoking
(not recommended for children under 18 years old, and
children under 18 years old are not admitted) in Brazil,
and r (restricted) and nC -17 (no one 17 and under is
admitted) in the united states (figure 1).
The analysis consisted of tables that were designed
crossing them to the percentage of exposure and
rating. initially, the percentage of movies in each rating
category in both countries was determined. secondly,
we examined the percentage of the total exposure time
to tobacco depictions for each rating category in each
country. Thirdly, we observed the percentage of total
number of occurrences of tobacco use by rating in
each country. finally, we verified what was the rating
attributed in Brazil for the r (restricted) movies in
united states in order to determine how movies classified
as r in the united states should be correlated to the
classification used in Brazil.
iispecialized portal in Brazil movies market, whose data are collected directly from the cinemas’ box offices or supplied by movies distribution companies.
available from: http://www.filmeb.com.br
iiionly for comparison purposes, in this case the definition of the World health organization to "adolescent" is not considered.
Brazil
United
States
L
10 12 14 16 18
G P G PG-13 R NC-
17
1 a 7 8 9 10 11 12 13 14 15 16 17 18
Age adequacy (years)
children late adolescence
early adolescence adults
Figure 1. Rating Classification System – Equivalence Table
RESULTS
the survey about the indicative classification
correlating the ratings found in the two countries,
suggests that, in most cases, movies (n = 412) were
classified in Brazil for "children", “early adolescence”
and “late adolescence” (l,10,12,14 and 16 years old in
Brasil), adolescence "and "late adolescence" with only
3% rated as for "adults", while in Brazil the admission
in movie theaters of those under 18 years old is not
allowed. The equivalent indicative classification to the
category "adult" was assigned in the u.s. in 31% of
these movies.
it should be noted that, in 2006, a new model
for indicative classification was implemented, , by
the Ministry of Justice with changes in the criteria of
content evaluation previously used. The data consider the
classification assigned for the ages (figure 2).
Brazilian Journal of Cancerology 2011; 57(3): 365-377
367

Vargas R, Thrasher J, Sargent J
368
adult
120%
100%
80%
60%
40%
20%
0%
late adolescence
31%
44%
50%
25% 34%
Brazilian Journal of Cancerology 2011; 57(3): 365-377
0
3%
12%
USA BRAZIL
early adolescence
children
Figure 2. Ratings for the same 412* movies in both countries
*among the 100 blockbuster movies, between 2002-2009
a total of 26.217 seconds related to tobacco depictions
was quantified among the 412 selected movies. of this
total time, 89% are classified into the category “children”,
“early adolescence” and “late adolescence”. regarding
to the classification assigned in the united states, this
percentage is 40% for the same categories (figure 3).
1807 occurrences from the sample were quantified
as "occurrences of tobacco use” and 90% of this total
are in movies accessible for teens under 18 years old in
Brazil. Considering the classification in the usa, 46% of
occurrences are classified in the "adult" category (r and
nC 17) (figure 4).
if we consider the movies that have been classified
only as "adult" in the united states (n = 128), grading
equivalent was observed in only 10% of the same movies
in Brazil (figure 5).
DISCUSSION
The movies market in Brazil has a greater audience
for foreign movies, although in recent years it has been
increased if observed the audience increase on national
productions, according to data from the national Cinema
agency (anCine). for information purposes, 89.8%
of the audience present in movie theaters in 2008 were
to watch foreign productions; in 2009, 85.7%; and in
2010 this percentage was 81.3%, which demonstrates the
importance, in terms of audience, of thinking about the
access to these productions in Brasil 18 .
and it is important to observe that in the periods
of school holidays (2009 and 2010) there were greater
audiences in conjunction with isolated months as october
(2010) and november (2009), also according to the data
collected from anCine 18 .
120%
100%
80%
60%
40%
20%
0%
60%
0%
35%
5%
adult
late adolescence
10%
30%
49%
10%
USA BRAZIL
early adolescence
children
Figure 3. Distribution of 26.617 seconds of tobacco depictions exposure,
following the indicative rating in both countries, in 412 movies, among
the 100 blockbuster movies in the countries, for the period 2002-2009
adult
Figure 4. Occurences of tobacco depictions, according to the
indicative rating in the two countries, in 412 movies, among the 100
blockbuster movies, 2002-2009 period
100%
80%
60%
40%
20%
0%
100%
80%
60%
40%
20%
0%
late adolescence
100%
adult
late adolescence
54%
41%
5%
11%
37%
51%
5%
29%
57%
9%
USA BRAZIL
1%
USA BRAZIL
early adolescence
children
early adolescence
children
Figure 5. Movies rated as “R” (n=128) in the US

Both in Brazil and in the united states the following
topics are considered: violence, sex and drug use (licit and
illicit) to determine the indicative rating for audiovisual
works, which provides a parameter for families to decide
whether allowing children to have access to films shown
in movie theaters. in Brazil, these contents are evaluated
considering if there are mitigating or aggravating
circumstances in the way the subject is shown, such as
scenes impact, image framing, topic appropriateness,
the context in which it appears and the message and is
conveyed 19-20 .
The evaluation of the indicative rating is performed
by professionals from the Ministry of Justice who search
for potentially inappropriate contents for children and
adolescents, based on topics such as sex, drugs, violence.
This procedure not only guarantees freedom for creation
in cinematographic works, but also guides audiences by
providing information about age groups and times (when
shown on tV), rating them according to the analyzed
contents defining whether or not they are recomended 19 .
Determining the indicative rating as "adult" varies
between the two countries. in Brazil, the classification "not
recommended for under 18 years" does not allow access
to underage people. even for the "not recommended for
children under 16" rating, underage children is grant
access to movie theaters, to movies with classification
above their age, provided they are with their parents or an
adult with authorizing document. in the united states, the
classification "r"(restricted) is close to majority age, and
children under 17 years old require the presence of parents
or legal representative to be admitted in these movies 19-20 .
When comparing the rating assigned to the same
movies in the united states and in Brazil, it seems there is
a reduction of grading in ratings to movies shown in Brazil,
according to the evaluation criteria of both countries. This
demonstrates that Brazilian children and adolescents have
access to movies that are restricted for these audiences in
the united states.
The number of occurrences of tobacco use and time
of display of tobacco depictions in movies where access to
children and adolescents is possible is significant, and this
is particularly alarming because it is the most vulnerable
smoking initiation group 14,17 .
in smoking-related contents in movies, smoking
is often depicted as socially acceptable and a way of
reducing tension, and also a socialization tool 21 .the
literature demonstrates that movies influence social
behaviors, which may lead to beliefs and misconceptions
about smoking by offering models. These depictions may
promote the perception that smoking is a behavior pattern
in real life, that is, a young adult is expected to smoke.
This information is relevant, because the social variables
movies and its Implication for Youth Smoking
that affect youth initiation of smoking like acceptance
by a group of friends, the search for an approved and
appreciated behavior by this group may be a behavior
suggested in the movies scenes¹.
as a way to counteract the exposure to these depictions,
contributing to a critical view of the audience, there are
studies underlying the diffusion of sanitary warning
messages developed by Public health, before movies that
include tobacco products images and smoking scenes are
exhibited 22 .
The World health organization (Who), considering
that there is a dose-response relationship to the exposure
to scenes containing tobacco depictions in movies and
adolescent smoking initiation, recommends countries
to consider the reduction of these contents exposure to
children and adolescents. a measure which would be
effective for this purpose without interfering directly with
movies contents, preserving artistic freedom expression for
films makers, would be the official rating as "adult" for
movies released containing such depictions. exceptions
would be applied to productions in which there is the
inclusion of a historic character who was actually a smoker
in real life, and contexts in which the risks of smoking are
presented clearly and unambiguously. Who considers
movies a powerful channel for the promotion of tobacco
depictions in the current globalized economy 23 .
the framework Convention for tobacco Control
(fCtC), the first international Public health treaty signed
in 2003 by Who, which Brazil is signatory, defines a list
of measures for tobacco control. in 2005, the treaty came
into force and at present has 173 parties. The guidelines
related to tobacco control on fCtC article 13 consider that
the comprehensive ban of tobacco advertising, promotion
and sponsorship effectively contributes for consumption
reduction. This would involve restrictions to numerous
promotion, advertising and sponsorship actions, such
as: product communication through different platforms,
brands marketing, displays at points of sale, internet use,
and many other ways. as to the entertainment media,
there is the concern that when exposure and use of tobacco
depictions occurs in movies, for example, there should
be a certification that no benefit has been received by
professionals involved in the production, distribution or
presentation. The guidelines inform the countries that this
type of content should be considered when rating a movie
and further recommends that no identifiable display of any
trademark should be allowed 24 .
Public health advocacy groups like the Smoke Free
Movies iv suggest that movies comprising depictions of
tobacco exposure and use should be rated as for adults, and
invest in order to increase awareness among professionals
of the film industry about the subject.
Brazilian Journal of Cancerology 2011; 57(3): 365-377
369

Vargas R, Thrasher J, Sargent J
370
in addition to considering contents for rating, it is
important to invest in awareness and partnership with
parents and educators in order to bring value to it. The
movies range is a challenge that goes beyond the audience
observed in theaters, once these movies can be later
accessed on tV and cable tV channels; in video rentals,
domestic computers through internet, besides the pirates
product market and spaces where access control is more
difficult. in this sense, it is fundamental to encourage
parents and educators to establish a dialogue with young
people about the content displayed in different media to
which they have access, aiming at the construction of a
critical view about this topic 25 .
one of the points considered as vulnerable by Public
Policies¹ is the exposure of people to tobacco products in
movies and careful thought of these contents when rating
them should be reinforced, reducing access of children
and adolescents to them.
CONCLUSION
The greater audience present in Brazilian movies
is to watch foreign films, which are the most frequent
cinematographic works commercially released in Brazil
every year.
Due the differences in practices and criteria in the
rating gradation in united states and Brazil, Brazilian
adolescents experience a greater possibility of access to
tobacco depictions, which appear in blockbuster foreign
movies shown in Brazilian movie theaters.
The rating systems are developed aiming to ensure
both the freedom of cultural and artistic expression
and children and adolescents protection. The causal
relationship, established by scientific evidences between
exposure to tobacco depictions in movies - far from its
lethal reality - and adolescents to smoking initiation,
defines these scenes as inappropriate content for these
audiences.
it is crucial to reinforce the relevance of considering
tobacco depictions, determining the right rating and
definition of contents as inappropriate, when assigning
ratings and adequacy of broadcasting schedules (when on
tV) for movies shown in Brazil.
ACKNOWLEDGEMENTS
to Doctor tania Cavalcante for the critical review of
this manuscript.
iv Smoke free movies. available from: http://www.smokefreemovies.ucsf.edu/
Brazilian Journal of Cancerology 2011; 57(3): 365-377
CONTRIBUTION
all authors worked on the conception and planning
of the research project, in obtaining, analyzing and
interpreting the data, and in writing and critical review.
Declaration of Conflicting Interests: Nothing to Declare.
We declare that James Thrasher, for part of this study,
received funding from the us national Cancer institute,
grant # P01Ca # 138389 and James sargent received
resources for encoding movies from us national Cancer
institute, grant # Ca077026.
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movies and its Implication for Youth Smoking
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372
1. 10,000 B.C.
2. 16 BloCKs
3. 17 aGain
4. 2 fast 2 furious
5. 2012
6. 27 Dresses
7. 28 Days later
8. 300
9. 50 first Dates
10. 500 Days of suMMer
11. 8 Mile
12. a Beautiful MinD
13. a ChristMas Carol
14. a Man a Part
15. aBout sChMiDt
16. aDaPtation
17. alien Vs PreDaDor
18. alien Vs. PreDator: reQuieM
19. alonG CaMe Polly
20. aMeriCan GanGster
21. aMeriCan Pie - the WeDDinG
22. aMeriCan Pie 2
23. aMityVille horror
24. analyze that
25. anGels & DeMons
26. anGer ManaGeMent
27. aPoCalyPto
28. aWaKe
29. BaD Boys 2
30. BarnyarD
31. BasiC
32. BasiC instinCt 2
33. BatMan BeGins
34. BeDtiMe stories
35. Bee MoVie
36. BeoWulf
37. BiG fish
38. Birth
39. BlaCK haWK DoWn
40. BlaDe 2
41. BlooD DiaMonD
42. BoDy of lies
43. BooGeyMan
44. Borat: Cultural learninG of aMeriCa...
45. Bourne ultiMatuM
46. BoWlinG for ColuMBine
47. BriDe Wars
48. BrinGinG DoWM the house
49. BroKeBaCK Mountain
50. BruCe alMiGhty
51. Burn after reaDinG
Brazilian Journal of Cancerology 2011; 57(3): 365-377
Appendix – movies Titles
52. Cars
53. Cat WoMan
54. CatCh Me if you Can
55. Cellular
56. ChanGelinG
57. Charlie anD the ChoColate faCt
58. Charlie's anGels: full throttl
59. Charlotte`s WeB
60. CheaPer By the Dozen
61. CheaPer By the Dozen 2
62. ChiCaGo
63. ChiCKen little
64. ChroniCles of narnia: PrinCe CasPian
65. CinDerella Man
66. CliCK
67. Closer
68. ClouDy With a ChanCe of MeatBalls
69. CloVerfielD
70. Colateral
71. ColD Mountain
72. Collateral DaMaGe
73. Confessions of a DanGerous Min
74. Constantine
75. Crash
76. CroniCles of riDDiCK
77. DaDDy Day Care
78. DareDeVil
79. DarK Water
80. DaWn of the DeaD
81. Day after toMorroW
82. DeraileD
83. Die harD 4.0
84. DistriCt 9
85. DisturBia
86. DouBt
87. DoWnfall
88. DraG Me to hell
89. DraGonBall eVolution
90. DraGonfly
91. DreaMCather
92. eternal sunshine of the sPotless MinD
93. eVan alMiGhty
94. eXorCist: the BeGinninG
95. fahrenheit 9/11
96. failure to launCh
97. fantastiC four
98. fantastiC four 2
99. far froM heaVen
100. fast & furious
101. final Cut
102. finDinG neMo

103. finDinG neVerlanD
104. fireWall
105. fliGht Plan
106. fraCture
107. freDDy Vs. Jason
108. fun With DiCK anD Jane
109. G.i. Joe
110. GanGs of neW yorK
111. GarfielD
112. GarfielD 2: a tail of tWo Kitties
113. Get sMart
114. G-forCe 3D
115. Ghost riDer
116. GoDsenD
117. GolDen CoMPass
118. GooDBye, lenin
119. GothiKa
120. Gran torino
121. hairsPray
122. hanCoCK
123. hannah Montana – the MoVie
124. haPPily n'eVer after
125. haPPy feet
126. harry Potter 2
127. harry Potter 3
128. harry Potter anD the GoBlet of fire
129. harry Potter anD the half-BlooD PrinCe
130. harry Potter anD the orDer of the
PhoeniX
131. haunteD Mansion
132. herBie fully loaDeD
133. hiDalGo
134. hiDe anD seeK
135. hiGh sChool MusiCal 3: senior year
136. hitCh
137. hollyWooD enDinG
138. hoMe on the ranGe
139. horton hears a Who!
140. hostaGe
141. hostel
142. hotel for DoGs
143. house of WaX
144. hoW to lose a Guy in 10 Days
145. hunteD
146. i aM leGenD
147. i aM saM
148. i noW PronounCe you ChuCK anD
149. i roBot
150. iCe aGe
151. iCe aGe 2
152. iCe aGe: DaWn of the Dinosaurs
153. iDentity
154. inDiana Jones anD the KinGDoM of the
Crystal sKull
movies and its Implication for Youth Smoking
155. inGlourious BasterDs
156. inKheart
157. insiDe Man
158. insoMnia
159. intoleraBle Cruelty
160. iron Man
161. Journey to the Center of the earth
162. JuMPer
163. JunGle BooK 2
164. Juno
165. Just MarrieD
166. KanGaroo JaCK
167. Kill Bill - Vol. 2
168. KinG arthur
169. KinGDoM of heaVen
170. KnoWinG
171. KunG fu PanDa
172. la Mala eDuCaCion
173. laDy in the Water
174. laDyKillers
175. lara Croft toMB raiDer the Cra
176. laWs of attraCtion
177. leaGue of eXtraorDinary Gentle
178. leMony sniCKet's a series unfortuna
179. liCense to WeD
180. lilo & stitCh
181. lions for laMBs
182. lorD of the rinGs
183. lorD of the rinGs: the tWo toWers
184. lost translation
185. MaDaGasCar
186. MaDaGasCar 2
187. MaMMa Mia!
188. Man on fire
189. Marley anD Me
190. Master & CoMManDer: the far siDe of
the WorlD
191. MatCh Point
192. MatChstiCK Men
193. MatriX reloaDeD
194. MatriX reVolutions
195. Meet DaVe
196. Meet the foCKers
197. Meet the roBinsons
198. MeMoirs of a Geisha
199. Men in BlaCK 2
200. MiaMi ViCe
201. MiChael JaCKson’s this is it
202. Million Dollar BaBy
203. Minority rePort
204. Mirrors
205. Miss ConGeniality 2
206. Mission iMPossiBle 3
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373

Vargas R, Thrasher J, Sargent J
374
207. Monster house
208. Monster in laW
209. Monsters Vs. aliens
210. MotorCyCle Diares
211. Mr. anD Mrs. sMith
212. Mr. Bean's holiDay
213. Mr. BrooKs
214. MuniCh
215. MusiC & lyriCs
216. My MoM's neW BoyfrienD
217. nanny MCfee
218. national treasure
219. neW Moon
220. neXt
221. niGht at the MuseuM 2: esCaPe froM the
sMithsonian
222. niGhts in roDanthe
223. no Country for olD Men
224. no reserVations
225. norBit
226. oCeans 12
227. oCeans 13
228. onCe uPon a tiMe in MeXiCo
229. oPen season
230. orPhan
231. out of tiMe
232. oVer the heDGe
233. P.s., i loVe you
234. PaniC rooM
235. ParanorMal aCtiVity
236. PerfeCt stranGer
237. Peter Pan
238. Phone Booth
239. PiGlet's BiG MoVie
240. PinK Panther
241. PinK Panther 2
242. Pirates of the CariBBean
243. Pirates of the CariBBean – DeaD´s Man ...
244. Pirates of the CariBBean 3
245. Planet 51
246. Polar eXPress
247. Pooh's heffaluMP MoVie
248. PoseiDon
249. PriMe
250. PuBliC eneMies
251. QuantuM of solaCe
252. raCe to WitCh Mountain
253. raCinG striPes
254. raMBo
255. ratatouille
256. reD DraGon
257. reD eye
258. resiDent eVil 2
Brazilian Journal of Cancerology 2011; 57(3): 365-377
259. resiDent eVil: eXtinCtion
260. roBots
261. roCKy BalBoa
262. runaWay Jury
263. s.W.a.t
264. saW 5
265. sCary MoVie 3
266. sCary MoVie 4
267. sCooBy-Doo
268. sCooBy-Doo 2: Monsters unleash
269. seCret WinDoW
270. seCretary
271. seVen PounDs
272. shall We DanCe?
273. shalloW hall
274. sharK tale
275. shooter
276. shreK 2
277. shreK the thirD
278. siGns
279. siMone
280. sin City
281. sin eater
282. sinBaD the leGenD of seVen sea
283. sKy hiGh
284. sluMDoG Millionaire
285. snoW DoGs
286. soMethinG's Gotta GiVe
287. son of the MasK
288. sPeeD raCer
289. sPiDer Man 3
290. sPiDer-Man
291. sPiDer-Man 2
292. sPiriteD aWay
293. sPy KiDs 3D: GaMe oVer
294. star treK
295. star Wars 3: reVenGe of sith
296. star Wars: ePisoDe 2
297. starDust
298. state of Play
299. street KinGs
300. stuart little 2
301. suPerhero MoVie
302. suPerMan returns
303. surf's uP
304. surroGates
305. sWeeney toDD
306. taKen
307. taKinG liVes
308. tears of the sun
309. teenaGe Mutant ninJa turtles
310. terMinator 3: rise of the MaCh
311. terMinator salVation

312. the 25th hour
313. the 40 year olD VirGin
314. the aDVentures of sharKBoy anD laVaGirl
315. the ant Bully
316. the aViator
317. the Bourne suPreMaCy
318. the BreaK-uP
319. the BuCKet list
320. the Butterfly effeCtt
321. the Core
322. the Count of Monte Cristo
323. the Curious Case of BenJaMin Button
324. the Da VinCi CoDe
325. the DarK KniGht
326. the DeParteD
327. the DeVil Wears PraDa
328. the fast anD the furious - toKyo Drift
329. the forGotten
330. the Ghost of GirlfrienDs Past
331. the GruDGe
332. the GuarDian
333. the hanGoVer
334. the haPPeninG
335. the heartBreaK KiD
336. the holiDay
337. the hours
338. the hulK
339. the inCreDiBle hulK
340. the inCreDiBles
341. the interPreter
342. the islanD
343. the italian JoB
344. the laKe house
345. the last saMurai
346. the leGenD of zorro
347. the ManChurian CanDiDate
348. the Mist
349. the MothMaM ProPheCies
350. the MuMMy: toMB of DraGon eMPeror
351. the noteBooK
352. the nuMBer 23
353. the oMen
354. the PaCifier
355. the Passion of the Christ
356. the Phanton of the oPera
357. the PrestiGe
358. the ProPosal
359. the Pursuit of haPPyness
360. the Queen
361. the Quiet aMeriCan
362. the reaPinG
363. the reBounD
364. the sentinel
movies and its Implication for Youth Smoking
365. the siMPsons MoVie
366. the sKeleton Key
367. the sPiDerWiCK ChroniCles
368. the stePforD WiVes
369. the stranGers
370. the sWeetest thinG
371. the taKinG of PelhaM 123
372. the terMinal
373. the uGly truth
374. the unBorn
375. the VillaGe
376. the WilD
377. the WilD thornBerry's
378. the X-files: i Want to BelieVe
379. tiM Burton's CorPse BriDe
380. tiMe MaChine
381. torQue
382. transforMers: reVenGe of the fallen
383. transforMers: the MoVie
384. troy
385. tWo WeeKs notiCe
386. unDerDoG
387. unDerWorlD: rise of the lyCans
388. uniteD 93
389. uP
390. V for VenDetta
391. ValKyrie
392. VantaGe Point
393. VolVer
394. WallaCe & GroMitt
395. Wall-e
396. WanteD
397. War of the WorlDs
398. WatChMen
399. WeDDinG Crashers
400. What haPPens in VeGas
401. White noise
402. WilD hoGs
403. WorlD traDe Center
404. X-Men - the last stanD
405. X-Men 2
406. X-Men oriGins: WolVerine
407. XXX - triPle X
408. yes Man
409. you Don't Mess With the zohan
410. you, Me anD DuPree
411. yu-Gi-oh
412. zoDiaC
Brazilian Journal of Cancerology 2011; 57(3): 365-377
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Brazilian Journal of Cancerology 2011; 57(3): 365-377
Appendix - Rating System
in the united states, the rating is performed by the Motion Picture association (MPaa), institution responsible for
performing the indicative classification of movies and trailers on screen in movie theaters. This entity is formed by
representatives of civil society, and has as a duty the mission of classifying films so that parents know which movies
are the most appropriate for their children. rating is made from the analysis of subject, language, violence, nudity,
sex and drug use.
five categories are established by MPPa, the first three are suggestive and the last two are prohibitive:
(G) - free for all ages (General audiences).
(PG) - Parts of the movie may not be suitable for children. suggest being accompanied by parent or legal guardians
(Parental Guidance suggested).
(PG-13) - some of the material of the film may be improper for children under 13. Monitoring by parents or legal
guardians is seriously recommended (Parents strongly cautioned).
(R) - restricted access. Children under 17 years require the presence of parents or legal guardians (restricted).
(NC-17) - under 17 are not admitted to the movies (no one 17 and under admitted)
Source: available from: www.mpaa.org.
film rating in Brazil is done by the Ministry of Justice, and aims to protect children and adolescents from
inadequate audiovisual contents. it informs about the age groups and times (when shown on tV) to whom the
movies are not recommended. in this evaluation, the following subjects are considered: sex, violence and drugs, and
grading is attributed, as described below, accompanied by the synthetic disclosure of the content of existing topics,
in conjunction with the degree of intensity with which they appear:
free - for all public
10 - not recommended for children under 10 years old
12 - not recommended for children under 12 years old
14 - not recommended for children under 14 years old
16 - not recommended for children under 16 years old
18 - not recommended for children under 18 years old
This rating aims to provide an indicative set of information to parents about the works displayed, so that they
can decide about the access to the content by their children who wish to watch such movie. even for the rating "not
recommended for children under 16 years" underage children are granted admission to movies with classification
above their age provided they are accompanied by parents or a legal authorized guardian. for movies classified as "not
recommended for under 18", access of underage children is not allowed.
During the preparation of this manuscript (March 2011), the rating criteria in Brazil was under discussion, through
a public consultation held by the Ministry of Justice, seeking for the preparation of new ordinance.
Source: available from: http://portal.mj.gov.br.

movies and its Implication for Youth Smoking
Resumo
Introdução: a maioria dos fumantes adultos iniciou o uso do tabaco antes dos 18 anos de idade. a exposição intensa,
nos filmes, a imagens de produtos de tabaco e seu consumo contribui para a iniciação de jovens ao tabagismo sendo
importante reduzir essa exposição. Objetivo: o presente estudo visa a comparar a classificação indicativa atribuída a
filmes de popularidade no Brasil e nos estados unidos, assim como refletir sobre a quantidade de imagens de produtos
de tabaco e seu consumo, presentes nos filmes estrangeiros classificados para adolescentes. Método: estudo documental
em 412 filmes estrangeiros entre os 100 com maior bilheteria no Brasil e estados unidos (2002 a 2009), identificando
a classificação indicativa nos dois países e quantidade de exposição a imagens de tabaco. a classificação indicativa nos
dois países foi harmonizada em quatro categorias: criança, início da adolescência, final da adolescência e adultos. a
quantidade de exposição a imagens produtos de tabaco e consumo nos filmes foi determinada para cada categoria.
Resultados: a atribuição de classificação indicativa dos filmes é mais baixa no Brasil. filmes acessíveis a adolescentes
no Brasil têm maior quantidade de imagens de uso de tabaco comparados aos filmes para este grupo nos estados
unidos. Conclusão: a quantidade de imagens de produtos de tabaco e de consumo é alta em filmes com classificação
indicativa para adolescentes no Brasil. há diferenças de classificação entre os países. a classificação indicativa em
filmes considerando esse conteúdo como inadequado poderia diminuir a exposição de adolescentes a essas imagens.
Palavras-chave: tabaco; Cinema como assunto; Publicidade de Produtos Derivados do tabaco; Comportamento do
adolescente
Resumen
Introducción: la exposición a imágenes de tabaco en películas promueve el tabaquismo durante la adolescencia, antes
de los 18, cuando la mayoría de los fumadores empiezan a fumar. se considera importante impedir la exposición a
estas imágenes para prevenir el tabaquismo. Objetivo: el presente estudio tuvo el objetivo de comparar las mismas
películas, exitosas en Brasil y los estados unidos, a través del sistema de clasificación de cada país, además de determinar
la cantidad de imágenes de tabaco en las películas extranjeras clasificadas para jóvenes de diferentes edades. Método:
De las 100 películas más taquilladas en Brasil y los estados unidos en cada año del 2002 al 2009, se identificaron 412
películas que fueron exitosas en los dos países. Para cada película, se determinó la cantidad de imágenes de fumar, el
auditorio adecuado según el sistema de clasificación de cada país: niños; adolescentes más jóvenes; adolescentes más
grandes; adultos y la suma de exposición a imágenes de fumar para auditorio. Resultados: el sistema brasileño calificó
las mismas películas para auditorios más jóvenes que el sistema estadounidense. entre las películas clasificadas para
auditorios más jóvenes, la prevalencia de imágenes de tabaco fue mayor en el sistema brasileño que el estadounidense.
Conclusión: los sistemas clasifican de manera distinta las mismas películas, resulta que el sistema brasileño califica
para adolescentes muchas películas que tienen altos niveles de imágenes de tabaco. Para reducir la exposición a imágenes
de tabaco en jóvenes se considera importante tomar en cuenta las imágenes de tabaco en los sistemas de calificación.
Palabras clave: tabaco; Cine como asunto; Publicidad de Productos Derivados del tabaco; Conducta del adolescente
Brazilian Journal of Cancerology 2011; 57(3): 365-377
377

Original Article
Breastfeeding among Postpartum Smokers
Article submitted on 03/17/11, accepted for publication on 06/21/11
Comparison between Postpartum Smokers and Ex-Smokers as to
Breastfeeding Duration and its Impact on the Health of Newborns
Comparação entre Puérperas Fumantes e Ex-Fumantes com Relação ao Tempo
de Amamentação e suas Consequências sobre a Saúde dos Recém-Nascidos
Comparación entre los Fumadores y ex Fumadores Después del Parto con Respecto
a la Duración de la Lactancia Materna y su Impacto en la Salud de los Recién
Nacidos
Adriani oliveira galão 1 , bruno rocha de macedo 2 , rafaela vanin pinto ribeiro 3 , roberto vanin pinto ribeiro 4 , carla maria De martini vanin 5
Abstract
Introduction: The harmful influence of tobacco smoking during pregnancy and breastfeeding is widely described in the
literature. Objective: to evaluate the relationship between the duration of breastfeeding and tobacco smoking among
mothers smokers and ex-smokers in the hospital de Clinicas de Porto alegre and its effects on their babies. Method:
a cross-sectional study applying a questionnaire by telephone among mothers smokers in the hCPa, separated in
two groups: women who had not smoked after delivery (G1) and those who smoked after delivery (G2). Continuous
variables were described by measures of central tendency and dispersion; categorical variables by absolute and relative
frequencies. Means were compared with student-t and complications between the groups with chi-square. Results:
154 mothers were evaluated, respectively, 75 in G1 and 79 in G2. age did not differ between groups (26.0 and 24.7
years); 67.5% had prenatal care and, of these, half did not smoke during the postpartum period. only 51.3% received
medical information that smoking could cause complications for her and her baby. There was no statistically significant
difference with respect to problems or respiratory problems in babies. The groups breastfed, on average, 7.2 (G1) and
6.2 (G2) months and there was no statistically significant difference between them. in group G2, there was a tendency
for breastfeeding cessation due to respiratory causes (p=0.058). Conclusion: There were no significant changes with
respect to respiratory problems in infants or early breastfeeding cessation in mothers who smoke. however, tobacco
smoking is a worrisome public health problem and should receive continued attention in this special group of women.
Key words: smoking; Breast feeding; tobacco; Postpartum Period
institution where study was performed: hospital de Clínicas de Porto alegre (hCPa) [Clinical hospital of Porto alegre], service of Gynecology and
obstetrics of the Department of Gynecology and obstetrics, faculty of Medicine (faMeD) of federal university of rio Grande do sul (ufrGs).
sponsor: fund of research and events encouraging-fiPe/hcPa
1 PhD in Clinical Medicine and health sciences in PuCrs. associate Professor at the Department of Gynecology and obstetrics of faMeD ufrGs.
Email: adrianig@brturbo.com.br. Porto alegre (rs), Brazil.
2 academic at faMeD, ufrGs. Email: brunomacedobrm@hotmail.com. Porto alegre (rs), Brazil.
3 academic at faMeD, ufrGs. Email: rafavan@terra.com.br. Porto alegre (rs), Brazil.
4 academic at faMeD, ufrGs. Email: rpribeiro@terra.com.br. Porto alegre (rs), Brazil.
5 PhD in Clinical Medicine by the university of toronto, Canada; ufrGs, Brazil. associate Professor at the Gynecology Department at federal university
of health sciences of Porto alegre (ufCsPa). email: carlavanin@terra.com.br. Porto alegre (rs), Brazil. Correspondence address: adriani oliveira Galão.
rua inconfidência, 1603 - Canoas (rs), Brasil. CeP: 92020-320
Brazilian Journal of Cancerology 2011; 57(3): 379-385
379

Galão AO, Macedo BR, Ribeiro RVP, Ribeiro RVP, Vanin CM De M
380
INTRODUCTION
The pernicious influence of smoking during pregnancy
and breastfeeding is widely described in medical
literature. Maternal smoking not only causes damage
to the baby during its intrauterine life, as, for example,
growth restriction, low birth weight, premature rupture
of membranes and placenta previa; its effects also affect
the postnatal period, including early termination of
breastfeeding and its effects on child development 1-2 .
according to the World health organization, there
is an increasing trend of smoking among women, and it
is known that its onset coincides in time with the period
of childbearing age 3 , but even though some women
quit smoking during pregnancy, many of them take
up smoking in the immediate postpartum period or
during the postpartum period and concomitantly with
breastfeeding 4-5 . it is known that these women generate
higher spendings on health care than nonsmokers 6 .
Breastfeeding rates in the united states are below
the recommended guidelines, and even lower among
smokers, among who there is a perception of lower
milk production 7-8 . smoking is associated with a shorter
duration of breastfeeding: lower volume and a lower fat
content in milk are some factors involved. furthermore,
the sleep of the baby is affected, which may also explain
the change in their eating pattern. a healthy lifestyle,
high educational level and previous positive breastfeeding
experience are characteristics that significantly improved
continuity rates for the maintenance of breastfeeding 9 .
american studies suggest that the prevalence of smoking
during pregnancy varies from 8.8% to 20.3% 10-11 . in
Brazil, there is a prevalence between 23% and 25%, and
the following risk factors are detected: white race, low
socioeconomic status, low educational backgrond and
single marital status 1,12 . not undergoing prenatal care is
more frequent in the population of smokers, which implies
an increased risk of maternal infections, complications
for the fetus and consumption of illicit drugs 13 . smoking
mothers expose their children to a risk of sudden infant
death syndrome 14-16 , type 2 diabetes mellitus in young
adults 17 , asthma 18 and deleterious cognitive effects 2 .
infants of mothers who smoke more than five cigarettes
per day tend to have symptoms that sometimes are not
noticed as fetal smoking withdrawal symptoms that can
be facilitators of cessation of breastfeeding, such as colic
and crying 19 .
nicotine decreases the production of breast milk
through inhibition of prolactin secretion and therefore
smoking reduction can substantially increase the
breastfeeding period 3,13 ; however, studies suggest that
the social and behavioral differences between smokers
and nonsmokers may be more important than possible
physiological effects of smoking 5 . among the immediate
Brazilian Journal of Cancerology 2011; 57(3): 379-385
effects of this substance significant reduction in infant
sleep 20 may occur; but smoking does not contraindicate
breastfeeding though, because its benefits are greater than
any risk associated to early weaning. Breastfeeding for
more than three months attenuates the effect of repeated
respiratory infections and the risk of developing asthma
between 1 and 10 years of age 21 .
in view of the numerous benefits that the period
of breastfeeding provides to the baby and the widely
proven harms that smoking causes at this stage of child
development, this study evaluated the relationship
between the duration of breastfeeding and postpartum
smoking among smokers and former smokers at the
hospital de Clínicas de Porto alegre (hCPa) and its
consequences for the health of babies.
METHOD
a prospective and cross-sectional study, with
application of a questionnaire by telephone on postpartum
women in hCPa, from october 2007 to March 2008.
the project has obtained approval of the research
ethics Committee of hCPa, n o 07-511, and all women
previously signed the term of consent.
the patients included were healthy, with complete
gestational periods (over 37 weeks), who delivered their babies
at hCPa, without complications during prenatal or childbirth.
all patients who could not be contacted during the study
period or had their data charts incomplete were excluded.
The protocol included identification data, history of
smoking in the postpartum period and its complications
on the health of newborns, feeding preferably with breast
milk (defined as breast feeding at least five times a day).
The variables analyzed were: (a) demographic data:
age, marital status, race, educational background and
parity, (b) history: smoking during the postpartum
period, information on treatments for smoking cessation,
abstinence time or smoking relapse after birth, and
number of cigarettes a day; perinatal data, pathological
diagnosis and hospitalization of the child in the
postpartum period, (d) postpartum data, breast feeding
duration predominantly with breast milk, breastfeeding
cessation causes.
for statistical purposes, the sample was divided into
two groups: (1) women who had not smoked after delivery
and (2) women who smoked after delivery. Continuous
variables were described by measures of central tendency
and dispersion (mean and standard deviation or median
and interquartile range as data show normal distribution
or not), and the groups were compared with student's
t and Mann-Whitney tests (with significance level of p

Table 1. Characteristics of studied groups
Variable
Group 1: did not smoke
after delivery (n=75)
Group 2: smoked after
delivery (n=79)
Breastfeeding among Postpartum Smokers
Age (years) 26.0+6.3 24.7+6.3 0.709 a
Skin color (n%)
White 49 (52%) 45 (48%)
Non-white 26 (43%) 34 (57%) 0.287 b
Educational Background (n%)
Illiterate and elementary
school
30 (46%) 35 (54%) 0.589b High school / higher
education
Prenatal (n%)
45 (51%) 44 (49%)
No 23 (46%) 27 (54%) 0.642b Yes 52 (50%) 52 (50%)
a = t test b = Chi square test.
RESULTS
The studied population was acquired as a result of a
previous study that assessed smoking during pregnancy in
a sample of 346 mothers 22 . of this initial sample, a total of
154 mothers were interviewed by telephone, with a followup
loss of 55%. of the patients interviewed, 49% (n = 75)
did not smoke in the postpartum period (group 1) and
51% (n = 79) smoked in the postpartum period (group 2).
The demographic characteristics are presented in table 1.
The average age was 25 years old, with an interval between
16-45 years of age, and did not differ between groups. of
the study group, 61% of patients were white, 58% had
high school our higher education and 67.5% received
prenatal care. of those who had prenatal care, that is,
at least six visits, half didn't smoke during postpartum
period.
only 51.3% of patients received medical information
during pregnancy that smoking could cause complications
for their child during breastfeeding. after postpartum and
breastfeeding period, only three women reported having
done some treatment to quit smoking. With regard to
marital status, among the unmarried, 40% of them never
quit smoking during the period of breastfeeding; among
married women, 60% didn't smoke in the same period
(p

Galão AO, Macedo BR, Ribeiro RVP, Ribeiro RVP, Vanin CM De M
382
Table 2. Characteristics of newborns during breastfeeding by groups
Problems:
Variable
Brazilian Journal of Cancerology 2011; 57(3): 379-385
Group 1: did not smoke
after delivery (n=75)
Group 2: smoked after
delivery (n=79)
None 57 (76%) 51 (64.5%)
Respiratory 13 (17.3%) 21 (26.5%) 0.294 a
Other 5 (6.7%) 7 (9.0%)
Hospitalizations:
None 51 (68%) 59 (74.6%) 0.647 a
Respiratory 15 (20%) 12 (15.2%)
Other 9 (12%) 8 (10.2%)
Time of breastfeeding
(months)
7.2+4.7 6.2 + 4.3 0.472b Reason of breastfeeding
interruption
Smoking-related 11 (14.7%) 23 (29.1%) 0.058a Other causes
a b = t test = Chi square test.
35 (46.6%) 33 (41.8%)
was related to the fact that our patients often exchanged
address or phone within a short time between studies 22 .
such an approach sometimes brings greater fragility
to data that could be underestimated with high rates
of false-negative or incur in recall bias, as in a similar
study 23 . Concentrations of metabolites of nicotine, as
cotinine, could be tested in mothers or in newborns in
order to confirm the information on the use of tobacco
in the puerperal period 24 . researches show that infants
breastfed by smoking mothers have urine cotinine levels
ten times higher than those without breastfeeding, but
with secondhand smoke exposure; and still 50 times
higher than those not exposed to smoke, regardless of
nourishment 2 .
The literature indicates that most women who get
prenatal care get to the first appointment with no history
of smoking or having already quit smoking before or
immediately when they find themselves pregnant 9 . With
respect to performing prenatal as a protective factor for the
maintenance of smoking in the period of breastfeeding,
this study showed no difference in the sense of protection.
it seems that perhaps our prenatal care is not effective
when it comes to properly inform our mothers about the
risks of smoking and its relationship with breastfeeding,
because only 51% of patients received some information
about it in their prenatal visits. These guidelines should
be encouraged by any health care provider.
the literature shows a greater risk of respiratory
problems and hospitalization among infants born to
mothers who smoke during breastfeeding 13, 21 . Besides the
direct effect of smoking, there seems to be a change in the
lower airway colonization by pathogens, increasing the
frequency and intensity of diseases of infectious etiology in
pediatric age 25 ; however, among the patients interviewed,
this was not significantly different between groups.
among pregnant women who smoke, only three
said they had some treatment during pregnancy to quit
smoking, two treated with homeopathic medication and
one with bupropion hydrochloride, which has B risk
during pregnancy and breastfeeding. This proves that
smoker mothers in postpartum period are inappropriately
treated and many treatment options that have been
discussed in the literature are not offered 2 . encouraging
smoking cessation is the minimum (up to 3 minutes of
information on risks, for example); evidence suggests that
psychosocial intervention must overcome it (5-15 minutes
of conversation with different health professionals offers, by
itself, a statistical advantage). Despite being controversial,
reducing the number of cigarettes smoked per day should
be encouraged. There are no studies in pregnant or lactating
demonstrating the benefit of pharmacotherapy, but overall
its use is recommended in any patient without a specific
contraindication to treatment. replacement with nicotine,
for example, must be used under strong supervision and
following guidance on the risks of treatment. Bupropion,
despite increasing the risk of birth defects when used in the
first quarter, can be used and has shown to increase rates
of smoking cessation 2 .
p

While breastfeeding time is been reported as lower
in mothers who smoke 3,13 , this study showed no such
difference. Perhaps this is due to a local culture that
emphasizes more and more the habit of breastfeeding as
a protective factor for newborns 21 , unlike what happens
in the united states, where breastfeeding is declining 7-8 .
The reasons leading to discontinuation of breastfeeding
as to smoking did not differ between groups, and perhaps
this is explained by the average length of breastfeeding
being 6.7 months between groups and the fact that it is a
cultural perception that, even for smoking mothers, the
benefits of breastfeeding outweigh the risks.
CONCLUSION
it should be noted that although this study did not
point out the risks, perhaps due to a biased sample,
smoking concomitant to breastfeeding remains an
important public health problem with consequences
that involve not only the health care system, but also the
economy of society as a whole. Therefore, it is necessary
that, in prenatal consultations, information about the risks
of smoking during postpartum continue to be delivered.
in this sense, guidance campaigns should keep on
addressing this issue in order to educate smoker mothers,
especially, of the dangers and harmful effects of smoking
on their newborn children during breastfeeding.
ACKNOWLEDGEMENTS
to all students who participated in the preparation of
projects and data collection: alícia Dorneles Dornelles,
andré Dias américo, Bárbara sabrine Kilp, Gustavo Julio
Dreher, João augusto P. Bergamaschi, lílian leão arais
da silva, Maicon antônio Carraro, Manuela Martins
Costa, rodolfo souza da silva, Julise a. Balvedi, Matheus
Dornelles fick and lucas Klassmann.
CONTRIBUTIONS
adriani oliveira Galão worked in the design and
research outline, methodology, analysis and interpretation
of data and final writing and overall coordination and
supervision of work; Bruno rocha de Macedo, rafaela
Vanin Pinto ribeiro, roberto Vanin Pinto ribeiro, Carla
Maria de Martini Vanin worked in the interpretation of
data, data analysis and final writing.
Declaration of Conflicting Interests: Nothing to Declare.
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result&selectedTitle=1%7E150

Breastfeeding among Postpartum Smokers
Resumo
Introdução: a influência nociva do tabagismo no período gestacional e na amamentação é amplamente descrita na
literatura. Objetivo: avaliar a relação entre o tempo de amamentação e o tabagismo entre as puérperas fumantes e
ex-fumantes do hospital de Clínicas de Porto alegre e suas consequências para a saúde dos bebês. Métodos: estudo
transversal com aplicação de questionário via telefone em puérperas fumantes do hCPa, divididas em 2 grupos:
mulheres que não fumaram (G1) e que fumaram (G2) após o parto. Variáveis contínuas foram descritas por medidas de
tendência central e dispersão; variáveis categóricas, por frequências absolutas e relativas. as médias foram comparadas
com t de Student e as complicações entre os grupos com Qui-quadrado. Resultados: avaliadas 154 puérperas: 75 (G1)
e 79 (G2). a idade não diferiu entre os grupos (26,0 e 24,7 anos); 67,5% tinham feito pré-natal e, destas, metade
não fumou no pós-parto. somente 51,3% receberam informação médica de que o fumo poderia trazer complicações
para ela e seu bebê. não houve diferença estatisticamente significativa com relação a problemas ou intercorrências
respiratórias nos bebês. as puérperas amamentaram em média 7,2 (G1) e 6,2 (G2) meses e não houve diferença
estatisticamente significativa entre os grupos. no grupo G2 houve uma tendência à interrupção da amamentação por
causas respiratórias (p=0,058). Conclusão: não houve alterações significativas com relação a problemas respiratórios
nos bebês ou parada da amamentação em puérperas fumantes. no entanto, o tabagismo é um preocupante problema
de saúde Pública e deve receber atenção constante nesse grupo especial de mulheres.
Palavras-chave: tabagismo; aleitamento Materno; tabaco; Período Pós-Parto
Resumen
Introducción: la influencia perjudicial del tabaquismo durante el período de embarazo y de lactancia está ampliamente
descripta en la literatura. Objetivo: evaluar la relación entre la duración de la lactancia materna y el acto de fumar
entre los fumadores y ex fumadores madres del hospital de Clínicas de Porto alegre y sus efectos sobre sus bebés.
Método: estudio transversal con un cuestionario por teléfono entre las mujeres fumadoras del hCPa. se dividieron: las
mujeres que no habían fumado después del parto (G1) y las que habían fumado después del parto (G2). las variables
continuas se describen con medidas de tendencia central y dispersión; las variables categóricas mediante frecuencias
absolutas y relativas. las medias se compararon con la t de student y las complicaciones entre los grupos con Chicuadrado.
Resultados: 154 mujeres evaluadas: 75 (G1) y 79 (G2). la edad no fue diferente entre los grupos (26,0 y
24,7 años), el 67,5% tenían control prenatal y de éstos, la mitad no fumó durante el período posparto. sólo el 51,3%
recibió la información médica que el fumar puede causar complicaciones para ella y su bebé. no hubo diferencias
estadísticamente significativas con respecto a los problemas o complicaciones respiratorias en los bebés. los grupos de
lactancia materna en meses promedio de 7,2 (G1) y 6,2 (G2), y no hubo diferencias estadísticamente significativas entre
ellos. en cuanto al motivo de finalización de la lactancia materna, en el grupo 2 hubo una tendencia a romperse por
causas respiratorias (p = 0,058). Conclusión: no hubo cambios significativos con respecto a los problemas respiratorios
en los bebés o la interrupción temprana de la lactancia materna entre las mujeres fumadoras. sin embargo, el tabaquismo
es un problema preocupante de salud pública y debe recibir atención continua en este grupo especial de las mujeres.
Palabras clave: tabaquismo; lactancia Materna; tabaco; Periodo de Posparto
Brazilian Journal of Cancerology 2011; 57(3): 379-385
385

Original Article
Precursor Lesions among Women who Smoke
Article submitted on 03/28/11, accepted for publication on 06/13/11
Cervical-Uterine Precursor Lesion Associated to Tobacco Smoking:
A Study about the Knowledge among Women who Smoke
Lesões Precursoras do Câncer Cervicouterino Associado ao Tabagismo: um
Estudo sobre o Conhecimento entre as Mulheres que Fumam
Lesiones Precursoras del Cáncer Cervical Uterino Asociado al Tabaquismo: un
Estudio sobre el Conocimiento entre Mujeres que Fuman
maria cristina de melo pessanha carvalho 1 , carmen Lucia de paula 2 , Ana beatriz Azevedo Queiroz 3
Abstract
Introduction: it is believed that a possibility to achieve results so as to favor the female population health concerning
the high incidence of cervical-uterine cancer is the design of strategies for the prevention of risk factors, like tobacco
smoking. Objective: to discuss the association between cervical-uterine cancer precursor lesions and tobacco smoking
evidenced in women’s talk who have these cervical changes. Method: Qualitative and descriptive research, carried out
in a federal Public institution in the city of rio de Janeiro. 40 women who were diagnosed with cervical-uterine cancer
precursor lesion participated, divided in 22 smokers and 18 women with past history in smoking within the age group
from 22 to 70. The data were collected by means of semi-structured interviews, and analyzed under the perspective
of the social representation Theory and categorized according to Bardin’s content analysis model. Results: in the
women’s talk, association between tobacco smoking throughout their lives and the development of cervical-uterine
cancer precursor lesions is noticed, and 4 categories are highlighted: the relationship between the disease and tobacco,
cigarettes; the disease and the attempt to change their life style; the media strength, contributing to the information
process; the blame for keeping the tobacco smoking. Conclusion: it can be noticed the need of strategic actions
based on the consensual universe of these women that contributes to the importance of fighting tobacco smoking as
a preventable risk factor for developing cervical-uterine cancer.
Key words: smoking; Cervical intraepithelial neoplasia; Women's health
Part of a Master's dissertation submitted to the Post-Graduate Program of anna nery nursing school, federal university of rio de Janeiro (eean/
ufrJ/2008)
1 Ph.D.c. in nursing at the Post-Graduate Program eean / ufrJ. specialist in oncology nursing. nurse at hospital federal de ipanema [ipanema's
federal hospital] and Píndaro rodrigues de Carvalho CMs [City health Center]. rio de Janeiro Brazil. Email: mcrismelo4@hotmail.com.
2 nurse. Master's degree in nursing by the rio de Janeiro state university (uerJ). nurse at the oncology Clinic of Brazilian national Cancer institute
(inCa) / hospital do Câncer ii (hC ii) / Mh. Collaborating Professor at the Post-Graduate Program of university Gama filho (nursing in the operating
room and sterilized material center). Email: carmenpaula@ymail.com
3 nurse. PhD in nursing. associate Professor, Department of Maternal and Child nursing, ufrJ. Coordinator of Multidisciplinary residence in Women's
health at hospital school são francisco de assis, ufrJ, Brazil. Email: anabqueiroz@oi.com.br. Correspondence Address: Carmen lucia de Paula. rua
Jaracatiá, 174/103. irajá, CeP: 21235-570 rio de Janeiro (rJ), Brazil.
Brazilian Journal of Cancerology 2011; 57(3): 387-394
387

INTRODUCTION
in Brazil, cervical cancer is considered a public health
problem, since it has the highest incidence and mortality
among women. according to estimates by the Brazilian
national Cancer institute (inCa), for the years 2010
and 2011, 18,000 new cases are expected, and this type
of tumor is the second most frequent and the fourth cause
of death by cancer to the female population in Brazil 1 .
Currently, 44% of cases of this disease are derived from
cervical cancer precursor lesions (CCPl) called carcinoma
in situ1. These lesions are distinguished by the presence
of modifications of the original epithelium, giving birth
to pre-cancerous manifestations that may develop into
cervical cancer 2-3 .
Cervical cancer, considered as invasive, evolves from
cervical intraepitelial neoplasia i (Cin i); however, not
all Cin will evolve into an invading illness. nevertheless,
it should be highlighted that all Cin must be considered
as significant lesions and, as such, must be treated and be
followed, because women early diagnosed and adequately
treated have 100% possibility of cure 4 .
it is worth highlighting that the main risk factor to
cause this type of cancer is human papillomavirus, hPV,
and this virus has some oncogenic subtypes, which are
related to malignant tumors, such as viral subtypes 16
and 18 1 .
however, it is noteworthy that less than 1% of women
with hPV infection with cancer risk will develop cervical
cancer, but this risk is intensified when the viral infection
is associated with smoking, thus highlighting that the
frequent use of cigarettes is a proven cause of the evolution
of this pathology 5 .
tobacco significantly diminishes the level of function
of langherans cells, which are responsible for defending
the epithelial tissue, and, besides, cigarettes contain over
300 carcinogenic substances 6 .
it should be noted that the number of smokers
among women has increased worldwide, influenced by
many social, cultural and economic factors, especially in
developing countries, making tobacco one of the biggest
causes of this type of tumor 7 . Confirming this fact, a
study that addressed the cytological and risk factors
illustrated that 48% of a total of 65 women with cervical
abnormalities were smokers 8 .
thus, the issue of this study emerged from the
practice of assistance to women with CCPl when it was
empirically identified that some of them linked smoking
to the situation they were in; however, other segments
besides not doing so, sometimes did not believe there was
a connection between these variables.
This was reflected in the different ways of thinking
and acting towards the experience of smoking and cervical
changes, which are permeated by rules established in
388 Brazilian Journal of Cancerology 2011; 57(3): 387-394
social and cultural environment that subjectivate and
individualize themselves in each person.
it is believed that one of the possibilities to achieve
different results, so as to promote health of the female
population against the development of cervical cancer, is
the formulation of strategies for prevention of avoidable
risk factors such as smoking, but strategies that take into
consideration the psychosocial aspects that are involved
in this phenomenon, and not only informative or
prescriptive conditionants.
Prevention and control of cervical cancer are among
the most important scientific and public health challenges
of our time, which must pervade both the use of condoms
in all sexual relations, and the fight to smoking among
women.
the need to review, design and propose new
approaches at different levels of expertise in health should
be seen as a priority in the fight against smoking, so as to
mobilize not only the professionals to work effectively,
but the population itself.
under this view, this study aims to discuss the
association of smoking with CCPl evidenced in the
speech of those women with cervical abnormalities.
METHOD
this is a study with qualitative approach and
descriptive typology, because the research requires a deeper
understanding of the reality experienced by these women.
regarding the problem described, to support the
interpretation and the subjectivity of the data produced
by the study subjects, the Theory of social representations
was used, as the theoretical framework, which provides
elements to give basis to cultural approaches, values and
beliefs of this group of women. This theory is seen as the
one that studies the common, popular and naive thought
of people about a particular thing or event that causes
individuals to act according to what they think 9-10 .
the survey was conducted in a federal Public
institution in the city of rio de Janeiro, a prominent
place considered as a reference in dealing with the cervical
pathology. This service receives women from Basic health
units for treatment of cervical abnormalities.
The survey consisted of 40 subjects, divided into two
groups: one group with 22 smoker women and precursor
lesions and another with 18 women with history of
smoking.
inclusion criteria were: diagnosis of CCPl
demonstrated by results of cervical cytology and/or
colposcopic; undergoing treatment at that institution,
self-declaration of being a smoker with history of smoking
and accepting to take part in the study.
exclusion criteria were delimited as women who did
not declare themselves smokers, even smoking one to three

cigarettes per day, and those who were in the process of
diagnosis confirmation.
Data were collected from february to June 2008,
through interviews, having in mind the need to
understand the information that circulates at different
times such as interaction, habit and social imaginary.
it is noteworthy that the data collection in a study
of social representation requires long semi-structured
interviews. Thus there was an average of 30-45 minutes
per interview 11 . a portable recorder was used to record
the speeches with prior permission of the interviewees.
The interview had a script with open questions that
were designed to explore the main speeches and statements
of the subjects about the causal factors of CCPl and
its relation to smoking, and revealing the respondent's
perceptions of the world, observing, evaluating and
understanding the common knowledge phenomenon.
The interviews were conducted in a private room
after medical appointment and with prior scheduling,
thus respecting the availability of the respondends.
subsequently, data were transcribed to facilitate the stage
of analysis.
With regard to ethical aspects, we followed the
recommendations of the resolution nº196/96, which
deals with standards for research involving humans.
Participants signed an informed consent form, stating
the purpose of the study, with guaranteed anonymity and
confidentiality of information provided.
the study was approved by the research ethics
Committee of anna nery nursing school / hospital
school são francisco de assis / federal university of rio
de Janeiro under the Protocol number 02/2008.
to organize the data, the tapes were transcribed and
fluctuating readings occurred. after exhaustive reading of
all the material, it was classified into themes that structured
the empirical categories for analysis according to Bardin’s
thematic orientation 12 . Category is a classification system
of the constituent elements of a set by differentiation
grouped into thematic categories 12 .
Given view, the categories were grouped together by
bonds which illustrated the correlation between cervical
change and smoking. finally, the data were analyzed under
the psychosocial perspective of the social representations
theory.
RESULTS AND DISCUSSION
the categories pointed to the relations that the
interviewees made between smoking and the results of
cytology and change in women's lives after learning the
test results.
Therefore, four categories emerged and were defined
as: 1) The relationship of the disease with tobacco, 2)
Cigarette, disease and attempt to change lifestyle, 3) The
Precursor Lesions among Women who Smoke
strength of the media in contributing with the information
process, and 4) The guilt for keeping smoking.
The reLATionship beTWeen The DiseAse AnD TobAcco
in this category, the relations the subjects made
between cervical abnormalities and smoking were
analyzed. of the 40 respondents, 35 acknowledged the
existence of some kind of association between smoking
and cervical changes. however, the value or weight of this
association presented itself quite diverse, and none pointed
the cigarette as the effective cause of CCPl.
i have always heard that smoking is harmful, that
it causes cancer! i don't know. i’ve always smoked.
i smoke about ten cigarettes a day, and i’ve always
wanted to quit [...]. Because i was supposed to have
quit, because i never quit (pause). ah whatever. i'm
always in hospitals. i have always done preventive
exams, it was always negative. i keep wondering:
has my partner got an illness, did he pass me? i
keep brooding it in my head. But it is obvious that
smoking worsens the problem. (interviewee no. 16
-48 years - smoker for 16 years - Cin i)
i cannot explain, smoking may have helped,
worsened the situation. But it was my husband.
i won't put my neck on the line for him. i think
that he's the cause. i know that smoking helped,
but he was the one who was transmitted me this.
(interviewee no. 31 - 58 years - a former smoker
- Cin iii)
i think it's the cigarette, the cigarette because it
harms you continuously, making you ill till you
have cancer. But i have smoked for a long time,
never quit, but i will try now. But in fact i do think
that sex was the cause, because men never undergo
treatment, thus, because of that they give us, which
must cause some lesion, to cause in women, i think
men's secretion causes this on us. i think sex is first
and then cigarettes. and obviously for those who
smoke is worse, the cure, the treatment is more
difficult. (interviewee n. 9 - 51 years old - 8 smoker
for 8 years - Cin iii).
in this category, it has become clear that most
interviewees link the source of the problem to the sexual
unfaithfulness from the partner and not to smoking.
This, in turn, was represented as a contributing factor to
the development of the disease and even being able of
causing cancer.
it is observed that they are aware that tobacco is
harmful to their health, and therefore perceive themselves
as more vulnerable to serious consequences, for smoking,
than those women who are not smokers.
Brazilian Journal of Cancerology 2011; 57(3): 387-394
389

Carvalho MCMP, Paula CL, Queiroz ABA
390
The various aspects of the association between smoking
and the cervical cell changes experienced are actually
coming from what they see in their daily life, in the media
and even in the hospital environment that are placed due
to treatment.
This influences the way they think, not only on the way
they got the problem, but mainly on coping and decision
making, such as whether quitting smoking or not. in face
of these facts, most people interpret what happens to
them, form an opinion about their own conduct or that
of relatives / people and guide their actions in accordance
with this interpretation 9 .
in contrast, there was a small segment of respondents
who did not believe there was any relationship between
smoking and the plight, questioning the actual existence
of the bad influence of smoking with this problem. see
the statement below:
i don't know. i don't know, is it because of
cigarettes? i question it a lot [...]. for me cigarettes
have no connection with it. This thing is something
that women catch and smoking has nothing to do
with it. Therefore, i don't quit smoking. i have to
take care of it somehow else. (interviewee n. 17 -
32 years old - smoker for 17 years - Cin ii)
We emphasize the position of Moscovici9 with respect
to individuals acting according to their guidelines and
interpretations, i.e., if the cigarette for this group of
respondents is not represented as one of the causes or
enhancers of CCPl, the decision to want to face it and
quit smoking will not be something a priority in their
lives, or even be part of their plans.
cigAreTTe, The DiseAse AnD ATTempT To chAnge LifesTYLe
This category reveals the attempt to change lifestyle
when you discover the diagnosis of CCPl and, within
these attempts, there is the possibility of quit smoking.
The acknowledgement of smoking as a factor in the
development of cervical abnormalities, causes emotional
distress, and contributes significantly to the development
of cervical cancer.
as smoking is seen in the reified universe of science as
a major risk factor for the development of cancers, because
it has more than 67 carcinogens, increasing the risk of
disease onset up to 15 times 13 , it is comprehensible that
there is an hegemonic transfer to the universe of consensus,
thus influencing the social understanding of the harms of
tobacco to individuals.
historically, women took up smoking as a social
advancement and gender equality issue. however, the
relationship between cigarette use with women today is
conflicting, comprised by emotional disorders, due to
the fact that they usually smoke in response to negative
Brazilian Journal of Cancerology 2011; 57(3): 387-394
situations of life, stress and the prospect of moderating
the low motivation to live 14 .
But when they see themselves in situations of danger,
or fear of worsening a disease or even death, as is the case
of cancer, which still today is represented with a load of
ideas that are part of common sense, shared by social
environment, where information that circulates and
crystallizes finiteness show themselves as motivators to
quit smoking.
some women see a need to change habits, especially
leaving behind harmful habits such as smoking, drinking,
eating poorly. it is worth noting that when it comes to
health itself, a social result of construction of comfort
standards for one's health is settled 15 . This can be identified
in the following statement:
smoking, i was not able to stop smoking yet. i've
tried, but could not yet. in terms of food, i've
been eating better. i've been eating certain things
that i once did not eat, plenty of fruit and many
vegetables. We hear that cauliflower is very good for
the uterus, so i quite like cauliflower, my hygiene is
more rigorous now, all this stuff changed a lot. The
only thing i could not quit was smoking, but i'll try.
(interviewee nº 23 - 32 years - smoker for 15 years
- Cin ii / Cin iii)
The practices of habit change are guided by a logic
that results from social experience 16 . Before this statement,
these women try to produce actions that will restore their
health, they recognize the need to change their way of
thinking and acting as to their well-being and body.
The role that the representation has to guide the
practices of the individual allows us to understand why
some problems are more evident in a society 17 . in this
case, as to women with CCPl, they raise decisions, such
as trying to quit smoking and changing lifestyle, which
are events that put precursor lesions in smoker women
in the role of guiding representations about these injuries
and that have been built and developed by the social
environment in which they live.
The poWer of The meDiA conTribUTing To The process of
informATion
Media influences the behavior and lifestyle of people
who often idealize living what a character or product
shows: be nice, beautiful, interesting and enjoyable. The
quest for acceptance in society and, often, self-assertion,
can lead people to acquire habits without a prior
questioning whether that can cause damage, including
damage to health. Thus, for many years, cigarettes were
strongly advertised in the media as a source of glamour
and charm, making much of its strength even among
the female group. the tobacco industry conveyed,

through marketing, that smoking was synonymous with
pleasure and adventure, and that this compensated any
possible health risks, because the socioeconomic and
cultural conditions also interfere with the acquisition
and maintenance of smoking. in face of this picture,
one realizes that the association between smoking and
an adventurous lifestyle and seduction is common in
cigarette advertising 18 .
Currently, there is a strong movement against the
tobacco positive cultural tradition, such as state and local
laws against smoking in certain places, as well as efforts of
the Ministry of health (Mh) against advertisement and
encouragement of tobacco consumption. Considering
this scenario, it becomes clear that the actions for
tobacco control depend on the articulation of different
types of strategies in the social, governmental and
nongovernmental sectors 19 .
Thus, the reference of care that one has is based on
the media discourse, emphasizing the value of health,
without tobacco, within a communication circuit.
the contribution of the population's greater access
to information and knowledge about the disease and
prevention of risk factors for cervical cancer should also
be emphasized.
The role of the media, especially television, is relevant
in the construction of subjectivity and common sense,
influencing the transformation of habits such as smoking
and cervical cancer prevention 20 . representations that
have a direct influence of what one hears about the
problem, either by the media, or by the social environment
in which we live, or by the medical discourse. Thus, some
women in the study acquire such information and try to
quit smoking.
however, we know that quitting does not depend
solely on the information on the hazardous effects of
smoking.
There are other factors involved, such as addiction,
willpower, continuous treatment, access to health services,
but as noted in the statement below, no doubt, awareness
seems to be the first step:
i used to smoke 10 cigarettes per day, then
i started to hear on television they say that
smoking is not good, it causes problems. But
i only quit after i started to feel tired, and the
physician said "quit it, woman, stop smoking,
if not you will get worse". i quit after 15 years
and soon after this thing started, this disease. i
heard on television one advertising saying this...
this saying comforted me a lot. The girl in the ad
would say: "see, this disease is dangerous, but it
is for people who do not take care of themselves.
While it is a little thing, and the person takes
care of it, it won't become anything". she said
Precursor Lesions among Women who Smoke
this on television, then i thought, i have to take
care of myself and stop smoking. it was hard but
i managed. Thank god! (interviewee 14 - 62 years
- a former smoker - Cin iii / carcinoma in situ )
added to this fact, one can also quote the massive
presence of television as a source of information, not
counting the circle of friends, which undoubtedly
contributed to the formation of social representations
of CCPl by women who use tobacco. Thus, one can
understand how social knowledge is constructed, because
it is a knowledge linked to the context of a relationship
with the social environment in which we live.
in this case, the media provides discourse and information
with different ideas and information added to its social
environment, i.e., the people who surround it. Women build
and organize their representations of this phenomenon. such
representations are elaborations formed by the information
circulating that renew and crystallize 9 . This way, women in
this study take ownership of information, trying to put them
into practice and quit smoking.
gUiLT for keep smoking
Thus, the difficult task of quitting smoking involves
feelings of failure, depression and guilt for not achieving
the goal, especially when it is recognized that this factor
is detrimental to the health problem that is experienced.
in this category, it was possible to identify this
viewpoint of guilt in face of the current diagnosis and of
what continuous tobacco use can cause in the future. The
process of guilt developed due to actions not taken, due
to care that was not practiced and habits that were not
suppressed, such as smoking, as a means of preventing
cervical cancer. herebelow follows a statement:
for i am a faineant, because i did not do preventive
exams, i didn't quit cigarettes, i smoke a pack a day,
i tried to cut it down, but i couldn't. it is addiction.
i get depressed when i do not smoke. i use to stand
barefoot, with my belly wet, i did not have any
care, because women are sensitive, they must care
for themselves, for example, if you fall and hurt if
you do not put medicine in it, you leave a wound
untreated, it will become infected, it may even turn
into a disease, the same thing, the cigarette, if you
know that's no good and continue, problems will
show up. and inflammation of the cervix is like
this, it begins like this, from little grain of sand, it
grows up. i think i got this for not taking care of my
health, not stop smoking, not going to the doctor
every six months, i think so. i've tried to stop, but it
is very difficult, i do not know how to quit smoking
[...]. (interviewee 27 - 31 years - smoker for 5 years
- Cin iii / carcinoma in situ )
Brazilian Journal of Cancerology 2011; 57(3): 387-394
391

Carvalho MCMP, Paula CL, Queiroz ABA
392
it is known that, for any health treatment, human
subjectivity, desires, limits of body and mind are present
and should be taken into consideration, because the human
being is not a machine that only obeys orders without
judgment, interpretations and representations. and when
it comes to smoking, there are several difficult barriers to
transpose in order to quit smoking, such as: withdrawal,
depression, anxiety and lack of concentration. about 80%
of smokers that want to quit smoking, only 3% do it with
no help 21 .
Therefore, the support of the multidisciplinary team is
necessary with these women, encouraging cessation. so it
is very important to bear in mind the concern to bring us
closer to this space, so one can better target and intervene
in the decision of these women. it is important to define
intervention practices, which will modify the behavior of
subjects to review their practices of care and prevention as
referenced by Jodelet about intervention 22 .
CONCLUSION
We conclude that the results of this study showed that
women believe in the association of smoking with the
development of precursor lesions of cervical cancer and
that this factor certainly could have been avoided.
it is observed that women recognize and understand
that tobacco is harmful to health; however, the statements
illustrate the subjectivity of the female population on
tobacco and the conflict that is experienced due to the
need to quit smoking.
The relationship of the disease with smoking was
evident in the discourse of these women, which illustrates
the strong social and cultural predominance anchored in
the relationship between women and tobacco. escape
feelings, uncertainties, doubts and questions are part of
the subjectivity of the female population through the
social representations.
The relevance of this study is to contribute to the
identification of psychosocial issues that affect the
attitudes related to smoking cessation. Many women
revealed that they could not quit smoking, even when
acknowledging it to be harmful to their health.
in this sense, it is essential to have reinforcements and
innovations in programs for non-adherence to smoking,
as well as emphasizing clarification of the dangers of its
use. it is possible the use of approaches, which, as to their
tenets and beliefs, are understood by the multidisciplinary
team, considering that there shouldn't be only a technicalscientific
context, but the psychosocial, historical and
cultural context of these women should also be taken
into account.
The study set up subsides in the pursuit of knowledge
of representations of women who smoke, suggesting an
innovative tool in our daily practice, besides enabling the
Brazilian Journal of Cancerology 2011; 57(3): 387-394
development of new strategies, because it is believed that,
given the representations of women who smoke and who
are suffering from precursor lesions, it will be possible to
create high-impact interventions to non-adherence to
tobacco by the female population.
CONTRIBUTIONS
Maria Cristina de Melo Pessanha Carvalho and
Carmen lucia Paula contributed to the conception
and planning of the research project, in obtaining and/
or analyzing and interpreting data, writing and critical
review; ana Beatriz azevedo Queiroz helped in obtaining
and/or analyzing and interpreting data and in writing and
critical review.
Declaration of Conflicting Interests: Nothing to Declare
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394
Resumo
Introdução: acredita-se que uma das possibilidades para alcançar resultados de modo a favorecer a saúde da população
feminina em relação à alta incidência de câncer cervicouterino seja a construção de estratégias para prevenção dos fatores
de risco, entre eles o tabagismo. Objetivo: Discutir a associação das lesões precursoras do câncer cervicouterino com o
tabagismo evidenciado na fala de mulheres portadoras dessas alterações cervicais. Método: Pesquisa qualitativa, do tipo
descritiva, realizada em uma instituição Pública federal no Município do rio de Janeiro. Participaram 40 mulheres
com o diagnóstico de lesão precursora do câncer cervicouterino, divididas em 22 tabagistas e 18 com história pregressa
de tabagismo entre a faixa etária de 22 e 70 anos. os dados foram coletados por meio de entrevistas semiestruturadas,
e analisados sob a perspectiva da teoria das representações sociais, sendo categorizadas de acordo com a temática
de Bardin. Resultados: na fala das mulheres, percebe-se a associação do ato de fumar ao longo de suas vidas com
o desenvolvimento das lesões precursoras do câncer cervicouterino, sendo destacadas quatro categorias: a relação da
doença com o tabaco, o cigarro; a doença e a tentativa de mudança de estilo de vida; a força da mídia, contribuindo
no processo de informação; e a culpa por manter o tabagismo. Conclusão: nota-se a necessidade de ações estratégicas
baseadas no universo consensual dessas mulheres, contribuindo para a importância do combate ao tabagismo como
um fator de risco evitável para o desenvolvimento do câncer cervicouterino.
Palavras-chave: tabagismo; neoplasia intra-epitelial Cervical; saúde da Mulher
Resumen
Introducción: se acredita que una de las posibilidades para alcanzar resultados de modo a favorecer a salud de la
población femenina en relación a alta incidencia de cáncer cervical uterino, sea la construcción de estrategias para
prevención de los factores de riesgo evitables, como el tabaquismo que entre otros, contribuye para el desarrollo del
mismo. Objetivo: el objetivo de este estudio consiste en discutir la asociación de las lesiones precursoras del cáncer
cervical uterino con el tabaquismo evidenciado en el habla de las mujeres. Método: la investigación es cualitativa,
de tipo descriptivo, realizada en una institución Pública federal en el Municipio del rio de Janeiro. Participaron 40
mujeres que tenían el diagnóstico de lesión precursora del cáncer cervical uterino, divididas en 22 tabaquistas y 18
mujeres con historia previa de tabaquismo entre la franja etaria de 22 y 70 años. los datos fueron colectados por
medio de entrevistas semiestructuradas, y analizados bajo la perspectiva de la teoría de las representaciones sociales
y se clasifican de acuerdo a la temática de Bardin. Resultados: en el habla de las mujeres se destaca la asociación del
acto de fumar a lo largo de sus vidas con el desarrollo de las lesiones precursoras del cáncer cervical uterino, siendo
destacadas 4 categorías: la relación de la enfermedad con el tabaco, el cigarrillo, enfermedad y la tentativa de mudanza
de estilo de vida; la fuerza de los medios de comunicación contribuyendo en el proceso de información; la culpa por
mantener el tabaquismo. Conclusión: en este aspecto, se observa que la necesidad de acciones estratégicas basadas
en el universo consensual de estas mujeres contribuye a la importancia de la lucha contra el tabaquismo como factor
de riesgo evitable para el desarrollo de cáncer de cervical uterino.
Palabras clave: tabaquismo; neoplasia intraepitelial del Cuello uterino; salud de la Mujer
Brazilian Journal of Cancerology 2011; 57(3): 387-394

Opinion Article
Tobacco Control: a Parallel between the World and Brazil
Article received on 6/10/11; accepted for publication on 7/18/11
Advances and Challenges in Tobacco Control: a Parallel between
the World and Brazil
Avanços e Desafios no Controle do Tabagismo: um Paralelo entre o Mundo e o
Brasil
Avances y Desarollos en el Control del Tabaco: un Paralelo entre el Mundo y Brasil
INTRODUCTION
The aim of this opinion session is to contextualize the
Brazilian program within the current international tobacco
control efforts, and highlight its successful outcomes that
have clearly resulted in a smoking prevalence reduction
over the last 20 years. It also explores the new country
challenges, highlighting the importance of tobacco control
in the national and global development agenda.
The time could not be better to talk about tobacco
control activities in Brazil and in the world. The
September 2011 United Nations General Assembly
High-Level Meeting on the Prevention and Control of
Non-communicable Diseases 1 will address one of the
most alarming global problems in public health and
unfortunately Brazil is not an exception. The Summit
will raise the profile of NCDs globally and will mobilize
the international community to react to the current
situation. Governments of different countries such as
Brazil are already working on their national agendas
sending a clear message to stakeholders, donors and
funders on their health priorities and needs to tackle
with the disease burden of NCDs. The Summit will also
ensure the commitment of Heads of State to lead the
cross-government effort and to tackle the multi sectoral
dimensions necessary to reverse the epidemic.
The recently launched Global Report on NCD 2
clearly shows that low-and middle-income countries
Douglas William bettcher 1 , vera Luiza da costa e silva 2
now bear nearly 80% of the burden from diseases like
cardiovascular disease, diabetes, cancer and chronic
respiratory diseases. Ageing, and rapid urbanization, are
important determinants. Powerful forces – many times
driven by the most unscrupulous commercial interests, are
behind this epidemic that unfortunately touches most if
not all countries in the world; in particular, these global
effects of globalization have impact on former culturally
healthy behaviors turning them into unhealthy lifestyles.
The proportion of NCD deaths in relation to all deaths
in Brazil continues to rise (representing 72% of all deaths
in 2007). Nevertheless, the country has implemented a
number of policies that have already impacted on agestandardised
mortality rates. They have fallen by 1.8%
per year since 1996, which is within the range of 1-3%
observed from 1970 to 2000 in high-income countries
such as Australia, Canada, Japan, the UK and the USA 3 .
Cost-effective tobacco control measures along with better
primary health care attention are considered to be the
major causes of this improvement, composed principally
of declining rates of cardiovascular and chronic respiratory
diseases.
Brazil efforts are in line with current global efforts
that are already showing promising results on a global
scale after the adoption of the World Health Organization
Framework Convention on Tobacco Control (WHO
FCTC) 4 , the first and single international treaty negotiated
under the auspices of WHO 5 .
1 Medical Doctor, Masters in Public health and PhD (econ). Director of the tobacco free initiative. World health organization. E-mail: bettcherd@who.int
2 Medical Doctor, MBa, PhD (Public health). associated Professor at the national Public health school. oswaldo Cruz foundation.
E-mail: veradacostaesilva@ensp.fiocruz.br
Corresponding author: Vera luiza da Costa e silva. rua Pinheiro Guimarães, nº 149 - casa 145 - rio de Janeiro (rJ), Brazil. 22281-080.
E-mail: veradacostaesilva1@gmail.com
Brazilian Journal of Cancerology 2011; 57(3): 395-399
395

Bettcher DW, Costa e Silva VL
396
The gLobAL sTATUs of The TobAcco epiDemic: The Who
reporT on The gLobAL TobAcco epiDemic 2011
Brazil‘s tobacco control country profile is part of the
recently released WHO Report on the Global Tobacco
Epidemic, 2011 6 . The report is the third report on the
status of the global tobacco epidemic published by WHO’s
Tobacco Free Initiative and addresses, this time with more
details, the efforts WHO Member States are making in
informing their population about the dangers of tobacco
use. The report follows up previous editions, on the status
of the global tobacco epidemic regarding six demand
reduction measures, intended to support WHO Member
States in implementing the WHO FCTC, labeled as
MPOWER measures including: monitor tobacco use
and interventions; protect people from tobacco smoke;
offer help to quit tobacco use, warn about the dangers of
tobacco; enforce bans on tobacco advertising, promotion
and sponsorship; and raise taxes on tobacco. The findings
of the report on the current status of these measures are
shown in Figure 1.
The information is unequivocal. Despite the advances,
the share of the world population covered by selected
tobacco control policies is far from being adequate.
Nevertheless, as countries continue to build on the
progress achieved since becoming Parties to the WHO
FCTC, more people are being protected from the harms
Share of world population
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
46%
Note: Changes of less than 1% are not labeled on the chart.
Figure 1. Current status of the tobacco epidemic regarding six demand reduction measures (MPOWER) of the WHO FCTC
Brazilian Journal of Cancerology 2011; 57(3): 395-399
11% 14% 15%
of second-hand tobacco smoke, provided with help to quit
tobacco use, exposed to effective health warnings through
tobacco package labelling and mass media campaigns,
protected against tobacco industry marketing tactics
and covered by taxation policies designed to decrease
tobacco use and fund tobacco control and other health
programmes. Perseverance by all countries in expanding
the reach of tobacco control programmes is needed to
achieve the goal of a tobacco-free world, and is critical to
saving the lives of the billion people who may otherwise
die from tobacco-related illness this century.
brAziL: sTATUs of The TobAcco epiDemic AnD pUbLic
heALTh responses
Brazil is doing well in the international picture.
From the developing countries that have completed the
Global Adult Tobacco Survey, Brazil has one of the lowest
prevalence of smokers (Figure 2) only behind Mexico
and is probably one of the most successful tobacco
control programmes among the major tobacco growing
developing countries. The success of countries like Brazil
in tobacco control have an additional value because of
the sharp contrast between public health efforts, many
times competing with many other health and social
needs and the economic appeal of tobacco growers and
manufacturing forces. In a major tobacco producer and
Share of the world population covered by selected tobacco control policies, 2010
M
Monitoring
P
Smoke-free
environments
O
Cessation
programmes
28%
W
Pack warnings Mass media
6%
E
Advertising bans
8%
R
Taxation

Proportion of adults currently using tobacco
Tobacco Control: a Parallel between the World and Brazil
Prevalence of adult tobacco use in the 14 countries that completed the Global Adult Tobacco Survey, 2008-2010
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
43%
39%
35%
31% 31% 30% 29% 28% 27%
Figure 2. Prevalence of adult tobacco use (Global Adult Tobacco Survey) in 14 countries
exporter such as Brazil, tobacco industry and allies are
constantly lobbying governments on the importance of
their business to economic growth, development and job
generation and virtually always trying to derail tobacco
control initiatives.
Brazil was among the countries that have shown that
despite the strong presence of the tobacco industry and
tobacco related economic interests, a tobacco growing
developing country can do pretty well in protecting their
population against the tobacco epidemic. Moreover,
Brazil has particularly contributed to the international
tobacco control efforts by chairing the Inter Governmental
Negotiation Body of the WHO FCTC through its
outstanding diplomacy.
brAziL besT prAcTices on TobAcco conTroL
The areas where Brazil is among the Highest Achieving
Countries and Territories – 2010 of the Global Report of
the Tobacco Epidemic 2011 include:
Article 11 - Pictorial Health Warnings: Brazil was the
first country in the world to ban misleading descriptors of
cigarette packs and the second in the world to introduce
pictorial health warnings in tobacco products packages.
Recent global developments have taken place since
then, with an increasing number of countries such as
the United States, Peru and Mexico mandating pictorial
health warnings. Australia’s government has proposed
25% 25%
20%
18% 16%
plain packaging of tobacco products as one additional
measure to ban the marketing of the tobacco industry
and this policy can eventually be considered as a further
step in Brazil’s regulation on packaging and labelling of
tobacco products.
Article 14 - Tobacco dependence treatment: According
to the Report, between 2008 and 2010, one additional
country (Turkey) has begun providing comprehensive
tobacco dependence treatment that includes a national
quit line as well as coverage of costs for nicotine
replacement therapy and at least some other cessation
services. The progressive effort Brazil’s government is
making in promoting smoking cessation is recognized in
the report as part of the highest achieving countries in the
world. Strengthening Brazil’s countrywide toll-free quit
line, offering health professionals training initiatives and
evaluating on a regular basis smoking cessation policies
for cost-effectiveness would contribute to this process.
Taking advantage of the National Program for Control
of Tuberculosis would be an opportunity to reduce both
tuberculosis mortality and tobacco use.
brAziL AnD The TobAcco epiDemic: confronTing neW
chALLenges
Despite the existing successes in tobacco control, there
are no grounds for complacency when it comes to the
tobacco epidemic. Brazil has still many challenges ahead
Brazilian Journal of Cancerology 2011; 57(3): 395-399
397

Bettcher DW, Costa e Silva VL
398
and has reported to be on the wedge of taking additional
tobacco control measures.
The first and probably the most urgent need is to
establish mechanisms to monitor and counteract the
growing pressure of the tobacco industry, who is using
different groups as a mass of manoeuvre to oppose sound
and needed tobacco control measures in the country.
A public consultation held by the Brazilian National
Health Regulatory Agency – Anvisa in 2011 has shown
how the industry can orchestrate a reaction against tobacco
control measures such as the ban of additives and
additional and important regulations at points of sales,
which are all recommended by the WHOFCTC Guidelines.
The tobacco industry undermines this consultation
process by using front groups, lobbying parliamentarians
and manipulating tobacco farmers, employees of the
hospitality industry and retailer groups 7-8 . The tobacco
industry also uses lobbyists in Brazil’s government. Recently,
a major newspaper in Brazil documented how the
tobacco industry has tried to influence a member of the
Brazil’s National Commission for the Implementation
of the WHOFCTC (CONICQ) who was also a part of
the Brazilian delegation to the Fourth Conference of the
Parties to the WHOFCTC 9 . This demonstrates, according
to article 5.3 Guidelines, the need for extending
the firewall boundaries between the government and the
tobacco industry.
Developments in other policy areas might also be
of importance in the country. Investing in grants from
national and international development and research
agencies for studying alternative livelihood seems to be
a sensible approach for a tobacco growing country. The
reason for that is simple. Tobacco farmers are the weakest
part of the tobacco production chain and should be
protected in regard to their health and livelihood. Furthermore,
by giving attention to farmer’s needs, they will
be more equipped to resist the influence of the tobacco
industry, being empowered to defend their legitimate
interests. The current initiative from the Brazil’s Ministry
of Agrarian Development should be commended and
strengthened and results of their initiatives can serve
as a basis to support other tobacco growing developing
countries.
The Global Tobacco Control Report also shows other
important areas where the country is not among the Highest
Achieving Countries and Territories – 2010 of the
Global Report on the Tobacco Epidemic 2011 that can
be addressed in Brazil:
Article 8 - 100% Smoke-free places: The GTCR2011
has shown that between 2008 and 2010, 16 countries
newly enacted nationwide comprehensive smoke-free
legislation, increasing to 31 the number of countries
that provide the highest level of protection against
second-hand tobacco smoke exposure, showing that this
Brazilian Journal of Cancerology 2011; 57(3): 395-399
is feasible and should be followed by other countries.
Brazil has a national tobacco control law as from 1996
regulating tobacco use in public places, but the smoking
designated areas allowed by the law have benefited
the tobacco industry, that has teamed up with retailers
associations and the hospitality industry to ensure a
more “reasonable” regulation 10 . A total ban of smoking
in public areas is still a challenge in the Brazil federal
legislation as it would complement the successful
initiatives in many Brazilian states, pioneered by the
state of São Paulo, that are already showing results 11 .
Article 13 - Comprehensive bans on tobacco advertising,
promotion and sponsorship (TAPS): According to the
GTCR2011, between 2008 and 2010, three additional
countries (Chad, Colombia and the Syrian Arab Republic)
enacted comprehensive bans on TAPS that covered all
forms of direct as well as indirect advertising. Brazil has
enacted a comprehensive ban on TAPS at the beginning
of this century but has allowed for an exception at points
of sale. This policy can be strengthened by amending the
law including a ban of advertising on points of sales as
well as corporate social responsibility and other marketing
strategies of the tobacco industry.
Article 12 – High hitting communication campaigns:
According to the GTCR2011, between 2008 and 2010,
there are currently 23 countries, with a total of more
than 1.9 billion people representing 28% of the world’s
population, who have conducted media campaigns
that were national in scope and that incorporated all
appropriate characteristics. Low-and middle-income
countries have been in the forefront of developing antitobacco
mass media campaigns, showing that countries
can successfully implement this intervention regardless
of income classification. Examples include India, Turkey
and regions from the Russian Federation.
In Brazil, national public campaigns could also be
strengthened and mass media campaigns would be
instrumental in addressing tobacco use prevalence
particularly among the poor and vulnerable populations
as the tobacco prevalence in other groups has been sharply
reduced over the years 12 . This would contribute to the
already successful initiatives of Brazil’s government to
reduce poverty and inequalities, in synchrony with the
Millennium Development Goals.
Article 6 - Taxes and prices increases: According to
the GTCR2011, there are now 26 countries and one
territory whose total taxes constitute more than 75%
of the retail price. Since 2008, there have been 11
countries and one territory (Argentina, Greece, Hungary,
Israel, Italy, Latvia, Lithuania, Madagascar, Romania,
Slovenia, Turkey and West Bank and Gaza Strip) who
have increased tobacco taxes so that they constitute more
than 75% of the retail price. Economic measures are the

est buy in tobacco control. Brazil, with taxes rates of
60% of retail price has considerable room to increase
taxes and prices establishing a tobacco taxes and prices
policy that will ultimately protect public health. Regular
and progressive increases in tobacco taxes will result in
further reduction in tobacco prevalence by reducing
affordability particularly among youth and the poor.
Strengthening policies to counteract illicit trade and
support the completion of the Protocol on Illicit Trade
will contribute additionally to further countries’ public
health objectives.
CONCLUSION
even considering that we are still far from protecting
a big share of the world’s population of health, social and
economic consequences of the tobacco epidemic, the
world is getting better when it comes to tobacco control.
More countries have introduced policies and measures
to curb the epidemic, in both developed and developing
world and the commitment and political will is present
in all Who Member states.
The Who fCtC has progressively more Parties
(174 Parties as of 18 July 2011) and the Conference
of the Parties has adopted several Guidelines with the
first protocol under the WhofCtC being finalized.
Brazil’s role model, experience and best practices have
been essential in supporting the treaty negotiation and
implementation, making history in tobacco control.
The world continues to watch Brazil’s paths and relies
on its leadership in advancing the global tobacco
control agenda.
ACKNOWLEDGEMENTS
The World Health Organization (WHO) has copyright
in this Manuscript and has granted the Instituto Nacional
de Câncer-Brazil permission for the reproduction of this
article in the Revista Brasileira de Cancerologia.
The authors thank A'Isha Alison Louise Commar for her
support in the preparation of this paper.
CONTRIBUTIONS
The authors of this paper directly participated in its
planning, analysis and writing, and have approved the
final version here submitted.
Conflict of Interest: None
Tobacco Control: a Parallel between the World and Brazil
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Monteiro CA, Barreto SM, et al. Health in Brazil 4.
Chronic non-communicable diseases in Brazil: burden and
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4. WHO Framework Convention on Tobacco Control
[Internet]. Geneva: World Health Organization; 2005
[cited 2011 Jul 16]. Available from: http://whqlibdoc.
who.int/publications/2003/9241591013.pdf
5. History of the WHO Framework Convention
on Tobacco Control [Internet]. Geneva: World
Health Organization; c2009 [cited 2011 Jul 16].
Available from: http://whqlibdoc.who.int/
publications/2009/9789241563925_eng.pdf
6. World Health Organization. WHO report on the global
tobacco epidemic, 2011: warning about the dangers of
tobacco. Geneva: WHO; c2011.
7. Quando falta informação, sobra dúvida para o
consumidor [Informe publicitário]. O Globo. 31 maio
2011: Caderno O País:5.
8. International Tobacco Growers’ Association. Brazil
(AFUBRA). Tobacco Courier. 2011 Mar; (49):21-2.
[cited 2011 Jul 18]. Available from: http://xa.yimg.com/
kq/groups/2165858/979909210/name/itga_tobacco_
courier_march_2011_SMALL%2Epdf
9. Carvalho MC. Servidora da União é acusada de espionar
para a Souza Cruz. Folha de São Paulo. 14 jul 2011:
Cotidiano:C6.
10. Bialous SA, Presman S, Gigliotti A, Muggli M, Hurt R.
A resposta da indústria do tabaco à criação de espaços
livres de fumo no Brasil. Rev Panam Salud Públ. / Pan
Am J Public Health. 2010;27(4):283-90.
11. Issa JS, Abe TM, Pereira AC, Megid MC, Shimabukuro
CE, Valentin LS, et al. The effect of Sao Paulo's smokefree
legislation on carbon monoxide concentration in
hospitality venues and their workers. Tob Control. 2011
Mar;20(2):156-62.
12. Instituto Brasileiro de Geografia e Estatística (Brasil).
Diretoria de Pesquisas. Coordenação de Trabalho
e Rendimento. Pesquisa Nacional por Amostra de
Domicílios: tabagismo 2008 [Internet]. Rio de Janeiro:
IBGE; 2009 [citado 2011 jul 16]. Disponível em:
http://www.inca.gov.br/inca/Arquivos/publicacoes/
tabagismo.pdf
Brazilian Journal of Cancerology 2011; 57(3): 395-399
399

Literature Review
FCTC, Workers’ Right to Health and Protection
Article received on 4/11/11; accepted for publication on 06/30/11
Article 8 of the World Health Organization Framework
Convention on Tobacco Control from the Perspective of the
Right to Health and Workers’ Protection
O Artigo 8o da Convenção-Quadro para o Controle do Tabaco da Organização
Mundial da Saúde sob a Perspectiva do Direito à Saúde e Proteção do Trabalhador
El Artículo 8o del Convenio Marco de la Organización Mundial de la Salud para
el Control del Tabaco bajo la Perspectiva del Derecho a la Salud y Protección al
Trabajador
cristiane galhardo ferreira vianna 1 , maria helena barros de oliveira 2 , felipe Lacerda mendes 3 , Tania maria cavalcante 4
Abstract
Introduction: This article addresses the Who framework Convention on tobacco Control and details article 8 of
the international treaty that provides protection from exposure to tobacco smoke and requires that states Parties shall
adopt executive, administrative, legislative and other measures to protect their populations from the risks of second-hand
tobacco smoke. Objective: to explore some of the challenges related to the implementation of smoke free environments
in Brazil and to discuss the perspective of achieving this right. Method: a study based on documents researched in
the Brazilian Congress, in the scielo library databank, in academic documents and in the media. Results: from
the analysis of the selected material on Brazilian tobacco control legislation, projects of law and lawsuits, some of the
challenges related to the implementation of smoke free environments in Brazil under the framework of the Brazilian
legal system from the perspective of the occupational health and Protection right are explored. Conclusion: as Brazil
has ratified the treaty, it is mandatory that smoke free environments be implemented, since an adequate framework
of legal instruments sets up the ideal scenario to welcome an effective protection of Brazilian population`s health to
the harms caused by second-hand tobacco smoke.
Key words: smoking/legislation & jurisprudence; tobacco smoke Pollution; smoking areas
¹lawyer and a Master in Public health from the oswaldo Cruz foundation. Deputy secretary of the executive secretariat of national Commission
for implementation of the framework Convention on tobacco Control (fCtC) from the Brazilian national Cancer institute (inCa). rio de
Janeiro (rJ), Brazil. Email: cfvianna@inca.gov.br.
² lawyer. PhD in Public health from the oswaldo Cruz foundation. researcher of the oswaldo Cruz foundation and Coordinator of the human
rights and health Group helena Besserman (Di hs), national school of Public health sergio arouca of fioCruz. rio de Janeiro (rJ), Brazil.
Email: mhelen@ensp.fiocruz.br.
³lawyer. expert in Civil responsibility and Consumer law from the universidade Candido Mendes (M uCa). executive secretary national
Commission for the implementation of fCtC inCa. rio de Janeiro (rJ), Brazil. Email: fmendes@inca.gov.br.
4 Doctor. Master in Public health from the oswaldo Cruz foundation. executive secretariat of the national Commission for implementation of
the fCtC/inCa. rio de Janeiro (rJ), Brazil. Email: taniac@inca.gov.br.
Correspondence Address: fCtC / inCa. rua resende, 128-302. Centro. rio de Janeiro (rJ), Brazil. CeP: 20231-092.
Brazilian Journal of Cancerology 2011; 57(3): 401-410
401

Vianna CGF, Oliveira MHB, Mendes FL, Cavalcante TM
402
INTRODUCTION
tobacco smoking is recognized as a Public health
problem worldwide. Thousands of studies demonstrate
that the use of tobacco is a causal factor of almost 50
different diseases, especially cardiovascular diseases, cancer
and chronic obstructive respiratory diseases 1 . according to
the World health organization (Who), smoking is the
leading cause of avoidable death in the world 2 .
at national level, the main policy adopted regarding
this subject by the national Program for tobacco Control,
developed by the Brazilian national institute of Cancer
(inCa) as from 1989 3 , and at international level, the
first international treaty of Public health was negotiated
under the auspices of Who – the framework Convention
on tobacco Control (fCtC). The idea of having an
international instrument for tobacco control arose with
the resolution of the World health assembly nº 48.11
in 1995, and has become a fact eight years later with the
adoption, unanimously, of the Wha resolution nº 56.1
during the 56 th Wha 4 . The treaty entered in force in
february 2003 after its 40 th ratification, becoming history
as one of the united nations treaties that could faster get
adhesions, entered into force and is being implemented.
The fCtC has legally binding character and do not
predict reserves, which means that states are obliged to
act in accordance with the provisions of the treaty, and
there may be legal consequences if not complied with and
it is not possible to modify in any way the obligations
assumed by them under the treaty. it articulates a set
of intersectorial actions based on scientific evidence to
respond to the globalization of tobacco epidemic and to
reaffirm the right of all people to the highest standards
of health, which is clearly assumed in the first paragraph
of its preamble: "The Parties to this Convention (are)
determined to give priority to protect the rights of Public
health [...]" 4 .
also in the preamble 4 , regarding secondhand smoking,
paragraphs 6 and 7 are highlighted:
recognizing that science has unequivocally shown
that the use and exposure to tobacco smoke are
causes of mortality, morbidity and disability and
that diseases related to tobacco do not appear
immediately after initiation of tobacco smoke
exposure and use of any tobacco-derived product;
recognizing, even further, that cigarettes and other
tobacco products are prepared in a sophisticated
manner to create and maintain dependence, and
that many of their compounds and the smoke
they produce are pharmacologically active, toxic,
mutagenic, and carcinogenic, and that tobacco
dependence is separately classified as a disease by the
main international diseases classifications systems.
Brazilian Journal of Cancerology 2011; 57(3): 401-410
athe fCtC expresses concern about the unfair
practices from the tobacco industry, in the sense of
"undermining or misrepresenting the activities of tobacco
control", and adds, among their general obligations (article
5.3), as follows:
By establishing and implementing their policies
for Public health on tobacco control, Parties shall
act to protect these policies from commercial or
other secured interests for the tobacco industry, in
accordance with the national legistation 4 .
Brazil became the 100 th Country to ratify the treaty,
with the promulgation of Decree # 5,658, of January
2 2006 5 , and is forced thereby to comply with the
obligations established by the treaty, many of which were
already been implemented in Brazil since their adoption
in 2003, since national and comprehensive actions for
tobacco control were already being articulated by the
government since 1989. however, a juridical and political
clash with direct repercussions on health has been taking
shape in the country regarding to the compliance of
article 8 from fCtC, which provides for the protection
from exposure to tobacco smoke, determining that the
countries that are states Parties adopt administrative and
legislative measures to protect their population from the
risks of secondhand smoking.
in July 2007, the Conference of the Parties (CoP),
a fCtC body formed by the states Parties to the
treaty, approved, at its second session, guidelines6 that,
despite not binding, aim to guide countries for the
implementation of article 8. such proposal recommends
banning smoking in closed environments as the only
way to protect the population of secondhand smoking
risks. The principles established in the guidelines are the
following:
Principle 1 - effective measures to promote protection
against exposure to environmental tobacco smoke (ets)
require the total elimination of smoking in certain places
in order to achieve a 100% tobacco free environment;
there are no safe levels of exposure to tobacco smoke;
different initiatives for total tobacco smoke elimination,
such as ventilation systems, air filtration and the use of
exclusive smoking areas (whether or not separated by
ventilation systems), have repeatedly shown its inefficiency
and there is conclusive evidence that no engineering
instrument can protect people against ets exposure and
therefore must be rejected.
Principle 2 - all people shall be protected against exposure
to tobacco smoke. all closed environments, wheter or not
for work, must be tobacco free.
Principle 3 - a legislation that protects people's exposure
to ets is necessary. Voluntary policies for smoke-free
environments have repeatedly shown their inefficiency

and that do not provide proper protection. to be effective,
legislation must be simple, clear and enforceable.
Principle 4 - Good planning and adequate resources are
essential for the successful implementation and oversight
of the legislation on smoke-free environments.
Principle 5 - Civil society has a central role to support
and ensure compliance to measures of tobacco free
environments and must be included as an active partner
in the process development, implementation and
enforcement of such legislation.
Principle 6 - The implementation of the smoke-free
environment legislation, its enforcement and impact
must be monitored and evaluated. This must include
monitoring and responding to the tobacco industry
activities to undermine the implementation and legislation
compliance, as specified in article 20.4 of the fCtC.
Principle 7 - Protecting people from exposure to tobacco
smoke must be strengthened and, if necessary, expanded.
these actions must include new or amended laws,
adjustments and improvements in order to fulfill them
and other measures that reflect new scientific evidence
and case study experiences.
The text guidelines warn about the fact that the duty
to protect the population against ets risks originate from
human rights principles and fundamental freedoms. in
view of the dangers related to the breathing of tobacco
smoke, the respective protection duty is implied to
the right to life and right to health, as well as of a
healthy environment, as quoted in many international
legal instruments *(Who Constitution, Convention
on the Childrens rights, elimination of all forms
of Discrimination against Women Convention and
international Covenant on economic, social and Cultural
rights) and formally embedded in fCtC preamble
and envisaged in the federal Constitution from many
countries, including ours, as seen articles 196 and 225
from our federal Constitution (fC).
This study aims to explore some of the challenges
related to the implementation of tobacco smoke-free
environments in Brazil, and finally, discuss the prospects
of achieving the right in question.
METHOD
regarding the methodology, this study is a qualitative,
based on archival and historical research. The present
study examined, in 2010, documental sources related
to the fCtC in Brazil, to the existing federal and state
legislations about the subject, law Projects (lP) related
FCTC, Workers’ Right to Health and Protection
to smoking bans in collective places and workers’ health
protection and Direct unconstitutionality actions (aDin)
in the period between 2006 and 2010. The documents
were available in websites from the Presidency of the
republic http://www.presidencia.gov.br, the senate in
http://www.senado.gov.br and the supreme Court (stf)
at http://www.stf.jus.br. normative instruments were
selected containing the following keywords: "Convenção-
Quadro para o Controle do tabaco, proibição de fumar
em ambientes fechados e proteção à saúde do trabalhador”
[framework Convention on tobacco Control, smoking
indoors bans and protecting the workers’ health].
The review was expanded by virtual search using
the same key words reported, from scielo database
(scientific electronic library online). The procedure was
also using snowball sampling to collect information on this
topic from monographs, thesis and dissertations available
at the inCa library documents published by experts in
law, technical documents and material for diffusion,
whether or edited, available on inCa/Ms webpages on
http://www.inca.gov.br, from nGo Government alliance
for tobacco Control on http://www.actbr.org.br, from
Who on http://www.who.int/tobacco, and CoP fCtC
on http://www.who.int/fCtC/n, as well as the national
media coverage.
The study uses the definitions of terms provided in
the guidelines 6 from article 8, such as: “environmental
tobacco smoke”- smoke emanated by a cigarette burning
or other tobacco product usually combined with the
smoke exhaled by the smoker"; tobacco smoke-free air -" is
the air that is 100% free of tobacco smoke. This definition
includes, but is not limited to the air in which tobacco
smoke may not be seen, smelled, felt or measured"; “closed
environment” – every place covered by a roof or enclosed
by one or more walls or sides, whatever material is used
for the ceiling, walls or sides, regardless of its permanent
or temporary structure.
RESULTS AND DISCUSSION
The enshrining of health as a human right and as a
fundamental right in the constitutions of several countries
occurred at a time in history when the so called state of
welfare was being defended.
in our country, the federal Constitution of 1988
inaugurated a new political and institutional moment
in Brazil when reaffirming a democratic state and
establishing a comprehensive social protection policy.
health was recognized as a citizenship social right, this
inscribing it in a list of integrated initiative actions set of
Public authorities and society, whose prime objectives are
* for further study on other international instruments in human rights, reading the following publication is recommended: exposicion al humo tobacco
ajeno en las americas: one derechos human perspective. Washington (DC): Paho, 2006.
Brazilian Journal of Cancerology 2011; 57(3): 401-410
403

Vianna CGF, Oliveira MHB, Mendes FL, Cavalcante TM
404
welfare and social justice. from the fC point of view, the
state is legally obliged to exert actions and health services,
aiming at the construction of the new social order 7 .
The right to health is related to the right to life, a
basic and fundamental right. in this understanding, as
a fundamental right, the right to health, including the
workers’ health, is subsumed in the concept of “human
dignity", a basic principle of the republic, provided for
in item 3, article 1 of the federal Constitution, because
it is not possible to talk about dignity if there is no any
guarantee for the minimal health conditions for the
individual. likewise, the protection of the right to health
is manifested in a caput from federal Constitution, article
5, which preconizes the inviolability of the right to life,
the most fundamental among the rights. irreconcilable,
likewise, to protect life, without acting similarly with
health8 and work.
in addition, article 196 of the Constitution provides
that "health is a universal right and obligation of the
state, guaranteed by social and economic policies aiming
at a reduction of disease risks and other ailments, and
universal egalitarian access to actions and services for its
promotion, protection and recovery", and article 225
says that a ecologically and balanced environment is a
right of all people, imposing to the Public authorities
and the community the duty to defend it and preserve it
for present and future generations.
By integrating the multilateral process that resulted
in the adoption of fCtC from Who, Brazil reaffirmed
its commitment with the Brazilian Public health and
at international level, with sustainable development
and social justice. recognition that tobacco control
has become a state Program was the creation of the
interministerial Commission for implementation of
the framework for tobacco Control (ConiCQ), by a
decree on august 1st 2003, in order to define strategies
to internalize the guidelines contained in the international
treaty. The main objective of fCtC is human welfare as
provided in its article 3:
protect present and future generations of devastating
health, social, environmental and economic
consequences generated by the use and exposure to
tobacco smoke, providing reference for measures on
tobacco control, to be implemented by the Parties
at national, regional and international levels in
order to continuously and substantially reduce the
use prevalence of tobacco use and tobacco smoke
exposure 4 .
ArTicLe 8 from fcTc: effecTive proTecTion AgAinsT
seconDhAnD smoking
secondhand smoking causes severe and fatal diseases
in adults, such as lung cancer, cardiovascular diseases
and acute and chronic respiratory diseases; in children,
Brazilian Journal of Cancerology 2011; 57(3): 401-410
it causes sudden death syndrome, and and in newborns,
low birthweight.
it is estimated that secondhand smoking causes
more than 600,000 premature deaths per year in the
world 9 . The number of deaths of non-smokers due to
secondhand smoking is alarming. in Brazil, according to
a study performed by inCa in partnership with the rio
de Janeiro federal university (ufrJ), every day, at least
seven Brazilians die from diseases caused by exposure
to second hand smoke. The study showed that at least
2,655 non-smokers die each year in Brazil due to diseases
attributable to secondhand smoking 10 .
however, the cost of ets exposure is not limited by
the impact on illness and life expectation. ets exposure
also imposes economic costs to people, businesses and
society in general. These sums do not include only medical
direct and indirect costs, but also productivity losses.
a study conducted by the Post-Graduation Program
in engineering from ufrJ showed that secondhand
smoking costs to government coffers at least 37 million
dollars every year. The Brazilian unified health system
(sus) spends r$ 19.15 million per year for diagnosis and
treatment of diseases caused by secondhand smoking and
the national institute of social security (inss) pays,
per year, more than r$ 18 million to due pensions and
benefits related to secondhand smoking 11 .
the international agency for research on CanceriarC
concluded that tobacco smoke that pollutes indoor
environments is genotoxic and carcinogen for humans, and
that non-smokers exposed to it inhale the same toxic active
elements inhaled by active smokers 12 . When breathing
ets, people are exposed to over four thousand chemical
substances 13 . in virtue of this and many other scientific
evidences attesting the harm caused by secondhand smoking,
the framework Convention, in article 8, provided for
protection against tobacco smoke exposure, and requires
that countries which are states Parties on the treaty adopt
administrative and legislative measures to protect their
populations from the risks of secondhand smoking 4 .
according to the publication Evaluating the Effectiveness
of Smoke-free Policies, also published by iarC in 2009, the
global situation regarding the promulgation of laws that
protect people against secondhand smoking started to
change after the approval of the fCtC in 2003 and was
leveraged after the approval of guidelines for the application
of article 8 in 2007. in alphabetical order, according to the
referenced publication, they highlight the countries that
have enacted laws that completely bans indoor smoking:
Bhutan, Botswana, estonia, france, Guinea, iran, ireland,
italy, Malta, nigeria, norway, new zealand, sweden,
uganda, uruguay and the united Kingdom 14 .
however, the Who report on tobacco epidemic 9
points a huge challenge faced in this area: of the 100 largest
cities in the world, only 22 are completely free of ets.

AziLiAn LegisLATion DeALing AboUT This sUbJecT
in Brazil, this matter is addressed nationally by the
law 9294, of July 15 1996, which provides restrictions
to the use and advertising of tobacco products, alcoholic
beverages, medicines, pesticides, pursuant to § 4 of article
220 of the federal Constitution.
Despite the possible influence of the tobacco industry in
its formulation and approval, the federal law n° 9,294/96
was, at that time, an important advancement step on
tobacco control in Brazil, when among other providences,
banned the use of tobacco derived products in public
premises, whether private or public, except in areas
exclusively dedicated to this objective, duly insulated and
with proper aeration (article 2).
By analyzing the provisions from article 2 of the law,
it is noted that the definition of the terms "public venue",
"area solely intended for that purpose, duly insulated
and proper aeration” was essentially important to apply
that to a legal command. however, these definitionswere
not written in the law, and the promulgation of Decree
2018 on october 1 1996 was needed, which regulates
the federal law. in the way it was written, the Brazilian
legislation allowed the cigarette industry to develop, in
Brazil, as they had done in other countries, programs to
keep tobacco as socially acceptable and permissible in all
environments, encouraging coexistence between smokers
and non-smokers. Motivation from this industry showed
evidence that 100% ets-free areas would decrese cigarette
consumption and, consequently, industry profits.
The strategy from cigarette industry, implemented
worldwide, to make partnerships with bars, restaurants
and hotels is also well documented. an example of
this partnership is a program called Coexistence in
harmony, in partnership with the international hotel
and restaurant association, ihra, whose goal is to ensure
that public spaces are to be divided in areas for smokers
and non-smokers, instead of being 100% free of ets 15 .
The interpretation of the referred law enables the
statement that smoking is tolerated only in "areas solely
designed for that purpose, properly insulated with
proper aeration". But what happens in practice is that
these places are not exclusively to smoking. in most of
these places there is effective service rendering, such as
bars and restaurants, which exposes workers from these
environments to the toxic effects of tobacco smoke on a
daily basis. This interpretation of the law, favorable to the
tobacco industry, was well documented in the article by
Bialous et al.: the answer of the tobacco industry was the
creation of smoke-free spaces in Brazil/ They researched
internal documents of the tobacco companies, and one
of these documents about this matter says 15 :
a federal law adopted in the two instances of
national Congress will restrict smoking in public
FCTC, Workers’ Right to Health and Protection
places, including work environments, to isolated
and properly ventilated areas. it is likely that the
law will be signed by the President. as the terms
for specific restriction must be regulated within the
next 60 days, the industry is jointly working to try
to ensure a language allowing reasonable adaptation.
the domestic legislation on smoking in closed
environments is outdated regarding the best practices
recommended by the fCtC as it allows areas reserved for
smoking. scientific evidence 16 shows that the implementation
of policies for an environment 100% free of tobacco smoke
is the only effective solution to eliminate ets exposure in
workplaces, and that separating smokers and non-smokers,
cleaning the air and ventilation of buildings are not sufficient
to eliminate non-smokers exposure to ets.
a survey on smoking, conducted by the institute of
Brazilian Geographic and statistics in 2008 showed that
although this law has been in force since 1996, 27% of
the population above 15 years old is still exposed to ets,
especially in work environments 17 , which proves that the
federal law is not effective for the protection of people
against tobacco smoke exposure.
to perfect the law, the Ministry of health developed
an lP proposing an amendment to article 2 of law
9,294/96 to ban smoking completely from public or
private collective places. This ll has been, apparently,
at least for 2 years under analysis at the Civil office 18 .
however, other 2 lPs are pending in the senate, they are:
lP no 315/08, introduced by senator tiao Viana and lP
316/08 authored by senator romero Jucá. an analysis
of the texts of these lPs identifies the lP authored by
senator tiao Viana as the legislative initiative that meets
the fCtC requirements, while lP of senator romero
Juca allows fumódromos [places exclusively designed for
smoking] with services provided in these areas, so more
people, especially workers, will be exposed to second hand
smoke. however, even though the project laws – lPs were
submitted in 2008, although there has been no decision
regarding approval or rejection of these lPs in the senate
because of intense activity of legislative referral for analysis
in several Committees of the office, this delay is attributed
to the intense lobby from tobacco companies 19 .
With the gap left by current federal law, laws
creating indoor environments that are 100% smoke-free
were enacted in seven states, such as amazon, Paraiba,
Parana, rio de Janeiro, rondonia, roraima and sao
Paulo; and in municipalities such as salvador, Juiz de
fora, Goiania, Maringa, Curitiba, Cornelio Procopio,
Belem and tubarao.
state standards, legislating on the subject already
laid down by federal law, led to questions about their
constitutionality by segments representing the interests of
the tobacco industry at the supreme federal Court - stf.
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405

Vianna CGF, Oliveira MHB, Mendes FL, Cavalcante TM
406
ADin emerges before The sUpreme coUrT
in the supreme Court, three aDin ** are in progress
in virtue of the laws enacted in the states banning smoking
indoors. The first aDin, n° 4,249, was presented by the
national Confederation of tourism and requires the
unconstitutionality of sao Paulo state law n° 13,541/09.
the second aDin (nº 4306), from the national
Confederation of Goods trade, services and tourism,
is against the rio de Janeiro state law n° 5,517/2009.
finally, the aDin n° 4,351 questions the constitutionality
of Parana state law n° 16,239/2009, and was required in
conjunction by the other two aDin applicants.
it should be noted that all laws questioned are in
compliance with Who recommendations, effectively
protecting the health of the population as they do not
allow indoor smoking. The arguments of aDin applicants
are that there was interference against the federal
legislative competence to establish general standards about
consumption and protection to health, because there is a
federal law on the subject and that state laws are violating
it, since they do not allow the fumódromos.
the proceedings have not been tried yet, but
there's an opinion from General attorney office 20 in
favor of declaring the law’s constitutionality based on
the understanding that with the advent of fCtC, an
international treaty ratified by Brazil in 2006, due it is
later and upper hierarchy, in addition to discipline in a
different way the fight against tobacco smoke exposure,
the federal law n° 9,294/96 would have been revoked.
although the opinion does not take binding effect, it will
be considered at occasion of the actions’ trial.
Workers’ righT To heALTh
the international labour organization (ilo)
estimates that at least 200,000 workers die each year due
to exposure to environmental ets at work environments 21
and recognizes that tobacco smoke exposure in these
environments is a threat to health and safety at work
because it causes cancer and other serious diseases, besides
bringing risk of fires and explosions 22 .
in addition, in workplaces, secondhand smoking
is considered an occupational hazard. in bars and
restaurants, for example, waiters that are non smokers and
are exposed to ets are, on average, two times more likely
to develop lung cancer than those who are not exposed to
environmental tobacco smoke 19 .
** direct action of unconstitutionality (aDin), provided in article 102, i, “a” of the federal Constitution (fC) is an action that aims to declare that
a law or a federal or state normative act, or part of them is unconstitutional, that is, contradicts the fC. article 103 has extensive writing as to the
legitimation of aDin proposition and, if upheld, will be declared unconstitutional, which produces effects against all and excludes the law of the legal.
against the decision that declares a unconstitutionality, no appeal is allowed, except for declared embargoes.
Brazilian Journal of Cancerology 2011; 57(3): 401-410
for adriana Pereira de Carvalho 23 ,
in the case of exposure to tobacco smoke in the
workplace, banning indoor smoking is a preventive
measure of occupational character that must be
guaranteed to all workers by the contractor for their
services, by the state and society.
according Celso antonio Pacheco fiorillo 24 , among
the aspects that include the environment, the working
environment is found, and it is not restricted to employee
work relations, but a place where human labor is provided,
being protected by the Constitution, article 7, item 12,
article 200, item 8 and article 225, also recognize that
the most important aspect of the constitutional subject in
the juridical protection is related to health of the human
being in harmony with the already mentioned article 1,
3 of the Constitution.
Therefore, the promotion of environments 100%
free of tobacco smoke is in consonance with the right
guaranteed to an appropriate, healthy and wholesome
work environment, as predicted in article 225 of the
Constitution, and the right of all employees to the
reduction of risks inherent to the work, as provided in
article 7, item 12, recognizing that the possibility of
smoking in workplaces violates these articles.
in this sense, between the prospects of achieving
the right of workers to implement environments free of
tobacco smoke in Brazil, the Public Ministry action in
some localities in the country can be highlighted, in the
implementation of the current legislation in accordance
with the terms of the fCtC and the fC, while a federal
law that bans smoking in enclosed environments is not
approved.
as to the matter regarding work environment, it
continues to be governed by the Consolidation of labor
laws (Clt), which, in article 157, assigns company the
responsibility to comply with the standards and practice
safety and occupational medicine regulations, in addition
to instructing employees about the precautions to be
taken to avoid work accidents or occupational diseases.
The norm for safety and health at Work***, nr 09,
establishes that the design and and implementation, by
all employers and institutions which hire employees,
of a Program for Prevention of environmental risks

is mandatory, aiming at the preservation of health
and integrity of workers, by anticipation, recognition,
evaluation and subsequent control of occurrence of
existing or future environmental hazards at the working
environment, taking into account environment and
natural resources protection.
according to nr 09, physical, chemical and biological
agents existing in the workplace are considered environmental
risks, which due to their nature, concentration or intensity
and time of exposure, are capable of causing damage to the
workers’ health (nr 9.1.5).
in the international scenario of work environment
protection, Brazil joined the two international treaties
related to this subject of study. They are Conventions #
148 and# 155 from ilo. The following provisions are
highlighted:
article 4 of the Convention n o 148
1. national legislation shall provide adoption of
measures in the workplace to prevent and limit
occupational hazards due to air contamination,
noise and vibrations and to protect workers against
such risks (emphasis added).
article 4 of the Convention n o 155
1. each Member must, after consultation with the
most representative organizations of employers and
workers concerned, and taking into account the
national conditions and practice, formulate, put
into practice and periodically review a national
policy coherent as to occupational security and
health and work environment (emphasis added).
2. This policy will have the objective of preventing
accidents and damage to health that are consequence
of the work, related to the work activity or supervene
at work, minimizing, to the extent that is reasonably
practicable, the causes of hazards inherent to the
work environment (emphasis added).
it is noteworthy that this scope perfectly fits ets in the
workplace, considered to be carcinogenic and genotoxic to
man, and for which there are no safe levels of exposure or
ventilation system for indoor environments that are able
to eliminate exposure to and risks of secondhand smoking.
according Cavalcante 25 , secondhand smoke violates
the worker's fundamental right to full health, guaranteed
by the federal Constitution, and indemnification for
FCTC, Workers’ Right to Health and Protection
individual and collective moral damages (in a typical
lawsuit of the Public Ministry of labor) based on articles
186 and 927 caput and sole paragraph, both from the
Civil Code, combined with articles 8 and 769 of the
Clt is due, when companies allow their employees to
inhale tobacco smoke at work, exhaled by other workers
or clients, thus exposing the worker to a situation of severe
risk to health.
CONCLUSION
it can be concluded that science has unambiguously
already and unambiguously demonstrated the harms
caused by exposure to the toxic substances present in
tobacco smoke. This text has tried to show that there
is a legal framework of national and international legal
instruments that conforms a legal background prepared
to welcome an effective protection to the health of the
Brazilian population, including workers, as to the harms
caused by ets.
The current scenario where antagonistic law projects
are simultaneously underway in the senate on the matter,
which is object of this study, whose guidelines have
already been approved in Brazil, seems to show a drop
arm between the interests of the Public health and the
tobacco industry.This confront is similar to the barriers
that Brazil faced in the process for the treaty ratification.
in this scenario, the omission of our legislators to approve
a law that takes into account the provisions of the fCtC,
will keep causing serious consequences to peoples’ health.
The fC was a milestone for the Brazilian Public
health by recognizing the fundamental right to citizens
and a duty of the state, to be provided through social and
economic policies aiming at reducing the risk of diseases
or other health problems and by ensuring universal and
equally access to Public health actions and services.
regarding the matter of smoke-free environments, the
right to health for all, smokers and non-smokers, must
be preserved, whether they are regular visitors to indoor
places, or workers who render services there, as well as the
right to a healthy environment ets-free.
anyway, it is important to remember that the
international obligations assumed by Brazil impose, to
all public authorities in the country, whether executive,
*** The regulating norms, also called nr, were published by the Ministry of Work and eMployment, through ordinance # 3214/78, to establish the
technical and legal requisites regarding the minimum occupational health and safety aspects. They are mandatory for any company or institution who
hires workers under Clt, including private and public enterprises, government bodies, wether under direct or indirect administration, as well as bodies
from legislative and Judicial Powers.
Brazilian Journal of Cancerology 2011; 57(3): 401-410
407

Vianna CGF, Oliveira MHB, Mendes FL, Cavalcante TM
408
legislative or judicial, the duty to promote the effective
internalization of the fCtC in our country.
CONTRIBUTIONS
Cristiane G. f. Vianna and Maria helena B. olveira
worked on the conception, participated in the survey, data
analysis and design of the final text of this article. other
authors have worked in design and review of the article.
Declaration of Conflicting Interests: Nothing to Declare
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health consequences of involuntary exposure to tobacco
smoke: a report of the surgeon general. Washington
(DC): Centers for Disease Control and Prevention; 2006.
17. Instituto Brasileiro de Geografia e Estatística (Brasil).
Diretoria de Pesquisas. Coordenação de Trabalho e
Rendimento. Pesquisa Nacional por Amostra de Domicílios:
tabagismo 2008 [Internet]. Rio de Janeiro: IBGE; 2009
[citado 2011 jul 15]. Disponível em: http://www.inca.gov.
br/inca/Arquivos/publicacoes/tabagismo.pdf
18. Duarte LC. Eu defendo o fumo em qualquer lugar, diz
Lula: Presidente afirma que decreto que proíbe fumo no
Planalto não vale em sua sala. Folha de São Paulo. 2008
set 4:C9.
19. Stycer M. O senador Tião Viana, porém, disse ao
Último Segundo que está pessimista. “O lobby
da indústria do tabaco é muito forte” [Internet].
IG: Último Segundo. 2009 maio. Disponível em:
http://ultimosegundo.ig.com.br/mauricio_
stycer/2009/05/21/anvisa+nao+vai+mais+regulam
entar+fumodromos+e+apoia+lei+que+proibe+o+fu
mo+6247930.html
20. Pereira DB. Parecer da Procuradoria-Geral da
República nº 21324/2010 [Ação Direta de
Inconstitucionalidade – ADI 4351] [Internet]. Disponível
em: http://redir.stf.jus.br/estfvisualizadorpub/jsp/
consultarprocessoeletronico/ConsultarProcessoEletronico.
jsf?seqobjetoincidente=3806258.
21. Takala J. Introductory report: decent work -
safe work [Internet]. Geneva: International

Labour Organization; 2005 [cited 2011 Jul 15].
Disponível em: http://www.ilo.org/public/libdoc/
ilo/2005/105B09_281_engl.pdf
22. Organização Internacional do Trabalho. Convenção n.º
139 sobre a prevenção e o controle de riscos profissionais
causados pelas substâncias ou agentes cancerígeros.
Genebra: OIT; 1974.
23. Carvalho AP. O direito fundamental a ambientes de
trabalho livres do fumo. In: Homsi CM. Controle do
FCTC, Workers’ Right to Health and Protection
tabaco e o ordenamento jurídico brasileiro. Rio de
Janeiro: Lumen Juris; 2011. p. 327-58.
24. Fiorillo CAP. Meio ambiente do trabalho em face do
direito ambiental brasileiro. [Internet]. [2010]. [citado
2011 jul 15]. Disponível em: http://www.nima.puc-rio.
br/aprodab/artigos/celso_antonio_pacheco_fiorillo.pdf
25. Cavalcante HC. Fumo passivo e indenização trabalhista.
XIV Congresso Nacional de Magistrados Trabalhistas;
2008; Manaus, Brasil.
Brazilian Journal of Cancerology 2011; 57(3): 401-410
409

Vianna CGF, Oliveira MHB, Mendes FL, Cavalcante TM
410
Resumo
Introdução: o artigo descreve em linhas gerais a Convenção-Quadro para o Controle do tabaco e trata de forma
mais detalhada o artigo 8 o do tratado internacional, que dispõe sobre a proteção da exposição à fumaça do tabaco,
determinando que os países que são estados Partes da Convenção-Quadro para o Controle do tabaco adotem
medidas executivas, administrativas, legislativas e outras, para proteção das suas populações dos riscos do tabagismo
passivo. Objetivo: explorar alguns dos desafios relacionados à implementação de ambientes livres da fumaça do
tabaco no Brasil e discutir as perspectivas de concretizar o direito em questão. Método: estudo baseado em pesquisa
documental nos arquivos do Congresso nacional, no banco de informações scielo, em documentos acadêmicos e
na mídia. Resultados: a partir da análise do material selecionado sobre a legislação brasileira relacionada ao tema, os
Projetos de leis relacionados ao assunto em trâmite e as ações judiciais, exploraram-se alguns dos desafios relacionados
à implementação de ambientes livres da fumaça do tabaco no Brasil com sua efetiva internalização no ordenamento
jurídico brasileiro sob a perspectiva do Direito à saúde e Proteção do trabalhador. Conclusão: Concluiu-se que,
como o Brasil ratificou o tratado, é mandatório implementação de ambientes 100% livres da fumaça do tabaco, já
que existe no ordenamento jurídico um arcabouço de instrumentos legais que conformam um cenário preparado para
recepcionar uma efetiva proteção à saúde da população brasileira com relação aos malefícios causados pela fumaça
ambiental do tabaco.
Palavras-chave: tabagismo/legislação & jurisprudência; Poluição por fumaça de tabaco; Áreas Destinadas ao tabagismo
Resumen
Introducción: ese artículo trata del Convenio Marco de la organización Mundial de la salud para el Control del
tabaco, con el punto de partida del análisis en la premisa establecida en el artículo 8 º del tratado internacional que
dispone sobre la protección en contra la exposición al humo del tabaco, y determina que los países que son estados Parte
adopten medidas ejecutivas, administrativas, legislativas y otras para la protección de sus poblaciones de los riesgos del
tabaquismo pasivo. Objetivo: explorar algunos de los desafíos relacionados a la implementación de ambientes libres
del humo del tabaco en Brasil y discutir las perspectivas de lograr el derecho en cuestión. Método: este estudio se basa
en la investigación de archivos en el Congreso nacional, en la base de datos scielo, en trabajos académicos y en los
medios de comunicación. Resultados: a partir del análisis del material seleccionado en la legislación brasileña sobre el
tema, proyectos de leyes y acciones judiciales se exploraron algunos de los desafíos relacionados a la implementación de
ambientes libres del humo del tabaco en Brasil y su efectiva incorporación en el ordenamiento jurídico brasileño bajo
la perspectiva del Derecho a la salud y Protección al trabajador. Conclusión: llega-se a la conclusión de que, como
el Brasil ha ratificado el tratado es obligatorio implementar ambientes 100% libre de humo de tabaco, ya que existe
un marco legal de instrumentos jurídicos que conforman un escenario preparado para acoger una efectiva protección
de la salud de la populación brasileña acerca de los daños causados por el humo de segunda mano.
Palabras clave: tabaquismo/legislación & jurisprudencia; Contaminación por humo de tabaco; Áreas Destinadas
a fumadores
Brazilian Journal of Cancerology 2011; 57(3): 401-410

Literature Review
Nursing Interventions on Tobacco Control
Article received on 3/23/11; accepted for publication on 6/17/11
Nursing Interventions on Tobacco Control: an Integrative
Review
Intervenções de Enfermagem no Controle do Tabagismo: uma Revisão Integrativa
Intervenciones de Enfermería en el Control del Tabaquismo: una Revisión
Integradora
marcione Aparecida de souza moura 1 , maria de fátima batalha de menezes 2 , renata Dória mariano 3 , vagnára ribeiro da silva 4 ,
Luana pinheiro de sousa 5
Abstract
Introduction: tobacco addiction is considered a serious public health problem and the nurse has got a very important
role in the design of strategies to control this disease. Objective: to identify nursing interventions related to tobacco
control. Method: it is an integrative review. articles and abstracts published between 2000 and 2010 were researched
in the lilaCs and MeDline databases, using the following keywords: enfermagem/tabagismo and tobacco/nursing;
and articles published in the Cinahl databases between 2008 and 2010, using the keywords: tobacco/nursing/
intervention. Result: following the strategies defined for the study, the search resulted in 1,394 publications. 55
publications were found in lilaCs, 1,231 in MeDline and 108 in Cinahl databases. of these productions, six
full papers were selected from the latin american and 119 from international databases, of which 16 were full articles
from Cinahl and 103 from MeDline. The first review found that 1,269 publications were not specifically related
to the research question or did not meet the proposed inclusion criteria, resulting in 125 productions that were finally
considered for the study. The findings suggest a number of interventions provided by nurses for various audiences and
that 39 of them were directed at smoking cessation. Conclusion: faced to the productions evaluated, it was found
that the nurse is a very important professional for tobacco addiction control and those interventions found show a
relationship with the recommendations from scientific literature.
Key words: smoking; nursing; intervention studies; smoking Cessat
1 nurse and resident in oncology nursing at the Brazilian national Cancer institute (inca). rio de Janeiro (rJ), Brazil. E-mail: marcionea@yahoo.com.br.
2 Coordinator of Continuing education of the nursing Division of the Cancer hospital i / inCa. supervisor of the area of teaching and nursing of inca. PhD
in nursing. rio de Janeiro (rJ), Brazil. E-mail: mfatbat@terra.com.br
3 nurse and resident in oncology nursing at the Brazilian national Cancer institute (inca). rio de Janeiro (rJ), Brazil. E-mail: renatamvet@hotmail.com.
4 nurse and resident in oncology nursing in inca. rio de Janeiro (rJ), Brazil. E-mail: vagnararibeiro@gmail.com
5 nurse and resident in oncology nursing in inca. rio de Janeiro (rJ), Brazil. e-mail: lua-pink@hotmail.com. Correspondence address: Marcione aparecida de
souza Moura. rua aymorés, 20 -apt. 301 – são sebastião – Viçosa (MG), Brasil. CeP: 365700-000.
Brazilian Journal of Cancerology 2011; 57(3): 411-419
411

Moura MAS, Menezes MFB, Mariano RD, Silva VR, Sousa LP
412
INTRODUCTION
The World health organization (Who) considers
smoking as the leading cause of preventable deaths in
the world 1 .
tobacco smoking is defined as a chronic disease with
multiple relapses 2 , and has an entry in the international
Classification of Diseases (iCD), due to the use of
psychoactive substances. according to the Who, it is
also considered a pediatric disease, since average smoking
initiation occurs around the age of 15 3 .
it is estimated that 3,000 children start smoking every
day 4 . Therefore, public health experts agree that efforts to
control tobacco use should be focused on youth 5 .
in the next 50 years, tobacco use may cause about
450 million deaths worldwide 6 . Who believes that if
this situation is not reversed, 10 years from now there
will be about 10 million annual deaths related to tobacco
consumption, and 70% of them will occur in poor
countries 3 .
it is believed that tobacco addiction is the cause
of more deaths and disabilities than all other drugs
combined 7 and that the annual mortality by tobacco is
greater than the combination of deaths related to drug
abuse, aiDs, suicide, homicide and vehicle accidents 4 .
Considering that the tobacco industry is influential
in most developing countries, fueling commerce and
advertising, health agencies recommend that advertising on
cigarette packages be inserted, warning about the danger
to the health of both smoker and nonsmoker population 8 .
This fact is part of a list of measures to prevent smoking
in Brazil, whose impact reveals that there was a significant
decline in its prevalence in our country between 1989 and
2006. about two decades ago, the government launched
the national Program for tobacco Control (Programa
Nacional de Controle do Tabaco - PNCT), with a noticeable
improvement on efforts as of 1990, with a focus on nonprice
interventions such as the ban of advertising and
smoking restrictions in public places 9 .
in a survey released by the Ministry of health 3 , it
was found that about 80% of smokers want to quit
smoking, except that only 3% succeed each year. Quitting
smoking is a very complex process, therefore the action
of specialized professionals, effective techniques for
treatment, and resources to assess individual needs, the
degree of nicotine dependence and readiness to quit
smoking are necessary 10 .
it is estimated that worldwide there are about 17.3
million nurses, making them the largest group of health
professionals. accordingly, this group represents an
important link to the development of actions for tobacco
control 11 .
according to PnCt, it is up to nurses: to participate
in the development of technical materials; to train
Brazilian Journal of Cancerology 2011; 57(3): 411-419
professionals; set goals; to train teams in health units,
workplaces and schools; to encourage and monitor
the process of smoking cessation by smokers; to adopt
educational, regulatory and organizational measures; to
implement preventive actions to secondhand smoke; to
perform nursing consults focusing on cognitive behavioral
approach and evaluation of the level of dependence on
tobacco 12 .
it is noteworthy that in the list of nursing diagnoses,
according to the taxonomy of the north american
nursing Diagnosis association (nanDa), there are
reports of a diagnosis related to the motivation for
smoking cessation, namely: health seeking behavior related
to smoking cessation 13 .
This diagnosis indicates a nursing intervention named
assistance to quit smoking, which in turn points to a
series of 33 related activities, as stated by the nursing
interventions Classification (niC), among the most
important: recording the current status of cigarette use
and history of the smoker; determining willingness of
patients to stop smoking; providing smokers with clear
and consistent advice; helping patients to identify reasons
to quit and barriers to smoking cessation; guiding the
patient on the physical symptoms of nicotine withdrawal
and reassure them about their transience; providing
information to patients about nicotine replacement
products; helping patients to recognize situations that lead
to smoking; encouraging them to participate in support
groups or individual therapy; maintaining frequent
contact by phone, always congratulating them on the
progress and offering help in difficulties and relapses 14 .
Given the above and considering nurses as health care
professionals in tobacco control activities worldwide, this
article aims to identify nursing interventions related to
tobacco control. Guided by this scenario, identifying these
interventions becomes critical, considering the timely
contribution that nurses provide in the process of health
care, working in various fields and specialties.
METHOD
it is an integrative review study with predetermined
steps 15 . to initiate the search, the theme, objectives, key
words and research question related to the inclusion of
nursing in tobacco control were defined first. The research
question was: what are the nursing interventions for
tobacco control? This question is within the context of the
creation of programs for tobacco control and emphasis on
efforts in the fields of health and legislation of countries
for the regulation of advertising and marketing of tobacco
products.
the searches were conducted in January 2011,
in the latin american and Caribbean literature of
health sciences (lilaCs), electronic index Medicus

of the national library of Medicine (MeDline) and
Cumulative index to nursing and allied health literature
(Cinahl) databases, by using the following keywords:
"tabaco / enfermagem" and tobacco and nursing. on the
latter database mentioned, the following descriptors:
tobacco / nursing / intervention were used to better
operationalize the study.
We used the following inclusion criteria: articles in
Portuguese, english and spanish, available for free in
these databases, abstracts and articles published during
the period between 2000 and 2010, in both lilaCs and
MeDline databases, and during the period from 2008
to 2010 at the Cinahl database, that mentioned, in the
abstract, reference to interventions / activities performed
by nurses related to tobacco control.
it is noteworthy that Cinahl database searches were
conducted between 2008 and 2010 considering that a
systematic review involving the subject in matter was
found, which had already analyzed existing publications
during the period from 1983 to 2007. The publications
mentioned in this review for the period between 2000 and
2007 were found and considered as part of the mentioned
systematic review.
exclusion criteria were theses and dissertations as well
as articles that did not address or report interventions /
activities performed by nurses related to tobacco control.
studies whose abstracts were unavailable and did not
discuss this subject were also excluded.
The searches were conducted by the authors of this
article and, for the pre-selection of the articles found, an
analysis of all abstracts available for categorization of the
studies was performed.
subsequently, we created three spreadsheets in excel
in order to organize the articles obtained in each base, and
duplicate publications were eliminated in one of them,
and the one that displayed the full text was preserved.
after pre-selection of articles by the initial reading of
abstracts, a second analysis was performed through the
perusal of pre-selected publications to decide the inclusion
and exclusion of these texts according to the established
criteria. in this stage, the work was performed by two pairs
of independent reviewers.
We used a specific tool for evaluating the articles
to be included, which consists of article title, author,
country, year, journal name, objectives, methodology,
interventions, target audience and stages related to the
smoker’s approach.
for the preparation of the results, the following steps
were performed: identification of articles that answered
the research question, number of articles related to the
topic by year of publication, type of methodology adopted
and the initiation and cessation interventions described in
the study. Quantitative analysis consists of determination
of frequency and percentage of items selected according
Nursing Interventions on Tobacco Control
to the databases, year of publication, area of specialty of
periodicals, countries of publication of periodicals and
implementation stages of interventions by nurses.
it is noteworthy that, despite recognizing the relevance
of nanDa and niC taxonomies for the systematization
of nursing care, we did not aim to correlate these activities
with those found in the publications.
RESULTS
following the strategies defined, the search resulted
in 1,394 publications. We found 55 publications in
lilaCs, 1,231 in MeDline and 108 in Cinahl.
of these productions, six full papers were selected in
the latin american database and 119 in international
databases, 16 full papers in Cinahl and103 productions
in MeDline, as shown in table 1.
The first review found that 1,269 publications were
not specifically related to the research question, or did
not meet the proposed inclusion criteria, leaving 125
productions that were finally considered for the study.
in table 2, we show the distribution of production,
according to year of publication in these bases, with
emphasis on 2006, 2008 and 2009, equivalent to 41.6%
(n = 52), and lower number of productions in 2001 and
2002, with only 8.8% (n = 11) studies, and the rest of the
production accounting for 49.4% (n = 62) were published
in other years.
of the selected publications, it was observed that
86.4% (n = 108) were published in journals that include
the field of nursing and the remaining 13.6% (n = 17)
were published in general health journals.
it was observed that there was a significant number
(n = 58) of review productions, including examples of all
classifications, while the others (n = 67) presented several
methods, describing an intervention provided by nurses
in various areas. of these, 14 were reports of experience,
13 were descriptive studies, 11 were randomized clinical
trials, 10 were epidemiological studies, seven were
qualitative studies, five were surveys, five were quasiexperimental
studies and two were experimental studies.
There was a range of interventions provided by nurses,
most notably those related to smoking cessation stage,
comprising 67.2% (n = 39) of studies. interventions related
to the phase of smoking initiation were documented in
19% (n = 11) of publications and only 13.8% (n = 8)
studies carried out maintenance work.
it should be noted that the studies classified
as maintenance were those who described some
intervention, but were not targeted directly to the
smoker, for example, studies that focused on: description
of smoking behavior, beliefs and practices of education,
nurses’ standpoint about the attitude of smoking; analysis
techniques employed in tobacco control; evaluation of
Brazilian Journal of Cancerology 2011; 57(3): 411-419
413

Moura MAS, Menezes MFB, Mariano RD, Silva VR, Sousa LP
414
Table 1. Quantitative analysis of the publications assessed and selected according to the databases
Publications Evaluated Publications Selected Publications
Database
N N% N N%
LILACS 2000-2010 55 4.0 6 4.8
MEDLINE 2000-2010 1231 88.3 103 82.4
CINAHL 2008-2010 108 7,7 16 12.8
Total 1394 100 125 100
Source: lilaCs and Medline from 2000 to 2010 and Cinahl from 2008 to 2010.
Table 2. Quantitative analysis of the publications assessed and selected according to the databases and publishing year
Year
Database
self-reflection of nurses and students, analysis of incidence
/ prevalence.
it was decided to deepen the analysis of publications
involving stages of smoking initiation and cessation, as
this is the main focus of the study. With respect to the
countries where these interventions took place, the sample
showed that 48% (n = 24) occurred in the u.s., only 4%
(n = 2) were performed in Brazil and the remaining 48%
(n = 24) occurred in various nations, totaling 15 countries.
a significant number of interventions were directed
to the population of smokers in various scenarios, such
as universities, schools and hospitals with a focus on
discussion or proposition of actions for tobacco control,
as well as analysis of their impact, or even the perception
of this, by health care professionals and / or academics.
as outlined in table 3, the main interventions are
presented and the most updated reference are quoted
in each topic listed, targeted for smoking initiation
/ cessation, according to the target population, and
having nurses as the primary professionals involved in
this process.
Brazilian Journal of Cancerology 2011; 57(3): 411-419
LILACS MEDLINE CINAHL Total
N N% N N% N N% N N%
2010 0 0 6 5,8 2 12.5 8 6.4
2009 1 16.7 5 4.9 9 56.3 15 12
2008 0 0 16 15.5 5 31.2 21 16.8
2007 1 16.7 7 6.8 - - 8 6.4
2006 1 16.7 15 14.6 - - 16 12.8
2005 0 0 11 10.7 - - 11 8.8
2004 2 33.2 10 9.7 - - 12 9.6
2003 1 16.7 10 9.7 - - 11 8.8
2002 0 0 5 4.9 - - 5 4
2001 0 0 6 5.8 - - 6 4.8
2000 0 0 12 11.6 - - 12 9.6
Total 6 100 103 100 16 100 125 100
Source: lilaCs and Medline from 2000 to 2010 and Cinahl from 2008 to 2010.
DISCUSSION
according to the results obtained in the three bases
selected, it appears that, in 2008, there was an increase
in the number of publications related to nursing
interventions for tobacco control, and a progressive
reduction in subsequent years could be noticed.
it is perceived that the most frequent nursing
interventions were those aimed at smoking cessation,
followed by actions related to smoking initiation. That
is worrisome considering that, to reduce the incidence
of smoking in the world, the best strategy would be to
prevent initiation, considering the growing participation
of adolescents in smoking and failure of cessation
programs targeted to this audience.
for interventions aimed at cessation, we observed
that only 6% (n = 3) mentioned the use of medication
associated with cognitive behavioral therapy. There is
evidence that pharmacologic therapy combined with
counseling and support is more effective and increases
success rates in the process of smoking cessation 16 .

Intervention
Number of
Publications
Phase of treatment
of smoking
Nursing Interventions on Tobacco Control
Table 3. Analysis of the publications that reported an intervention directed at the initiation and / or the phase of smoking cessation according to the target
audience
Audience
T, G, N, CI, PW /
Creation of a specific program 16 C, I
PPW, H
Griffiths M, Kidd SA, Pike S, Chan J.The tobacco addiction recovery program: initial outcome findings. Arch Psychiatr
Nurs. 2010 Aug; 24(4):239-46.
Counseling 8 C, I T, PW/PPW, H, N, CI
Butler KM Rayens MK, M Zhang, Maggio LG Riker C., et al. Tobacco dependence treatment education for
baccalaureate nursing students. J Nurs Educ. 2009 May;48(5):249-54.
Use of lectures 6 C, I T, N
Chan SS, So WK, Wong DC, Lam TH. Building an integrated model of tobacco control education in the nursing
Curriculum: findings of a student’s survey. J Nurs Educ. 2008 May 47 (5) :223-6.
Use of a questionnaire for evaluation and
4 C, I G, N
further action
Carlsson N, Johansson A, G Hermansson, Andersson, B. Gare Child health and attitudes in nurses' roles
reducing children´s tobacco smoke exposure. J Clin Nurs. 2010 Feb, 19 (3-4) :507-16.
Telephone interview 4 C, I PW /PPWP, H, G
McGowan A, Hamilton S, Barnett D, Nsofor M, Proudfoot J, et al. Breathe: the stop smoking service for
pregnant women in Glasgow. Midwifery. 2010 Jun, 26 (3): e1-e13.
Evaluation of efficacy 2 C. T, G
Pbert L Osganian SK Gorak D Druker S, G Reed, et al. A school nurse-delivered adolescent smoking cessation
intervention: a randomized controlled trial. Prev Med 2006 Oct; 43 (4):312 20.
Advice together with pharmacotherapy 2 C. G, N
Percival J, Milner D. Pharmacological management of smoking cessation. Br J Community Nurs. 2002 Apr; 7 (4)
:202-5.
Attendance at clinic 1 C. G
Wadland WC, Soffelmayr B, Ives K. Enhancing smoking cessation of low-income smokers in managed care.
JFam Pract. 2001 Feb; 50 (2) :138-44.
Multi-component treatment 1 C. G
Buchanan LM El-Banna M, White A Moses S Siedlik C., et al. An exploratory study of multicomponent
Intervention treatment for tobacco dependency. Nurs Scholarsh J 2004, 36 (4) :324-30.
Cognitive behavioral therapy 1 C. PW/PPW
J Groner, French G, K Ahijevych, Wewers ME. Process evaluation of a nurse-delivered smoking relapse
prevention program for new mothers. J Community Health Nurs. 2005, 22:157-67.
Using the literature combined with monitoring 1 C. H
Gies CE, Buchman D, Robinson J, Smolen D. Effect on inpatient nurse-directed smoking cessation program.
West J Nurs Res 2008 Feb, 30 (1) :6-19.
Interview followed by monitoring 1 C. H
Browning KK Ahijevych JL Jr Ross P Wewers WW. Implementing the Agency for Health Care Policy and
Research´s Smoking Cessation Guideline in a lung cancer surgery clinic. Oncol Nurs Forum 2000;27, 1248-54.
Creation of a monitoring program 1 C. H
Jonsdottir H, Jonsdottir R, Geirsdottir T, Sveinsdottir KS, Sigurdardottir T. Multicomponent individualized smoking
cessation intervention for patients with lung disease. J Adv Nurs. Dec 2004, 48 (6) :594-604.
Counseling together with pharmacotherapy and
1 C. G
following
Chan S, Lam TH. Protecting sick children from exposure to passive smoking through mothers’ action: a
randomized controlled trial of a nursing intervention. J Adv Nurs. 2006 Apr, 54 (4) :440-9.
Counseling followed by monitoring 1 C. G
SS Chan, TH Lam, Salili F, Leung GM DC Wong, et al. A randomized controlled trial of an individualized motivational
intervention on smoking cessation for parents of sick children: a pilot study . Appl Nurs Res 2005 Aug;18(3):178-81.
Caption: i = initiation, C = Cessation, t = teenager, G = general, n = nurse / nursing student, Ci = Chronically ill, PW / PPW = Pregnant women / postpartum
women, h = hospitalized Patient.
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Moura MAS, Menezes MFB, Mariano RD, Silva VR, Sousa LP
416
Currently, pharmacotherapy is used as a support and
serves to facilitate the cognitive behavioral approach, which
is the basis for smoking cessation. There are, at this time,
some medications of proven effectiveness, mainly nicotine
replacement medication, which is considered topnotch drugs 17 .
Community nurses are well positioned to intervene
with smokers, and currently nicotine replacement
products are in the recipe form of these professionals 16 .
regarding countries where these interventions
occurred, the u.s. is at a prominent position, accounting
for almost half of the sample of publications. in this
country, even with advances in educational campaigns
to control the disease in recent decades, there are more
than 45 million smokers and approximately 440,000
deaths per year.
Considering the demand of smokers in the u.s., it is
extremely important that nurses adopt the evidence-based
practice to aid in smoking cessation, thereby contributing
to the reduction of approximately 157 billion dollars in
health costs per year 18 .
in publications that focused on interventions
for tobacco control in hospital environments, it was
observed that 37.5% of these reported the maintenance
of monitoring actions after discharge with a continuing
professional approach to adults, adolescents, parents of
sick children, and patients of heart and lung diseases.
in the publications assessed, studies that performed
counseling alone or in combination with pharmacotherapy
with nicotine replacers, with or without contact after
discharge were found.
in a meta-analysis made by rigotti et al. 19 , the authors
found that counseling of patients for smoking cessation
done by nurses during the hospital stay, with maintenance
of contact for over a month after discharge increased the
chances of success by about 65% since a 6-12-month
follow-up after hospitalization is recommended. The
same authors point out that there is no evidence that
the counseling intervention, carried out only during
hospitalization, is effective in promoting smoking
cessation. Counseling intervention is effective when given
to all hospitalized smokers, being held in an intensive and
prolonged way.
Counseling and nicotine replacement therapy should
be provided to all hospitalized smokers who are motivated
to try to quit smoking 20 . for those who are not motivated,
this is a favorable time and an excellent opportunity for
nurses starting the approach.
With regard to interventions aimed at women, there is
the opportunity to approach smokers during the cervical
screening test performed by the nurse. Concerning the
interventions aimed at pregnant women, half of the studies
that targeted this audience advocated for the maintenance
of contact started during pregnancy until the postpartum
period, aiming to prevent relapse.
Brazilian Journal of Cancerology 2011; 57(3): 411-419
These interventions are characterized by counseling
alone, either by telephone or home visit, or the adoption
of a counseling approach associated with nicotine
repository drugs. This finding corroborates the u.s.
guidelines regarding the treatment of tobacco directed
to pregnant women, which recommends counseling for
smoking cessation associated with drugs, starting with
short duration nrt 20 .
in this sense, the findings suggest that nurses are aware
that smoking poses a threat to the health of the fetus and
neonate, in view of the various interventions targeted
to pregnant and postpartum women. This fact suggests
that the gestational and postpartum period seem to be
moments of extreme sensitivity to quit smoking.
another approach found in the publications was
related to interventions targeting smokers with some kind
of chronic disease, such as: chronic obstructive pulmonary
disease (CoPD), cardiovascular disease and cancers of the
lung and head / neck.
Considering that smoking is a well established risk
factor for cardiovascular disease 21 , it was found that nurses
in this specialty proved themselves to be concerned with
this situation, due to the number of actions related to
these clients. accordingly, the poor production of nurses
in oncology is extremely worrisome, given that smoking
is a risk factor for the development of several cancers.
among the studies that included adolescents in the
sample, we could notice that only a few of them were
aimed at preventing smoking initiation. That shows that
the approach to the subject should start from childhood.
several studies have shown that smoking initiation
occurs primarily between late childhood and young
adolescence 22 . furthermore, the majority of smokers
reports that they began smoking in adolescence when it
is not perceived as a health risk 23 .
nurses can contribute significantly in reducing the
incidence of smoking initiation among young people,
once they are considered as the main health professionals
involved in education 22 .
no intervention targeted at the elderly in an
environment outside the hospital could be noted
in this sample, which shows disagreement with the
recommendations, by which all smokers of any age should
be benefited from the interventions for smoking cessation.
it has been reported in the literature that these
interventions are offered to seniors at rates below the
ideal; however, it is stated that clinical nurses have a great
opportunity to promote smoking interventions for this
age group 24 .
Many publications have focused on targeted
interventions for nursing students and nurses with the
purpose of contributing to this professional training,
mentioning the need to approach the topic in the
curriculum structure.

Clearly, the approaches and the credibility of future
nurses and health professionals as agents for the treatment
of smoking and tobacco-related diseases can be influenced
by smoking 25 . This shows a need for greater awareness
of these future professionals in order to be primarily
responsible for controlling this epidemic.
it was found that the methodological option of
randomized studies targeted to nursing interventions for
tobacco control was poor. on this finding, it is suggested
that evaluative research in this area of nursing, from the
perspective of effectiveness be carry out, given that the
nurse is an active health care professional in the control
of tobacco-related diseases.
CONCLUSION
During the nursing practice in tobacco control,
intense motivation is needed to overcome the challenges
encountered during this process, especially for specialists
in oncology.
in this sense, an innovative action was the creation
of a site called "tobacco free nurses", sponsored by the
american nurses association, which aims to provide
instructional material to support the educational
initiatives by nurses having in mind the development of
interventions related to tobacco control.
We highlight the inclusion of smoking on the agenda
of discussions and projects of the international Society of
Nurses in Cancer Care (isnCC), promoting trainings and
updating for oncology nurses, focusing on interventions
directed at smoking cessation.
We were able to identify that, although nurses spend a
considerable time with patients / families, working directly
in the process of health education, we realized the need for
targeted interventions to prevent initiation of smoking,
with subsequent reduction in the incidence the disease.
this study provided an overview about nursing
interventions for tobacco control, but it had limitations
in terms of Cinahl database references, for reasons
explained above, without, however, having affected the
scope of results.
it was found that smoking is a promising area for
nurses’ activities at all levels of care. in Brazil, such insight
becomes crucial, since the country has a national program
to fight smoking with the possibility of training for these
professionals.
CONTRIBUTIONS
all authors contributed to all phases of the study
design, methodological design, data collection and
analysis, critical revision and final writing.
Declaration of Conflict of Interest: Nothing to Declare.
Nursing Interventions on Tobacco Control
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Nursing Interventions on Tobacco Control
Resumo
Introdução: o tabagismo é considerado um grave problema de saúde Pública e o enfermeiro é um profissional
importante no desenvolvimento de estratégias relacionadas ao controle dessa doença. Objetivo: identificar as
intervenções de enfermagem relacionadas ao controle do tabagismo. Método: trata-se de uma revisão integrativa.
realizou-se a busca de artigos e resumos publicados no período de 2000 a 2010, nas bases de dados lilaCs e
MeDline, por meio dos seguintes descritores: enfermagem/tabagismo, tobacco/nursing; e artigos publicados na
Cinahl, no período de 2008 a 2010, através dos descritores tobacco/nursing/intervention. Resultado: seguindo as
estratégias definidas para o estudo, a busca resultou em 1.394 publicações. foram encontradas 55 publicações no
lilaCs, 1.231 no MeDline e 108 na Cinahl. Dessas produções, foram selecionados seis artigos completos
na base latino-americana e 119 nas bases internacionais, sendo 16 artigos completos na Cinahl e 103 produções
no MeDline. a primeira análise verificou que 1.269 publicações não estavam relacionadas especificamente com
a questão norteadora, ou não atendiam aos critérios de inclusão propostos, restando; portanto, 125 produções que
foram definitivamente consideradas para esse estudo. os achados evidenciaram diversas intervenções prestadas por
enfermeiros para públicos variados, sendo que 39 delas foram direcionadas à cessação do fumar. Conclusão: Diante das
produções avaliadas, verificou-se que o enfermeiro é um profissional de extrema importância no controle do tabagismo
e as intervenções encontradas mostraram relação com o recomendado pela literatura científica.
Palavras-chave: tabagismo; enfermagem; estudos de intervenção; abandono do hábito de fumar
Resumen
Introducción: el tabaquismo es considerado un grave problema de salud pública y el enfermero es un profesional
importante en el desarrollo de estrategias relacionadas al control de esa dolencia. Objetivo: identificar las intervenciones
de enfermería relacionadas con el control del tabaquismo. Método: se trata de una revisión integradora. fue hecha la
búsqueda de artículos y resúmenes publicados en el período de 2000 a 2010, a partir de las bases de datos lilaCs y
MeDline por medio de los siguientes descriptores enfermería/tabaquismo y tobacco/nursing y artículos publicados
en la Cinahl en el período de 2008 a 2010, por medio de los descriptores tobacco/nursing/intervention. Resultados:
a partir de las estrategias definidas para el estudio, la búsqueda resultó en 1.394 las publicaciones. 55 publicaciones
se encuentran en lilaCs, 1.231 en MeDline y 108 en Cinahl. De las producciones, seis trabajos completos
se seleccionaron en la base de américa latina y 119 en las bases de datos internacionales, 16 artículos completos
en Cinahl y 103 producciones en MeDline. la primera análisis encontró que 1.269 publicaciones no estaban
relacionados específicamente a la pregunta de investigación o no cumplían los criterios de inclusión propuestos, dando
como resultado, 125 producciones que se consideraron finalmente para este estudio. los hallados evidenciaron diversas
intervenciones prestadas por enfermeros para públicos variados, siendo que 39 de ellas fueron encaminadas a cesación
del fumar. Conclusión: Delante de las producciones evaluadas, se verificó que el enfermero es un profesional de extrema
importancia en el control del tabaquismo y las intervenciones encontradas mostraron relación con el recomendado
por la literatura científica.
Palabras clave: tabaquismo; enfermería; estudios de intervención; Cese del tabaquismo
Brazilian Journal of Cancerology 2011; 57(3): 411-419
419

Literature Review
Polymorphisms, Nicotine and Lung Cancer
Article submitted on 02/15/11; accepted for publication on 06/27/11
Genetic Polymorphisms in the Nicotinic Receptors and Lung
Cancer: an Overview
Polimorfismos Genéticos nos Receptores Nicotínicos e Câncer de Pulmão: uma
Visão Geral
Polimorfismos Genéticos en los Receptores Nicotínicos y Cáncer de Pulmón: una
Visión General
Alessandra bernadete Trovó de marqui 1 , vera Lúcia bonfim 2 , mariangela Torreglosa ruiz 3
Abstract
Introduction: lung cancer is the most common malignant tumor. it was responsible for 20,485 deaths in 2008 in
Brazil and 90% of diagnosed cases are associated with tobacco consumption. nicotine is the primary component of
tobacco in cigarettes and variants in the genes that encode subunits of the nicotinic acetylcholine receptor participate
in both etiology and progression of lung cancer. Objective: to carry out a review about lung cancer and single
nucleotide polymorphisms in genes which encode subunits of the nicotinic acetylcholine receptors. Method: a review in
literature of articles published in the last five years, in english and in researches with human beings, through electronic
search at PubMed database. Results: The 15q25 region contains single nucleotide polymorphisms of the CHRNA5,
CHRNA3 and CHRNB4 genes and is associated with risk of lung cancer and nicotine addiction. There is a strong
association between single nucleotide polymorphisms 1192G>a and 645C>t from CHRNA5 and CHRNA3 genes
respectively, and lung cancer. other polymorphisms in 15q25 associated with this kind of cancer include: 24289a>G,
28757t>C, 14621a>C, 10611t>C and 5539C>G from the CHRNA5 gene27011C>t, 3393G>a, 30238C>t from
the CHRNA3 gene and 49711634C>G from the CHRNB4 gene. Conclusion: The studies published suggested that
in the investigation of single nucleotide polymorphisms, both ethnicity and functional effect of that variant should
be considered to the functioning and genic expression.
Key words: Polymorphism, single nucleotide; lung neoplasms; receptors, nicotinic; Chromosomes, human, Pair 15
1 PhD in Genetics from universidade estadual Paulista (unesP). adjunct Professor at the Department of Biological and natural sciences. universidade federal
do triângulo Mineiro.
2 PhD in functional and Molecular Biology from universidade estadual de Campinas (uniCaMP). adjunct Professor at the exact and natural sciences and
education institute. universidade federal do triângulo Mineiro.
3 PhD in health sciences from faculdade de Medicina de são José do rio Preto (faMerP). adjunct Professor at the exact and natural sciences and education
institute. universidade federal do triângulo Mineiro.
Corresponding address: Mariangela torreglosa ruiz. Department of Biological sciences. exact and natural sciences and education institute. universidade federal
do triângulo Mineiro. av. frei Paulino, 30 - Bairro abadia. uberaba (MG), Brazil. Ce P: 38025-180. Email: mariangela@cienciasbiologicas.uftm.edu.br.
Brazilian Journal of Cancerology 2011; 57(3): 421-428
421

Marqui ABT, Bonfim VL, Ruiz MT
422
INTRODUCTION
lung Cancer is the most common of all malignant
tumors, showing a 2% increase each year in its world
incidence. in Brazil, it was responsible for 20,485 deaths in
2008, and was the type the caused more deaths. for 2010,
about 27,630 new cases were estimated 1 .
this type of cancer is frequently mentioned as a
malignancy attributed only to environmental factors
and, in 90% of the cases diagnosed, it is associated to the
consumption of tobacco derivatives 2 .
approximately 4,000 chemical products have been
identified in cigarette smoke, more than 60 of which are
considered carcinogenic, according to analysis done by the
international agency for research on Cancer 3 . of these
compounds, nicotine is the primary component of tobacco,
being a weak base (pKa=8.0), as its absorption through
mucous membranes is ph dependent. studies demonstrated
that nicotine absorption through the oral mucosa is low while
absorption through the lungs is fast 4 . nicotine is metabolized
rapidly and extensively, mainly by the liver, within 1-2 hours,
especially by the CyP2a6 enzyme (and to a lesser extent
by CyP2B6 anD ByP2e1) to the formation of cotinine.
Cotinine is the non-active metabolite and has a long plasma
half-life, and it is widely used as a quantitative marker of
nicotine exposure and as a way of measuring smoking habits 4 .
in the central nervous system, nicotine influences
cholinergic transmission by acting on the nicotinic
acetylcholine receptors (naChr), opening cation channels
and causing neuronal excitation, mediating, thus, the
complex nicotine actions in tobacco users. it has also
been observed that chronic exposure to nicotine produces
behavioral and physiological changes, which include increase
in synaptic force, altered gene expression and upregulation
of naChr 5 . other studies have demonstrated that nicotine
can promote the proliferation of cancer cells, migration,
invasion and tumor angiogenesis, besides performing a key
role in apoptosis suppression in lung cancer cells, through
akt pathway activation 4,6-9 .
The nicotinic acetylcholine receptors (naChrs) present
nine a subunits (a1 to a7, a9 to a10) and four b subunits
(b1 to b4). The a3, a5 and a7 subunits are present in
bronchial epithelium; b4 in cells of the alveolar epithelium;
and a3, a5, a7, b2 and b4 in neuroendocrine lung cells and
cell lines from human small cell lung cancer. Genes for the
nicotine acetylcholine receptors coding for the a subunit are
denominated, according to the name in english, Cholinergic
receptor nicotinic and are subdivided into CHRNA1,
CHRNA2, CHRNA3, CHRNA4, CHRNA5, CHRNA6,
CHRNA7, CHRNA9, CHRNA10 and CHRNB1, CHRNB2,
CHRNB3 and CHRNB4 for b subunits 8 .
recently, three studies have been mapping lung cancer
susceptibility locus 15q25 containing CHRNA3, CHRNA5
and CHRNB4 genes 10-12 . nicotinic acetylcholine receptors
Brazilian Journal of Cancerology 2011; 57(3): 421-428
expressed in key regions of the brain perform an important
role in controlling the act of smoking. These receptors
are also expressed in lung epithelial cells, where they
execute signal transduction, binding to nicotine and or its
carcinogenic derivatives [ex.: 4-methtylnitrosamino)-1-(3pyridyl)-1-butanone,
nnK), resulting in cell proliferation
and neoplastic transformation. Thus, variations in these
receptors are strong candidates of risk factors for nicotine
addiction and lung cancer. Therefore, it seems plausible that
genetic variations such as: single nucleotide polymorphism
(snP) in the nicotinic acetylcholine receptors that affect
gene expression or protein function can be associated to the
act of smoking and the lung cancer risk related to smoking.
The present study had as its objective to perform a review
on lung cancer and snP in genes coding for subunits of the
nicotinic acetylcholine receptors.
METHODS
This work consists in a bibliographical review that used
the PubMed databank (http://www.ncbi.nlm.nih.gov/).
The key words used in the articles search were “nicotinic
receptor anD lung cancer”.
The time period for the search was 5 years (2005-
2010), related to the human species and in the english
language. also, relevant articles cited in the references of
the studies found in PubMed and which were within the
inclusion criteria for this work were analyzed: complete
original articles that approached information on lung
cancer, nicotine and polymorphisms in nicotinic receptors.
for those articles which were not available online, a copy
of the manuscript was requested to the author by email.
The excluded articles associated snPs in these genes
to other types of cancer, nicotine addiction, alcohol
addiction, other pulmonary conditions (emphysema,
chronic obstructive pulmonary disease (CoPD), were
either reviews or letters to the editor, or approached gene
expression, methylation and silencing.
RESULTS AND DISCUSSION
after bibliographical search, 57 articles were found
about the subject and, following the previously established
inclusion criteria, 25 were selected, 15 associating
polymorphism in the 15q25 chromosomal region to
lung cancer.
recent studies identified the 15q25 chromosomal
region as a susceptibility locus to lung cancer. this
region includes six genes, among them: PMsa4, ireB2,
loC123688, Chrna5, Chrna3 and ChrnB4,
the last three coding for nicotinic acetylcholine receptor
subunits 10-12 . Considering that nicotine is the main alkaloid
from tobacco and this is a risk factor for lung cancer,
polymorphisms in the genes of nicotinic acetylcholine

eceptors can be involved in lung tumorigenesis. This
observation has been inducing researchers to investigate
snP effects on genes CHRNA5, CHRNA3 and CHRNB4
in the pathogenesis of lung cancer. table 1 contains
the synthesis of articles that related snPs in the 15q25
chromosomal region to lung cancer and presents the
summarized findings of these works (table 1).
the gene that codes for α5 subunit (Chrna5)
contains the snP 1192G>a, characterized by a
Table 1. Summary of the articles that correlated SNP in the 15q25 chromosomal region to lung cancer
Gene
CHRNA5
CHRNA3
SNP identifier
(dbSNP)/ Nucleotide
change
16969968/1192g>A
1051730/645c>T
Polymorphisms, Nicotine and Lung Cancer
Sample size Study type/Main findings Reference
1,154 smokers of european origin
1,137 population based controls
711 patients with lung cancer
362 population based controls
CHRNA3 1051730/645c>T 13,945 smokers
4,302 non-smokers
655 patients with lung cancer
28,752 population based controls
CHRNA5
CHRNA3
16969968/1192g>A
1051730/645c>T
1,989 lung cancer cases
2,625 controls central europe
CHRNA5 16969968/1192g>A 2,284 individuals dependent on
alcohol and their families
CHRNA5 16969968/1192g>A 17,300 individuals
- 3,989 lung cancer cases
- 3.968 upper aerodigestive tract
cancer cases
- 9,434 population controls
CHRNA5 16969968/1192g>A pulmonary tissue from 68 patients
with lung cancer
CHRNA5 16969968/1192g>A
3 haplotypes (delTTc, insATc,
and insTgg)
Tumor tissues of 68 patients who
underwent lobotomy
CHRNA5 16969968/1192g>A 302 patients with lung
adenocarcinoma
CHRNA3 1051730/645c>T 467 patients with lung cancer
388 African-American controls
CHRNA3 1051730/645c>T 9,040 smokers with european
ancestors
CHRNA5
CHRNA3
16969968/1192g>A
1051730/645c>T
819 smokers from hawaii
99 patients from the Tobacco
reduction intervention study
program
137 smoker patients
substitution of the aminoacid aspartic acid/D (coded by
the G allele) to asparagine/n (coded by a, the risk allele)
in position 398 (D398n) of the Chrna5 protein. This
gene variant is localized in the central portion of the
second intracellular loop and although the function of
this loop and the biological consequences of this alteration
have not been completely understood yet, this aminoacid
is highly conserved among species, suggesting it might
have functional importance 10-12 . Bierut et al. 13 did some
case-control/increased risk for lung cancer /
or = 1.32; p< 1,10 -17 )
case-control/Association with the quantity of
cigarettes (5 x 10 -16 )
case-control/strong association with the disease
(p= 3.10 -9 and 5,10 -9 ) respectively for genes
CHRNA5 and CHRNA3
cohort/functional analysis of polymorphism –
variants do not differ in expression (p=0.007)
case-control/elevated risk for lung cancer
regardless of alcohol and cigarette (or= 1.30,
ci 95% 1.23–1.38, p= 10 -18 )
case-control/mrnA levels 2.5-fold lower in
individuals homozygous for the non-risk allele
(p = 8.04.10 -6 )
cohort/significance with transcript levels (units
for relative quantification = 1.82)
cohort/snp is rare in the Japanese population
and correlates with reduced survival (log rank
test p=0.0146)
case-control/Association of the variant to lung
cancer in individuals that never smoked (or =
1.81, ci 95% = 1.26 a 2.59, p = 0.00137)
case-control/Association to lung cancer (p =
1.4 × 10 -8 )
cohort/elevated risk for lung cancer (p =
0.003)
Amos et al., 2008 10
Thorgeirsson et al.,2008 11
hung et al., 2008 12
bierut et al., 2008 13
Lips et al., 2010 14
falvella et al., 2009 15
falvella et al., 2010 16
sasaki et al., 2010 17
Amos et al., 2010 19
Thorgeirsson et al., 2010 20
Le marchand et al., 2008 21
Brazilian Journal of Cancerology 2011; 57(3): 421-428
423

Marqui ABT, Bonfim VL, Ruiz MT
424
Table 1. Continuation
Gene
CHRNA5
CHRNA3
CHRNA5
CHRNA5
CHRNA3
CHRNA5
CHRNB4
CHRNA3
CHRNA5
CHRNA3
CHRNA3
SNP identifier
(dbSNP)/ Nucleotide
change
16969968/1192g>A
1051730/645c>T
16969968/1192g>A
684513/5539c>g
1051730/645 c>T
11637635/24289A>g
17408276/28757T>c
17486278/14621A>c
16969968/1192g>A
7178270/49711634c>g
578776/30238c>T
667282/10611T>c
12910984/27011c>T
6495309/3393g>A
functional studies of this polymorphism in smokers and
alcohol dependent and their family. evidences that this
aminoacid change is functionally relevant was supported
by the fact that, in vitro, the nicotinic receptor with the
aspartic acid variant (D398) showed a higher maximum
response to the nicotinic agonist when compared to the
nicotinic receptor with substitution of the aminoacid
asparagine (n398). another finding is that these two
variants do not differ in expression, indicating that such
variants of the α5 subunit alter the receptor function
without affecting its expression. lips et al. 14 also did
some detailed analysis of snP 1192G>a in 17,300
individuals (3,898 cases of lung cancer/lC; 3,968 cases
of upper aerodigestive tract cancer/uaDt – oral cavity,
oropharynx, hypopharynx, larynx and esophagus – all
types of cancer strongly associated with smoking and
9,434 population based controls). This polymorphism
was associated to elevated risk of lung cancer among
smokers, former smokers and non-smokers, that is, in
regardless of tobacco smoking, possibly through a direct
effect on the bronchial epithelium. a previous study using
cell lines showed that genes for the nicotinic receptor are
expressed in lung cancer lC cells and could perform a
role in lung carcinogenesis 7 . an association between snP
1192G>a of the gene CHRNA5 and uaDt cancer was
also demonstrated, but smaller when compared to lC.
Brazilian Journal of Cancerology 2011; 57(3): 421-428
Sample size Study type/Main findings Reference
1,250 cases of lung cancer (562
adenocarcinomas, 391 squamous
cell carcinomas, 297 small cell
carcinomas)
1,154 individuals with lung cancer
1,137 population based controls
547 individuals with kidney or
bladder cancer
448 african-american patients with
lung cancer
611 population controls
1,152 patients with lung cancer from
the chinese population
1,152 chinese population controls
cohort/haplotype associated to susceptibility to
lung cancer in a small subgroup of the
population of Japanese regardless of smoking
habit (or= 2.3, ci 95% = 1.5–3.7,
p= 0.00028)
case control/ Association of variants of the
region 15q25 with lung cancer (or= 1.31;
p =9.84x10 -6 )
case-control/snp rs17486278 in gene chrnA5 has
or = 1.28; ci 95% 1.07-1.54; p = 0.008 and
snp rs 7178270 g in gene CHRNB4 has or 0.78, ci
95%: 0.66-0.94; p =0.008 for the lung cancer risk.
The associations to lung cancer remain significant
after adjustment to cigarette packages consumed per
year. rs7178270 decreased the risk for lung cancer in
women but not in men; interaction of gender
(p = 0.009)
case-control/or = 1.52; ci 95% (1,35-1,71;
p = 2.0 x 10 -12 )
or= 1.44; ic 95% (1.28–1.63; p = 2.7 × 10 -9 )
or = 1.43; ic 95% (1.27–1.61; p = 2.6 × 10 -9 )
shiraishi et al., 2009 22
spitz et al., 2008 23
hansen et al., 2010 24
Wu et al., 2009 25
another interesting finding was the association of this
snP with early age for lC beginning; however, according
to the authors, this information needs to be confirmed
in additional studies. still as to CHRNA5 gene, a study
showed that levels of this transcript were elevated by
30-fold in lung adenocarcinoma when compared with
normal lung tissue in patients that were submitted to
pulmonary lobectomy 15 . These authors also showed that
the mrna levels corresponding to CHRNA5 were about
2.5-fold lower in individuals homozygous for the risk
allele (n398), compared to individuals homozygous to
the non-risk allele.
falvella et al. 16 identified six haplotypes of the
CHRNA5 gene, three of which are in the 5´ promoter
region and the others in the 3´utr. The association
between these polymorphisms and CHRNA5 expression
levels was evaluated by real time PCr. The three variants
of the promoter region were associated to statistically
significant differences in the expression of CHRNA5,
opposite to what happened to 3´utr variants. Thus, the
results point out to a critical role for polymorphisms in
the CHRNA5 promoter region in transcription regulation.
such polymorphisms can modify the binding sites for
transcription factors and can alter expression levels of
CHRNA5 and the risk for nicotine dependence, lung
cancer and CoPD. still, haplotypes of the promoter

egion (delttC, insatC and instGG) of the CHRNA5
gene were evaluated as to snP 1192G>a (asp398asn)
of Chrna5 exon 5. The variant instGG is associated
to the risk allele asn398 and associated with low mrna
levels in normal lung tissue and high risk to nicotine
dependence, lung cancer and CoPD. on the other hand,
the other two polymorphisms are associated with allele
asp398, elevated mrna levels and low risk to previously
mentioned conditions.
The sasaki et al. 17 study investigated the D398n
polymorphism of CHRNA5 among Japanese with lung
adenocarcinoma and detected that only nine cases
(2.98%) exhibited this genetic variant. however, patients
with this polymorphism presented a worse prognosis (five
out of nine patients had died, average survival time of 27.1
months), when compared with patients with the wild allele
(74 out of 293 had died, average survival time of 113.9
months). such results evidence that this snP is rare in the
Japanese population and correlates with reduced survival.
another variant associated with lung cancer is the snP
645C>t of the gene CHRNA3 also localized in 15q25 10-12 .
a previous study showed that variations in the nicotinic
acetylcholine receptor gene can increase the risk for lung
cancer through a mechanism in which a subunit from
CHRNA3 binds to nnK and, subsequently, encourages
nfkB to induce cell proliferation 18 . a recent study from
amos et al, in 467 patients with lung cancer and 388
population based controls, showed association of this
variant with lung cancer only in individuals that never
smoked 19 . This snP was also associated to lung cancer
by Thorgeirsson et al. 20 .
the variants in genes CHRNA5 (1192G>a) and
CHRNA3 (645C>t) were evaluated in 819 smokers and
showed elevated risk for lung cancer when compared
with smokers that do not have this allele, even if they
smoke the same number of cigarettes 21 . these same
polymporphisms showed association as to histological
types and the act of smoking in 1,250 patients with lung
cancer (562 with adenocarcinoma, 391 with squamous
cell carcinoma and 297 with small cell carcinoma) and
936 hospital-based Japanese controls. The results indicated
that snP in the gene CHRNA confer susceptibility to lung
cancer in a small subgroup of Japanese in a way that is
regardless of smoking 22 . spitz et al. 23 tried to associate the
polymorphisms in genes CHRNA5 and CHRNA3 through
genotyping of smokers with bladder or kidney cancer
and smoking population based controls and did not find
association, reinforcing the hypothesis of participation
of these polymorphisms only in lung carcinogenesis. The
snP 5539C>G, localized in the first intron of the gene
CHRNA5, was also associated to the risk of lung cancer,
besides the ones previously described above 19 .
a study done by hansen et al. 24 identified,
besides snP1192G>a, three other polymorphisms
Polymorphisms, Nicotine and Lung Cancer
associated with lung cancer, pertaining to gene
CHRNA5 (24289a>G, 28757t>C and 14621a>C)
and one to gene CHRNA3 (30238C>t). This was the
only study that correlated variant in gene CHRNA4
(49711634C>G) to lung carcinogenesis and an
association to lower risk of this neoplasia only among
females, showing a gender-specific effect. it is still
worth highlighting that, according to the literature, the
polymorphism 1192G>a is one of the most commonly
associated to lung cancer and the 30238C>t is widely
related to nicotine dependence.
as to ethnical distribution, polymorphisms 645C>t
and 1192G>a of genes CHRNA3 and CHRNA5,
respectively, were associated with elevated risk for lung
cancer in european caucasians 10-12 and among Japanese 22 .
however, these two snPs were investigated in 1,152
cases of lung cancer and 1,152 controls and have not
been associated with lung cancer risk in the Chinese
population 25 . Thus the data obtained by Wu et al. 25
reinforce the region 15q25 as one of susceptibility to lung
cancer, but emphasize the difference in genetic markers
among ethnical different populations and the need to
conduct these studies in several populations. This same
study identified three new polymorphisms associated to
lung cancer in these populations: 10611tt and 3393G>a of gene CHRNA3.
such variants were investigated in 3,565 cases of lung
cancer and 3,456 controls from north and south China.
still, polymorphism 3393G>a localized in the promoter
region of the gene CHRNA3 affected the binding capacity
to the transcriptional factor oct-1, resulting in increased
expression of CHRNA3, suggesting it might be a causal
snP for lung cancer susceptibility.
CONCLUSION
in conclusion, the studies that showed association of
snP from region 15q25 with lung cancer are very recent.
The polymorphisms associated with lung carcinogenesis
belong mainly to genes CHRNA5 and CHRNA3, with
special attention to variants 1192G>a and 645C>t.
however, the articles describing investigation of
the contribution of these polymorphisms to lung
carcinogenesis are scarce. This shows the necessity of
additional studies in populations of different ethnical
origins, since a genetic association, although valid for
a specific ethnical population might not be relevant to
individuals of other ethnicity. Besides that, the functional
effect of every snP has to be considered to determine
if that genetic variant plays its role on the function and
expression of the gene, even if it is rarely observed in
that specific population.
Brazilian Journal of Cancerology 2011; 57(3): 421-428
425

Marqui ABT, Bonfim VL, Ruiz MT
426
CONTRIBUTIONS
alessandra Bernadete trovó de Marqui and Mariangela
torreglosa ruiz participated in the conception, design,
acquisition and interpretation of the data and in the
critical and final writing of this manuscript; Vera lúcia
Bonfim participated in the acquisition and interpretation
of data and the final and critical writing of the manuscript.
Declaration of Conflicting Interests: Nothing to declare
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Brazilian Journal of Cancerology 2011; 57(3): 421-428
427

Marqui ABT, Bonfim VL, Ruiz MT
428
Resumo
Introdução: o câncer de pulmão é o mais comum de todos os tumores malignos. responsável por 20.485 mortes, em
2008, no Brasil, e, em 90% dos casos diagnosticados, está associado ao consumo de derivados de tabaco. a nicotina é
o componente primário do tabaco presente no cigarro e, variantes genéticas nos genes que codificam subunidades do
receptor de acetilcolina nicotínico participam na etiologia e progressão do câncer de pulmão. Objetivo: realizar uma
revisão sobre o câncer de pulmão e polimorfismos de nucleotídeos únicos em genes codificadores de subunidades dos
receptores de acetilcolina nicotínicos. Método: foi realizada uma revisão bibliográfica por meio de busca eletrônica na
base de dados PubMed, tendo como limites artigos publicados nos últimos cinco anos, publicação em língua inglesa
e pesquisas em seres humanos. Resultados: a região 15q25 que contém os polimorfismos de nucleotídeos únicos
dos genes CHRNA5, CHRNA3 e CHRNB4 está associada a risco de câncer de pulmão e dependência a nicotina. os
trabalhos selecionados mostraram forte associação dos polimorfismos de nucleotídeos únicos 1192G>a e 645C>t dos
genes CHRNA5 e CHRNA3, respectivamente com câncer de pulmão. outros polimorfismos localizados em 15q25
associados a esse tipo de câncer incluem: 24289a>G, 28757t>C, 14621a>C, 10611t>C e 5539C>G do gene
CHRNA5; 27011C>t, 3393G>a, 30238C>t do gene CHRNA3 e o 49711634C>G do gene CHRNB4. Conclusão:
os trabalhos publicados evidenciaram que, na investigação de polimorfismos, devem ser considerados a etnicidade e
o efeito funcional daquela variante para o funcionamento e expressão gênica.
Palavras-chave: Polimorfismo de um Único nucleotídeo; neoplasias Pulmonares; receptores nicotínicos; Cromossomos
humanos Par 15
Resumen
Introducción: el cáncer de pulmón es el más común de todos los tumores malignos. responsable de 20.485 muertes
en 2008 en Brasil, siendo que el 90% de los casos diagnosticados está asociado al consumo de tabaco. la nicotina es
el principal componente primario del tabaco presente en el humo del cigarrillo y variantes genéticas en los genes que
codifican las subunidades del receptor nicotínico de acetilcolina participan en la etiología y progresión del cáncer de
pulmón. Objetivo: realizar una revisión sobre el cáncer de pulmón y polimorfismos de nucleótido único en genes que
codifican las subunidades de los receptores nicotínicos de la acetilcolina. Método: se realizó una revisión bibliográfica,
mediante la búsqueda electrónica en la base de datos PubMed, de los artículos publicados en los últimos cinco años,
publicaciones en idioma inglés e investigaciones en seres humanos. Resultados: la región 15q25 que contiene los
polimorfismos de nucleótido único de los genes CHRNA5, CHRNB4 y CHRNA3 está asociada con el riesgo de cáncer
de pulmón y adicción a la nicotina. los trabajos seleccionados mostraron una fuerte asociación entre los polimorfismos
de nucleótido único 1192G>a y 645C>t de los genes CHRNA5 y CHRNA3, respectivamente, con cáncer de pulmón.
otros polimorfismos localizados en 15q25 asociados a este tipo de cáncer incluyen: 24289a>G, 28757t>C, 14621a>C,
10611t>C y 5539C>G del gen CHRNA5; 27011C>t, 3393G>a, 30238C>t del gen CHRNA3 y 49711634C>G
del gen CHRNB4. Conclusión: los trabajos publicados muestran que en la investigación de polimorfismos debemos
considerar el origen étnico y el efecto funcional de aquella variante para el funcionamiento y la expresión génica.
Palabras clave: Polimorfismo de nucleótido simple; neoplasias Pulmonares; receptores nicotínicos; Cromosomas
humanos Par 15
Brazilian Journal of Cancerology 2011; 57(3): 421-428

Digest
Special Research on Tobacco (PETab) – Brazil Report
Digest submitted on 05/31/11; accepted for publication on 06/15/11
Global Adult Tobacco Survey – Brazil Report
Pesquisa Especial de Tabagismo (PETab) – Relatório Brasil
Encuesta Global de Tabaquismo en Adultos – Informe Brasil
National Cancer Institute (Brazil). Pan-American Health Organization.
Rio de Janeiro: INCA, 2011. 199p.
ISBN: 978-85-7318-182-1 (INCA)
978-92-75-73137-6 (OPAS)
Taís facina 1
The book Special Research on Tobacco (PETab) – Brazil Report, released in June, 2011 in a partnership between
the Brazilian national Cancer institute (inCa) and the Pan-american health organization (oPas), provides an
unprecedented overview on the use of tobacco derived products in Brazil.
Petab is the name given in Brazil to the Global Adult Tobacco Survey (Gats), a systematic monitoring survey about
tobacco use and key indicators for tobacco control, which follows a global model and has already been implemented
in 14 countries, favoring the production of comprehensive and standardized information with national representation
and international comparability.
Coordinated by the Ministry of health, through an executive Committee composed by the secretariat for health
surveillance (sVs), by inCa and by the national health surveillance agency (anVisa), Petab also counted on
the collaboration of the following institutions: 1) oswaldo Cruz foundation (fiocruz), responsible for the health
supplement of the national survey by home sampling (PnaD); 2) Brazilian institute of Geography and statistics
(iBGe), responsible for the implementation of the research following the Gats standard protocol; 3) oPas; 4)
Gats international Committee.
among Gats general objectives are: to produce national and regional estimates on the tobacco use, environmental
exposure to tobacco smoke and cessation; to evaluate the impact of tobacco control and prevention initiatives; to
support the capacity of the countries to project, implement and evaluate programs for control and prevention of tobacco
use; to allow international comparison of data. and, among the specific objectives: the prevalence of use of smoked
and non-smoked tobacco products; environmental exposure to tobacco smoke; cessation; exposure to pro- and antitobacco
advertisements; knowledge and attitudes; average price and average monthly cost with industrialized cigarettes.
The research involves several dimensions related to the most important strategies to reduce the morbidity and
mortality associated to tobacco and had, as target population, people who were 15 years old or above, summing up
about 40 thousand interviews.
The results showed there was in Brazil, in 2008, 24.6 million smokers in this adult population (17.2%), with
21.6% of prevalence among men and 13.1% among women. another observation was that the average age for smoking
initiation ranged from 17 to 19 years old (among daily smokers and former daily smokers with ages ranging from 20
to 34 years old).
although this percentage is larger among men, it is also among people in the range of 45 to 64 years old (22.7%),
among those living in the south (19%), among the ones living in rural areas (20.4%), among the ones having lower
school levels (25.7% among the ones who have not gone to school or who have gone for less than a year) and among
the ones with lower income (23.1%).
1 Journalist, post-graduated in “Production of the Book”, editor of scientific publications at the Brazilian national Cancer institute.
Brazilian Journal of Cancerology 2011; 57(3): 429-430
429

another important observation was that in the north and northeast, there is a significant percentage of smokers
that use handmade rolled cigarettes, a factor that causes concern as to the actions that can be taken to inform them
about the risks and methods of smoke cessation.
regarding the motivation of the Brazilian smokers to interrupt tobacco use, it is possible to realize that a significant
part of this population tried to quit smoking within the last 12 months (45.6%), which corresponds to approximately
12 million smokers, and this rate is 48% among young people. and in order to offer more adequate quitting strategies
to different smoker groups who wish to quit, the greatest challenge of the national Program for tobacco Control is
exactly what this survey adds in contribution: understanding the characteristics of the smoker populations (degree of
addiction, population groups more vulnerable to the actions of the tobacco industry, differences in access to health
services, etc).
another aspect that causes concern and that was revealed by the survey was the quantity of non-smokers exposed
to second hand smoke in at least one of the environments studied, which is about 22 million people, either in the
work environment, or health centers, or restaurants, or public transportation or in government offices and buildings.
These data point out to the urgent necessity that the recommendations envisioned by the framework Convention
for tobacco Control, mainly regarding the article that refers to protection from second-hand smoking, be totally
implemented in Brazil.
about the dissemination of information on the risks of use and exposure to second hand smoke for health, the
survey indicated that the country is on the right path: about 96% of those who were interviewed believe smoking can
cause serious damages to health, while 91% believe smoking can cause serious health damage to non-smokers. it was
also found that 67% of individuals had noted anti-tobacco information on the radio or television and 65% thought
about quitting after seeing the warnings on cigarette packages. These data reveal that there is, among people, great
awareness about the health problems related to tobacco and high perception of the counter-advertisement diffused
in the media in general and on cigarette packages, a result of the several actions of the national Program for tobacco
Control over the last decades.
regarding the economic aspects, it was observed that the expenses with cigarettes vary from 4.8% to 7% of the
family expenses, enabling the conclusion that a prices and taxes policy is more and more necessary, mainly in a scenario
where the purchasing power of the Brazilians has increased and justifies an increase in cigarette taxes.
it is expected that Petab will have a five-year periodicity and the next steps of the national Policy for tobacco
Control will be guided by them.
430 Brazilian Journal of Cancerology 2011; 57(3): 429-430

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both composed of renowned professionals in various areas of oncology. in this process, confidentiality and anonymity
will be ensured for the author(s) and reviewers. reviewers’ analysis follows is based on the form “Parecer do Conselho
editorial” [editorial Board opinion] available in the rBC publication guidelines at http://www.inca.gov.br/rbc.
after the opinion issuing, the manuscript is sent to the scientific editor who acknowledges and analyzes the
opinions in compliance with the Journal publication standards and decides whether the article, as well as the alterations
required, should be accepted or not, process on which he/she has full decision authority. The opinion is then sent to
the authors by email.
after assessing the manuscripts, they can be classified as: manuscript approved without restrictions, which will be
forwarded to the technical reviewer for review and publication; manuscript approved with restrictions, which will be
sent to the author(s) with the adjustment requirements by email. The manuscript reviewed should be resubmitted by the
author(s) to the rBC by e-mail, with a letter stating the changes made or, if there were none, providing justifications.
if the manuscript is not returned in forty-five (45) days, it will be considered that the authors no longer have interest
in publishing; in case of a non-approved manuscript, the author will receive a refusal notification by e-mail.
The manuscript approved will be published according to the flow and chronogram of the Journal editorial.
cATegories of mAnUscripTs
The following types of manuscripts are considered for publication:
• Original Articles – articles which report results of original experimental or empirical nature whose results can be
replicated and/or generalized. Qualitative methodology research and discursive formulations which have a theorizing
effect will also be considered original. . as for the structure, a manuscript must contain: introduction, method,
findings, discussion and conclusion. There is a maximum of 20 pages, including a maximum of 5 pictures, tables,
graphics etc.
• Literature Review - a systematic and updated literature review on a specific theme which should provide the reader
with the general background to a subject. narrative reviews will not be accepted. types of reviews (integrative,
systematic, meta-analysis), methods and procedures adopted for the work should be described. The interpretation and
conclusion of the authors must be included. as for the structure, it must contain: introduction, method, findings,
discussion and conclusion. There is a maximum of 20 pages, including a maximum of 5 pictures, tables, graphics
etc.
• Case Reports / Case Series – a detailed description and critical analysis of one or more typical or atypical cases,
based on an extensive and updated literature review on the topic. The author should present a problem considering
its many aspects and its relevance. There is a maximum of 15 pages, including a maximum of 4 pictures, tables,
graphics etc.
• Opinion Article - a qualified opinion on a specific oncology topic. It does not require an abstract. There is a maximum
of 10 pages, including a maximum of 2 tables, graphics etc., which should not.
• Review – a critical review of a book in the field of oncology, published in the previous year. There is a maximum of
4 pages.
• Abstracts of dissertations, theses, and papers which are of highlighting prominence or have been presented in
oncology events in the last 12 months from the date of abstract submission - this is information in the form of short
essay. Therefore, it must bear the nature and purposes of the research and a comment on the methodology, results
432 Brazilian Journal of Cancerology 2011; 57(3): 431-459

and major conclusions. Their aim is to inform researchers on the nature of work quickly and easily, as well as the
study´s basic characteristics of achievement and scientific reach. There should be at least 150 to a maximum of 250
words and follow the standards of the Journal as to structure, format and content, including descriptors.
• Letters to the Editor – whether concerning an article published in a previous issue of the journal or not, it should
still contain relevant information to the readers. in case of criticism of papers published in the previous number of
the Journal, the letter is forwarded to the authors so their answer can be published simultaneously. The letters can
be summarized by the editors, but the main points will be maintained. There is a maximum of 4pages.
mAnUscripT prepArATion
The original manuscript should be written in the third-person singular and the verb in the active voice (aBnt.
nBr-6028, 2003, p.2.)
The word processor used must be Microsoft Word 6.0 or 7.0, times new roman font size 12, 30mm margins on
both sides, double-spaced in all sections, paper size a4 (210 x 297mm) and numbered pages.
to provide greater clarity in the delivery of the subject and direct location of each item, the text is divided into
logical parts, according to related topics.
example:
introDuCtion (PriMary seCtion)
Material anD MethoD (PriMary seCtion)
Data collection (secondary section)
Variables (tertiary section)
for the presentation of section titles, the type and size of letters should be gradually highlighted, noting that all
primary sections must be written in the same way, and so must all the secondary sections and so on.
The text of each section of a document may include a series of paragraphs which should be characterized by lowercase
letters of the alphabet (a, b, c,...) followed by parentheses, and immediately preceding the first word of your text.
example:
a) write a scientific article.
b) illustrate the text.
mAin gUiDeLines on eAch secTion
1. Title page or cover sheet
it should contain: a) title of article, alternating uppercase and lowercase letters, in Portuguese, english and spanish;
b) short title with up to 40 characters; c) author’s full name(s). The designation of authorship should be based on the
iCMJe resolutions which considers author the one who contributes substantially to the design or planning of the study,
the retrieval, analysis or interpretation of data, as well as to the writing and/or critical review and final approval of the
published version. in institutional (collective authorship) and multicenter studies, those who are responsible for them
should have their names specified and everyone who is considered an author must meet the criteria mentioned above;
d) informing, in a footnote, each author’s professional category, his or her highest academic degree, the name(s) of
department(s) and institution(s) to which the research must be assigned, email address, city, state, country; e) name,
address and telephone number of the author who is responsible for the correspondence on the manuscript; f) description
of each author’s individual contribution for the manuscript (e.g.: .... he/she worked with the conception and final writing
and ......with the research and methodology); g) acknowledgements: other collaborators who do not meet the authorship
criteria mentioned above should have their names listed in this item and their type of collaboration specified. The authors
are responsible for obtaining written authorization from the people acknowledged, since they are thought to agree with
the research content; h) conflict of interest statement (write in "no comment" or disclose any conflicts); i) for subsidized
research, the sponsor and process number (if any) must be informed.
2. Abstract and descriptors (keywords)
all articles should include structured abstracts in Portuguese, english and spanish, followed by descriptors in their
respective languages. The terminology for the descriptors must be named in the article as follows: palavras-chave,
key words and palabras clave. each abstract should contain at least 150 and maximum of 250 words, introduction,
objective(s), methodology, results, conclusion and at least three and maximum of six descriptors. The descriptors are
key words that help the indexing of articles in national and international databases. to determine the descriptors, you
Brazilian Journal of Cancerology 2011; 57(3): 431-459
433

should consult the list of “Descritores em Ciências da saúde” [Descriptors in health sciences] (DeCs-lilacs- http://
decs.bvs.br) prepared by BireMe.
in the abstract, reference citations must not be made, and abbreviations and/or acronyms, as well as charts, tables
and images must not be included.
in case of abstracts of papers presented in oncology events or that should be highlighted and have been accepted for
publication in rBC, it is the authors’ responsibility to ensure compliance with the Journal standards before forwarding
them, and it is his/her full responsibility to ensure language accuracy and correction.
3. Introduction
The introduction must be objective with clear definition of the problem studied, highlighting its importance and
the gaps in knowledge; the literature review must be strictly relevant to the subject of the study, in order to provide
the background for understanding the current knowledge on the subject and highlighting the importance of the new
study. it must inform the objective(s) of the study.
4. Methods
it should objectively inform the type of study (prospective, retrospective; clinical or experimental trial; if the
distribution of the cases was randomized or not; qualitative etc.), the methods employed, the population studied
(clearly describe the selection of subjects for observational and experimental studies – patients or laboratory animals,
including control groups-, as well as for qualitative studies), the data source and selection criteria or experimental
group, including control groups. identify the equipment and reagents used. also describe the statistical methods used
and the comparisons for which each test was employed.
Clinical trial reports should present information on all major elements of the study, including the protocol
(population studied, interventions or exposures, outcomes - and the logic of statistical analysis), intervention
characteristics (methods of randomization, indication of treatment groups) and masking methods.
authors submitting review articles should present the procedures used to locate, select, obtain, classify and synthesize
information in addition to defining the inclusion and exclusion criteria of studies selected for review.
When experiments in humans are reported, inform if the procedures were followed in accordance with the ethical
standards of the institutional ethics Committee for human research, with the helsinky Declaration (latest version
of 2000) and the resolution 196/96 (res. Cns 196/96). Do not use patients’ names, initials or registration numbers,
especially in illustrative material. for experiments involving animals, inform the compliance with the standards of
institutions, the national research Council or any national law concerning the use and care of laboratory animals.
This section also includes the mentioning of the document, indicating the protocol number, the eC of the institution
to which the authors are bound and which approved the study performed.
5. Results
relevant results for the study purpose which will be discussed must be presented. only results which have been
found must be described, without any interpretations or comparisons. results, tables and illustrations must be presented
in a logical sequence. The text must complement and not repeat what is being described in tables and illustrations.
tables and illustrations must be restricted to those that are really necessary to explain the argument of the article and
to support it. use graphs as an alternative to tables with too many entries; do not duplicate data in graphs and tables.
avoid non-technical uses of technical terms in statistics, such as: "random" (which implies a randomizing device),
"normal," "significant," "correlation" and "sample" non-technically. statistical terms, abbreviations and symbols must
be defined. in case reports, the sections "methods" and "results" are replaced by the case description.
6. Discussion
This section should provide the authors' interpretation, compare the results with the literature, relate the
considerations to other relevant studies, indicate the study limitations, and highlight new and important aspects of
the study and its conclusions, including suggestions for future research.
The discussion can be presented along with the results according to the author’s preference.
Do not repeat, in detail, data or other materials described in the sections "introduction" or "results".
7. Conclusion
The conclusion should be based on the findings and bound to the study aims. unqualified statements and conclusions
not fully supported by data should not be reported in this section. The allusion to studies that have not been completed
434 Brazilian Journal of Cancerology 2011; 57(3): 431-459

must be avoided. new hypotheses can be suggested provided they are clearly justified as such. recommendations,
when appropriate, can be included.
8. References
in the text, references should be numbered in arabic numerals, in superscripted (e.g.: The extension of survival,
among others1), consecutively, according to the order they first appear in the text and without reference to the authors.
The same standard can be applied to tables and legends. in case of sequential citation, separate the numbers by a dash
(e.g.: 1-2); when intercalated, use commas (ex: 1, 3, 7).
references are limited to 25.
references should not be included in the abstract. only relevant references and those which were used in the study
must be considered.
references should be checked in the original documents. in case of a citation of a reference mentioned by another
author, the term "apud" should be used.
The accuracy of references is the authors’ responsibility.
The guidelines below aim to provide authors with examples of references presented in their researches informing
on their standardization. They are based on standards for Manuscripts submitted to Biomedical Journals: writing
and editing for Biomedical Publication, Vancouver style, made by the iCMJe. The most common occurrences of
references by type of referenced material will be presented. some comments listed below are the result of occurrences
in journal articles submitted for publication.
to standardize the journals titles in the references, locatorPlus is used as a guide; referencing source of the National
Library of Medicine, which provides, on the option Journal Title, the title and/or the abbreviation used. in some sources,
the title is already standardized (PubMed, lilacs and Medline). if the form used is not standard, inform it in full and
avoid using a nonstandard abbreviation that makes identification difficult.
to inform authorship, names must be inserted in the order they appear in the publication up to a maximum of
six authors, starting by surname and followed by initials of all pre-names, separating each author by a comma (1). if
the publication presents more than six authors, the first six are mentioned; then, a comma followed by the expression
et al is used. (2).When the author's surname includes kinship - filho, sobrinho, Junior, neto [common for names
in Portuguese] - this must be placed after the last name: João dos santos de almeida filho - almeida filho Js, José
rodrigues Junior – rodrigues Junior J.
to standardize titles, lowercase letters must be used for the whole period, except for the first word which is always
capitalized. The following proper nouns are exceptions: personal names, names of sciences or disciplines, educational
institutions, countries, cities or similar, and names of public or private establishments.
EXAMPLES Of REfERENCES IN JOuRNALS
1. Article by a maximum of six authors
Kakuda Jt, stuntz M, trivedi V, Klein sr, Vargas hi. objective assessment of axillary morbidity in breast cancer
treatment. am surg 1999; 65: 995-8. note.: use 995-8, do not use 995-998.
2. Article by more than six authors
zheng h, takahashi h, Murai y, Cui z, nomoto K, Miwa s, et al. Pathobiological characteristics of intestinal
and diffuse-type gastric carcinoma in Japan: an immunostaining study on the tissue microarray. J Clin Pathol
2007 Mar; 60(3):273-7.
3. Article whose author is an institution
use the name of the institution indicating in brackets the country, if it is a public institution (a) in case of a private
institution, only the name of the institution is used. inform the hierarchy (b) to which the institution is subject to for
its perfect identification (do not use directly: Department of health Care. Where from?).
4. Article with multiple organizations authorship
include all. (a) Brazilian national Cancer institute (Brazil). encontro internacional sobre rastreamento de
Câncer de Mama. revista brasileira de cancerologia 2009 abr.-jun.; 2 (55): 99-113. (b) Brazil. Ministry of health.
1 available at: (http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&PaGe=first).
Brazilian Journal of Cancerology 2011; 57(3): 431-459
435

Department of health Care. Department of Primary Care. national Coordination of oral health. Projeto sB Brasil
2003: condições de saúde bucal da população brasileira 2002-2003: resultados principais. Brasília, 2004b. [accessed
on apr 2004]. available at:
5. Author indicating kinship in his/her name
Mattes rD, Curram Jr WJ, alavi J, Powlis W, Whittington r. Clinical implications of learned food aversions in
patients with cancer treated with chemotherapy or radiation therapy. Cancer 1992; 70 (1): 192-200..
6. Article without indication of authorship
Pelvic floor exercise can reduce stress incontinence. health news 2005 apr; 11(4):11.
7. Article indicating its type (review, abstract, editorial)
facchini luiz augusto. aBrasCo 30 anos: ciência, educação e prática com compromisso social. [editorial] Public
health supplement [journal on the internet]. 2010 Jan [cited 2010 aug 23]; 26 (1): 4-4. available at: .
8. Article published in a journal supplement
nascimento af, Galvanese atC. avaliação da estrutura dos centros de atenção psicossocial do município de são
Paulo, sP. rev saúde Pública 2009; 43 suppl.1: 8-15.
9. Article published in a part of an edition
fukuzawa M, oguchi s, saida t. Kaposi's varicelliform eruption of an elderly patient with multiple myeloma. J
am acad Dermatol. 2000 May; 42(5 Pt 2):921-2.
10. Article published without indicating the volume or number of edition
schwartz-Cassell t. feeding assistants: based on logic or way off base? Contemp longterm Care. 2005 Jan: 26-8.
11. Article published with pagination indicated in Roman numerals
nagpal s. an orphan meets family members in skin. J invest Dermatol. 2003; 120(2):viii-x.
12. Article with retraction or erratum published should have its publication informed in the reference
Mokdad ah, Marks Js, stroup Df, Gerberding Jl. Correction: actual causes of death in the united states, 2000.
JaMa. 2005 Jan 19; 293(3):293-4. erratum for: JaMa. 2004 Mar 10; 291(10):1238-45.
13. Article with electronic publication before print version
Bicalho PG, hallal PC, Gazzinelli a, Knuth aG, Velásquez-Meléndez G. atividade física e fatores associados em
adultos de área rural em Minas Gerais, Brasil. rev saúde Pública [accessed on aug 23, 2010]. available at: Published in 2010.
epub 30-Jul-2010. doi: 10.1590/s0034-89102010005000023.
14. Article provided with DOI
Caldeira aP, fagundes GC, aguiar Gn de. intervenção educacional em equipes do Programa de saúde da família para
promoção da amamentação. rev saúde Pública 2008;42(6):1027-1233. doi: 10.1590/s0034-89102008005000057.
15. Article in press
Barroso t, Mendes a, Barbosa a. analysis of the alcohol consumption phenomenon among adolescents: study
carried out with adolescents in intermediate public education. rev latino-am enfermagem. in press 2009.
EXAMPLES Of REfERENCES IN BOOKS AND OTHER MONOGRAPHS
16. Book
hoppenfeld s. Propedêutica ortopédica: coluna e extremidades. rio de Janeiro: atheneu; 1993. 294 p.
17. Book indicating editor, organizer, coordinator
Bader MK, littlejohns lr, editors. aann core curriculum for neuroscience nursing. 4th. ed. st. louis (Mo):
saunders; c2004. 1038 p.
18. Book edited by an institution
World Cancer research fund (usa). food, nutrition, physical activity and prevention of cancer: a global
perspective. Washington (DC): american institute for Cancer research; 2007.
19. When the author of the chapter is the author of the book; reference of book chapter
ferreira sa. nervos proximais do membro superior. in: ____. lesões nervosas periféricas diagnóstico e tratamento.
são Paulo: santos; 2001. p. 35-48.
436 Brazilian Journal of Cancerology 2011; 57(3): 431-459

20. Book with no authorship informed
hiV/aiDs resources: a nationwide directory. 10th ed. longmont (Co): Guides for living; c2004. 792 p.
21. Conference annals
harnden P, Joffe JK, Jones WG, editors. Germ cell tumours V. Proceedings of the 5th Germ Cell tumour Conference;
2001 sep 13-15; leeds, uK. new york: springer; 2002.
22. Paper presented at conferences
Christensen s, oppacher f. an analysis of Koza's computational effort statistic for genetic programming. in: foster
Ja, lutton e, Miller J, ryan C, tettamanzi aG, editors. Genetic programming. euroGP 2002: Proceedings of
the 5th european Conference on Genetic Programming; 2002 apr 3-5; Kinsdale, ireland. Berlin: springer; 2002.
p. 182-91.
23. Legislation
Provides for the regulation of nursing Practice. law no. 7.498, June 25, 1986. federal official Gazette. section
i, fls. 9.273-9.275 (Jun 26, 1986). 1986.
24. Theses and dissertations
Verde sMMl. impacto do tratamento quimioterápico no estado nutricional e no comportamento alimentar de
pacientes com neoplasia mamária e suas consequências na qualidade de vida [dissertation]. são Paulo: university
of são Paulo; 2007.
9. Tables
tables must be on separate sheets. Do not submit tables in image format, so that an occasional editing can be
performed. tables must be numbered consecutively according to the first citation in the text and each one must have
a brief title. for each column, define a short or abbreviated heading. Write explanations in footnotes, not in the
header. explain, in footnotes, all nonstandard abbreviations used in each table. for footnotes, use roman numerals.
identify statistical measures of variations, such as: standard deviation and standard error.
Do not use internal, horizontal or vertical lines.
Make sure that each table is cited in the text by their numbers rather than: the following table, the table below.
if data from another source, published or not, are used, you must obtain permission and fully acknowledge it.
The use of large tables or in excess, in relation to text, may cause difficulty in the presentation of the pages.
10. Illustrations
send the required number of illustrations or "images". handmade drawing or typewritten legends are not allowed.
Photos must be scanned, in black and white, usually 12 x 17cm, not larger than 20 x 25cm, X-ray films or other
materials. letters, numbers and symbols should be clear and large enough so that, when reduced for publication, they
are still legible. titles and explanations must be below the legends and not in the illustrations.
if photographs of people are used, the subjects must not be identifiable or their pictures must be accompanied by
written consent for publication.
Pictures must be numbered according to the order they are mentioned in the text. if a picture has been published,
the original source must be acknowledged and a written authorization from the copyright holder must be submitted
to reproduce the material. The authorization is required, either from the author or the publishing company, except
for public domain documents.
rBC is published in black and white and all illustrations are reproduced in black and white.
illustrations should be provided as follows:
• Digital file format .TIFF, .JPG, .EPS, with minimum resolution of:
300 dpi for common photographs
600 dpi for photographs containing thin lines, arrows, legends, etc.
1,200 dpi for drawings and graphics
11. Nomenclature
Biomedical nomenclature standardization must be strictly followed, as well as abbreviations and conventions used
in specialized disciplines.
original texts in Portuguese must be in compliance with the orthographic agreement from January 1st, 2009.
Brazilian Journal of Cancerology 2011; 57(3): 431-459
437

TechnicAL reQUiremenTs overvieW for mAnUscripTs sUbmission
Before sending the manuscript by email to rbc@inca.gov.br, check whether the “instruções para autores” [Publication
Guidelines for authors] available at www.inca.gov.br/rbc were followed and check the items listed below:
• Submit the complete manuscript file in Microsoft Word 6.0 or 7.0.
• Use double-spacing throughout the document.
• Begin each section or component on a new page.
• Review the sequence: title page/cover sheet - title in Portuguese, English and Spanish; abbreviated title; authorship;
resumo and palavras-chave; abstract and key words; resumen and clave; acknowledgements; conflict of interest
statement; statement of grant; text; references; tables; charts; pictures with legends (each on separate pages).
• Provide three to six keywords and the respective palavras-chaves and palabras clave.
• References: numbered, superscribed, in order of appearance in the text, properly spelled and no more than 25. Verify
that all work is cited in the list of references and that all work listed is cited in the text.
• Provide illustrations, photos or drawings separately, not assembled (20 x 25 cm maximum).
• Include a submission letter available at “Instruções para Autores” [Publication Guidelines for Authors]. If the
manuscript was produced by more than one author, each one must complete and sign the letter and the author
responsible for submission must send it in digitized format .JPG with the manuscript file to rbc@inca.gov.br.
• Include permission to reproduce previously published material or to use illustrations that may identify individuals.
• Include written permission from persons acknowledged, when applicable.
• Include document evidencing the approval of the paper by the EC or ICF, when applicable.
438 Brazilian Journal of Cancerology 2011; 57(3): 431-459

Submission Letter to Revista Brasileira de Cancerologia (Brazilian Journal of Oncology)
Please, complete and submit this form along with the original manuscript of your paper to: rbc@inca.gov.br. if the
manuscript has more than one author, each one must complete, sign and forward this letter to the author responsible
for submitting it so as it is converted into the format .JPG and sent to rBC together with the manuscript.
Manuscript title ________________________________________________________________________
______________________________________________________________________________________
Classification of the manuscript:
( ) original article
( ) systematic review of literature
( ) Case report / Case series
( ) article opinion
( ) review
( ) abstract
( ) letter to the editor
each author must inform his/her contributions, marking with the letter X the fields below:
1. The author contributed to:
( ) The design and planning of the research project
( ) obtaining and/or in analyzing and interpreting data
( ) Writing and critical review
2. Conflict of interest:
( ) The author has no conflicts of interest, including specific financial interests and relationships and affiliations
relating to the subject or materials discussed in the manuscript.
( ) The author confirms that all funds, other financial support, and material/human support for this research
and/or work are clearly identified in the manuscript submitted to assessment from the "editorial Board of the rBC"
3. acknowledgements:
( ) The author confirms that people who have contributed substantially to the work developed in this manuscript,
but who do not meet the criteria for authorship, have been mentioned in the "acknowledgments" section of the
manuscript containing the description of their specific contributions.
( ) The author confirms that people mentioned in the "acknowledgements" have given their written permission
to be included in it.
( ) The author confirms that if the "acknowledgements" were not included in the manuscript submitted was because
there was no substantial contribution to the manuscript other than the authors’.
4. Copyright transfer / Publication
i state that, in case this manuscript is accepted for publication, i agree that its copyright will be owned by rBC,
and that its reproduction in other journals, even if partially, is prohibited whether printed or electronic, as well as its
translation into other languages for publication, without previous rBC authorization and that, in case of acceptance,
i will acknowledge this Journal.
_
author _________________________________ signature ___________________________________
Date ___________________________________ e-mail ____________________________________
Brazilian Journal of Cancerology 2011; 57(3): 431-459
439

InSTRuÇÕES PARA AuTORES
informAções gerAis
a revista Brasileira de Cancerologia (rBC) é uma publicação trimestral que tem por finalidade divulgar trabalhos
relacionados a todas as áreas da Cancerologia. são aceitos para publicação textos em português, inglês e espanhol.
a rBC adota os "Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for
Biomedical Publication" do International Committee of Medical Journal Editors (iCMJe) (http://www.icmje.org). o
original, incluindo tabelas, ilustrações e referências, deve seguir esses requisitos.
os manuscritos devem ser inéditos e destinar-se exclusivamente a rBC, não sendo permitida sua apresentação
simultânea a outro periódico. os conceitos e opiniões expressos nos artigos, bem como a exatidão e a procedência
das citações, são de exclusiva responsabilidade do(s) autor(es). Manuscritos que se referem a partes de uma mesma
pesquisa têm a submissão desencorajada por essa revista.
os manuscritos publicados passarão a ser propriedade da rBC, sendo vedada tanto sua reprodução, mesmo que
parcial, em outros periódicos, como sua tradução para publicação em outros idiomas, sem prévia autorização desta.
os manuscritos aceitos para publicação poderão ser modificados para se adequar ao estilo editorial-gráfico da
revista, sem que, entretanto, nada de seu conteúdo técnico-científico seja alterado.
no caso de o manuscrito incluir tabelas e ilustrações previamente publicadas por outros autores e em outros
veículos, é dever do autor fornecer comprovante de autorização de reprodução, assinado pelos detentores dos direitos
autorais dos mesmos.
os leitores de periódicos biomédicos merecem ter a confiança de que o que estão lendo é original, a menos que
exista uma declaração clara de que o artigo está sendo republicado por escolha do autor e do editor. as bases para essa
posição são as leis internacionais de direito autoral, a conduta ética e o uso de recursos, obedecendo a uma lógica de
custo efetividade.
Quando parte do material do manuscrito já tiver sido apresentada em uma comunicação preliminar, em simpósio,
congresso etc., esse fato deve ser citado como nota de rodapé na página de título, e uma cópia do texto da apresentação
deve acompanhar a submissão do manuscrito.
na submissão de manuscritos ou resumos de pesquisa clínica, ensaios clínicos, pesquisa básica, pesquisa aplicada,
pesquisa de tradução; estudos laboratoriais, estudos epidemiológicos (prospectivos ou retrospectivos); utilização de dados
de prontuários, pesquisa em banco de dados; relatos de casos; entrevistas, questionários, inquéritos populacionais; é
obrigatória a inclusão de documento, com o número de protocolo, de que todos os procedimentos propostos tenham
sido avaliados e aprovados pelo Comitê de Ética em Pesquisa (CeP) da instituição a que se vinculam os autores ou,
na falta deste, por um outro CeP indicado pela Comissão nacional de Ética em Pesquisa do Ministério da saúde.
os pacientes têm direito à privacidade, fato que não deve ser infringido sem um consentimento informado. as
informações de identificação pessoal não devem ser publicadas em descrições escritas, fotografias, genealogias e relatos
de caso, a menos que a informação seja essencial para propósitos científicos e que o paciente (ou seus pais ou tutores)
outorgue um consentimento informado por escrito, autorizando a publicação.
Devem omitir-se detalhes de identificação se não forem essenciais, mas os dados do paciente nunca deverão ser
alterados ou falsificados numa tentativa de conseguir o anonimato. o anonimato completo é difícil de conseguir,
devendo-se obter o consentimento informado se houver alguma dúvida. Por exemplo, mascarar a região ocular em
fotografias de pacientes é uma proteção inadequada para o anonimato.
a rBC, ao reconhecer a importância do registro e divulgação internacional, em acesso aberto, de informações
sobre estudos clínicos, apoia as políticas para registro de ensaios clínicos da organização Mundial da saúde (oMs) e
do iCMJe. Desta forma, serão aceitos para publicação apenas os artigos de pesquisas clínicas que tenham recebido um
número de identificação em um dos registros de ensaios Clínicos validados pelos critérios estabelecidos pela oMs e
iCMJe, cujos endereços estão disponíveis no sítio do iCMJe (http://www.icmje.org).
Conflitos de interesses devem ser reconhecidos e mencionados pelos autores. entre essas situações, menciona-se a
participação societária nas empresas produtoras das drogas ou equipamentos citados ou utilizados no trabalho, assim
como em concorrentes da mesma. são também consideradas fontes de conflito os auxílios recebidos, as relações de
subordinação no trabalho, consultorias etc.
Brazilian Journal of Cancerology 2011; 57(3): 431-459
441

a submissão do manuscrito à rBC deve ser por e-mail para rbc@inca.gov.br, com o texto integral, tabelas, gráficos,
figuras, imagens, CeP e termo de Consentimento livre e esclarecido (se aplicável) e de acordo com as normas da
revista. a “Carta de submissão” individual e assinada por cada um dos autores (modelo disponível em http://www.
inca.gov.br/rbc) deve também ser enviada nesta oportunidade.
processo De AvALiAção Dos mAnUscriTos
a publicação dos trabalhos dependerá da observância das normas da rBC e da decisão do seu Conselho editorial.
o processo de avaliação inicia-se com o editor científico que avalia se o artigo recebido traz contribuições para a área da
Cancerologia e se é de interesse para os leitores. avalia também se o original está elaborado de acordo com as instruções
recomendadas pela revista. os manuscritos considerados pertinentes, mas, em desacordo com essas instruções, serão
devolvidos aos autores para as adaptações necessárias, antes da avaliação pelo Conselho editorial.
o manuscrito aceito é encaminhado para análise e emissão de parecer dos membros do Conselho editorial e/ou
Conselho Ad Hoc, ambos formados por profissionais de notório saber nas diversas áreas da oncologia. nesse processo,
o sigilo e o anonimato serão adotados para autor(es) e pareceristas. a análise dos pareceristas é realizada com base no
formulário “Parecer do Conselho editorial” disponível nas instruções para publicação na rBC em http://www.inca.
gov.br/rbc.
após emissão do parecer, o manuscrito é enviado ao editor científico que toma ciência dos pareceres emitidos
e os analisa em relação ao cumprimento das normas de publicação da revista e decide sobre a aceitação ou não do
artigo, assim como das alterações solicitadas, processo sobre o qual tem plena autoridade de decisão. o parecer é então
enviado para os autores por e-mail.
após avaliação os manuscritos, poderão ser classificados em: manuscrito aprovado sem restrições, que será
encaminhado ao revisor técnico para revisão e posterior publicação; manuscrito aprovado com restrição, que será
encaminhado ao(s) autor(es) com as solicitações de ajuste por e-mail. o manuscrito revisado deve ser reapresentado
pelo(s) autor(es) à rBC, por e-mail, acompanhado de carta informando as alterações realizadas ou, quando não
realizadas, apresentando as devidas justificativas. não havendo retorno do trabalho em quarenta e cinco (45) dias,
será considerado que os autores não têm mais interesse na publicação; manuscrito não aprovado, nesse caso o autor
receberá notificação de recusa por e-mail.
o manuscrito aprovado será publicado de acordo com o fluxo e o cronograma editorial da revista.
cATegoriA Dos mAnUscriTos
são considerados para publicação os seguintes tipos de manuscritos:
• Artigos Originais – são artigos nos quais são informados os resultados obtidos em pesquisas de natureza empírica ou
experimental original cujos resultados possam ser replicados e/ou generalizados. também são considerados originais
as pesquisas de metodologia qualitativa e as formulações discursivas de efeito teorizante. Como estrutura devem
apresentar: introdução, método, resultados, discussão e conclusão. o máximo de laudas é 20, incluindo figuras,
tabelas, gráfico, etc. que não devem ultrapassar 5.
• Revisão da Literatura – trata-se de revisão sistematizada e atualizada da literatura sobre um tema específico e que
deve dar ao leitor uma cobertura geral de um assunto. não serão aceitas revisões narrativas. Devem ser descritos
os tipos de revisão (integrativa, sistemática, metanálise), os métodos e procedimentos adotados para a realização
do trabalho. a interpretação e conclusão dos autores devem estar presentes. Como estrutura devem apresentar:
introdução, método, resultados, discussão e conclusão. o máximo de laudas é 20, incluindo figuras, tabelas, gráfico,
etc. que não devem ultrapassar 5.
• Relato de Casos/ Série de Casos - é a descrição detalhada e análise crítica de um ou mais casos, típicos ou atípicos,
baseado em revisão bibliográfica ampla e atual sobre o tema. o autor deve apresentar um problema em seus múltiplos
aspectos, sua relevância. o máximo de laudas é 15, incluindo figuras, tabelas, gráfico etc. que não devem ultrapassar 4.
• Artigo de Opinião – trata-se de opinião qualificada sobre tema específico em oncologia. Não necessita de resumo.
o máximo de laudas é 10, incluindo tabelas, gráfico, etc. que não devem ultrapassar 2.
• Resenha – resenha crítica de livro relacionado ao campo temático da Cancerologia, publicado no último ano. O
máximo é de 4 laudas .
• Resumos de dissertações, teses, de trabalhos que mereçam destaque ou apresentados em eventos de oncologia nos
últimos 12 meses, contados da data de envio do resumo - trata-se da informação sob a forma sucinta de trabalho
442 Brazilian Journal of Cancerology 2011; 57(3): 431-459

ealizado. Portanto, deve conter a natureza e os propósitos da pesquisa e um comentário sobre a metodologia,
resultados e conclusões mais importantes. seu objetivo é a transmissão aos pesquisadores de maneira rápida e fácil
da natureza do trabalho, suas características básicas de realização e alcance científico afirmado. Devem conter no
mínimo 150 até 250 palavras e seguir as normas da revista quanto à estruturação, à forma e ao conteúdo, inclusive
no que se refere aos descritores.
• Cartas ao Editor – podem estar relacionadas à matéria editorial ou não, mas devem conter informações relevantes
ao leitor. no caso de críticas a trabalhos publicados em fascículo anterior da revista, a carta é enviada aos autores
para que sua resposta possa ser publicada simultaneamente. as cartas podem ser resumidas pela editoria, mas serão
mantidos os pontos principais. o máximo é de 4 laudas.
prepAro Do mAnUscriTo
o original deve ser escrito na terceira pessoa do singular com o verbo na voz ativa (aBnt.nBr-6028, 2003, p.2).
o processador de textos utilizado deve ser o Microsoft Word 6.0 ou 7.0, fonte times new roman tamanho 12,
margens de 30mm em ambos os lados, espaço duplo em todas as seções, tamanho do papel a4 (210 x 297mm) e
páginas numeradas.
Para permitir maior clareza na exposição do assunto e localização direta de cada item, divide-se o texto em partes
lógicas, ordenadas por assuntos considerados afins.
exemplo:
introDuÇÃo (seÇÃo PriMÁria)
Material e MÉtoDo (seÇÃo PriMÁria)
Coleta de dados (seção secundária)
Variáveis (seção terciária)
na apresentação dos títulos das seções, deve-se dar destaque gradativo ao tipo e corpo das letras, observando que
todas as seções primárias devem estar escritas da mesma maneira, assim como todas as secundárias e assim por diante.
o texto de cada seção de um documento pode incluir uma série de alíneas, que devem ser caracterizadas pelas
letras minúsculas do alfabeto (a, b, c,...) seguidas de parênteses e que precedam imediatamente à primeira palavra
de seu texto.
exemplo:
a) escrever um artigo científico.
b) ilustrar o texto.
principAis orienTAções sobre cADA seção
1. Página de título ou folha de rosto
Deve conter: a) título do artigo, alternando letras maiúsculas e minúsculas, em português, inglês e espanhol; b) título
abreviado com até 40 caracteres; c) nome(s) por extenso do(s) autor(es). a designação de autoria deve ser baseada nas
deliberações do iCMJe, que considera autor aquele que contribui substancialmente na concepção ou no planejamento
do estudo; na obtenção, na análise e/ou interpretação dos dados; assim como na redação e/ou revisão crítica e aprovação
final da versão publicada. em estudos institucionais (de autoria coletiva) e estudos multicêntricos, os responsáveis devem
ter seus nomes especificados e todos considerados autores devem cumprir os critérios acima mencionados; d) indicar para
cada autor, em nota de rodapé, a categoria profissional, o mais alto grau acadêmico, o(s) nome(s) do(s) departamento(s)
e instituição(ões) a que o trabalho deverá ser atribuído, endereço eletrônico, cidade, estado e país; e) nome, endereço
e telefone do autor responsável pela correspondência sobre o manuscrito; f) descrição da contribuição individual de
cada autor no manuscrito (ex: .... trabalhou na concepção e na redação final e ...... na pesquisa e na metodologia); g)
agradecimentos: os demais colaboradores, que não se enquadram nos critérios de autoria acima descritos, devem ter
seus nomes referidos nesse item especificando o tipo de colaboração. os autores são responsáveis pela obtenção de
autorização escrita das pessoas nomeadas nos agradecimentos, já que se pode inferir que as mesmas concordam com o
teor do trabalho; h) declaração de conflito de interesses (escrever “nada a declarar” ou revelar quaisquer conflitos); i) para
trabalhos subvencionados, identificar o patrocinador e número de processo (se houver).
2. Resumo e descritores (palavras-chave)
todos os artigos deverão conter resumos estruturados em português, inglês e espanhol, acompanhados dos
descritores nos respectivos idiomas. a terminologia para os descritores deve ser denominada no artigo como a seguir:
Brazilian Journal of Cancerology 2011; 57(3): 431-459
443

palavras-chave, key words e palabras clave. Cada resumo deverá conter no mínimo 150 palavras e no máximo 250,
introdução, objetivo(s), metodologia, resultados, conclusão e vir acompanhado de no mínimo três e no máximo
seis descritores. os descritores são palavras fundamentais que auxiliam na indexação dos artigos em bases de dados
nacionais e internacionais. Para determinar os descritores, deve-se consultar a lista de “Descritores em Ciências da
saúde” (DeCs-lilaCs- http://decs.bvs.br) elaborada pela Bireme.
no resumo, não devem ser feitas citações de referências, nem se devem incluir abreviaturas e/ou siglas, bem como
quadros, tabelas ou figuras.
no caso de resumos de trabalhos apresentados em eventos de oncologia ou que mereçam destaque e que foram
aceitos para publicação na rBC, caberá aos autores proceder à adequação às normas da revista antes de encaminhálos,
sendo de sua inteira responsabilidade a precisão e correção da linguagem.
3. Introdução
Deve ser objetiva com definição clara do problema estudado destacando sua importância e as lacunas do
conhecimento; a revisão de literatura deve ser estritamente pertinente ao assunto tratado no estudo, de modo a
proporcionar os antecedentes para a compreensão do conhecimento atual sobre o tema e evidenciar a importância do
novo estudo. Deve conter o(s) objetivo(s) do estudo.
4. Métodos
Deve indicar de forma objetiva o tipo de estudo (prospectivo, retrospectivo; ensaio clínico ou experimental; se a
distribuição dos casos foi aleatória ou não; qualitativo etc), os métodos empregados, a população estudada (descrever
claramente a seleção dos indivíduos dos estudos observacionais ou experimentais - pacientes ou animais de laboratório,
incluindo controles, bem como dos estudos qualitativos), a fonte de dados e os critérios de seleção ou grupo experimental,
inclusive dos controles. identificar os equipamentos e reagentes empregados. Descrever também os métodos estatísticos
empregados e as comparações para as quais cada teste foi empregado.
os relatos de ensaios clínicos devem apresentar informação de todos os elementos principais do estudo, incluindo
o protocolo (população estudada, intervenções ou exposições, resultados - e a lógica da análise estatística), atributos
das intervenções (métodos de aleatorização, indicação dos grupos de tratamento) e os métodos de mascaramento.
os autores que enviarem artigos de revisão deverão apresentar os procedimentos adotados para localizar, selecionar,
obter, classificar e sintetizar as informações além de definir os critérios de inclusão e exclusão dos estudos selecionados
para a revisão.
Quando forem relatados experimentos com seres humanos, indicar se os procedimentos seguidos estiveram de
acordo com os padrões éticos do Comitê de Pesquisa em seres humanos institucional, com a Declaração de Helsinky
(última versão de 2000) e com a resolução 196/96 (res. Cns 196/96). não usar os nomes dos pacientes, iniciais ou
números de registro, especialmente no material ilustrativo. no caso de experimentos envolvendo animais, indicar se
foram seguidas as normas das instituições, dos Conselhos nacionais de Pesquisa ou de alguma lei nacional sobre uso
e cuidado com animais de laboratório.
Dessa seção, também faz parte a menção do documento, indicando o número de protocolo, do CeP da instituição
a que se vinculam os autores e que aprovou o estudo realizado.
5. Resultados
apresentar os resultados relevantes para o objetivo do trabalho e que serão discutidos. Devem ser descritos somente
os resultados encontrados, sem incluir interpretações ou comparações. apresentar os resultados, tabelas e ilustrações
em sequência lógica, atentando para que o texto complemente e não repita o que está descrito em tabelas e ilustrações.
restringir tabelas e ilustrações àquelas necessárias para explicar o argumento do artigo e para sustentá-lo. usar gráficos
como uma alternativa às tabelas com muitas entradas; não duplicar os dados em gráficos e tabelas. evitar uso de
termos técnicos de estatística, tais como: “random” (que implica uma fonte de aleatorização), “normal”, “significante”,
“correlação” e “amostra” de forma não técnica. Definir os termos estatísticos, abreviações e símbolos. nos relatos de
casos, as seções “métodos” e “resultados” são substituídas pela descrição do caso.
6. Discussão
Deve conter a interpretação dos autores, comparar os resultados com a literatura, relacionar as observações a outros
estudos relevantes, apontar as limitações do estudo, enfatizar os aspectos novos e importantes do estudo e as conclusões
derivadas, incluindo sugestões para pesquisas futuras.
444 Brazilian Journal of Cancerology 2011; 57(3): 431-459

a discussão pode ser redigida junto com os resultados se for de preferência do autor.
não repetir em detalhe dados ou outros materiais colocados nas seções de “introdução” ou “resultados”.
7. Conclusão
Deve ser fundamentada nos resultados encontrados e vinculada aos objetivos do estudo. afirmações não qualificadas
e conclusões não apoiadas por completo pelos dados não devem constar dessa seção. evitar fazer alusão a estudos
que não tenham sido concluídos. estabelecer novas hipóteses, quando estiverem justificadas claramente como tais.
recomendações, quando apropriadas, poderão ser incluídas.
8. Referências bibliográficas
Devem ser numeradas no texto por números arábicos, em sobrescrito (ex: a extensão da sobrevivência, entre
outros 1 ), de forma consecutiva, de acordo com a ordem que são mencionadas pela primeira vez no texto e sem menção
aos autores. a mesma regra aplica-se às tabelas e legendas. no caso de citação sequencial, separar os números por traço
(ex: 1-2); quando intercalados, use vírgula (ex.: 1,3,7).
as referências não podem ultrapassar o número de 25.
não devem ser incluídas referências no resumo. Deve-se constar apenas referências relevantes e que realmente
foram utilizadas no estudo.
as referências devem ser verificadas nos documentos originais. Quando se tratar de citação de uma referência citada
por outro autor deverá ser utilizado o termo “apud”.
a exatidão das referências é de responsabilidade dos autores.
as orientações abaixo objetivam trazer para os autores exemplos de referências apresentadas em seus trabalhos
informando sobre a padronização das mesmas. estão baseadas nas normas para Manuscritos submetidos a revistas
Biomédicas: escrever e editar para Publicações Biomédicas, estilo Vancouver, formuladas pelo iCMJe. serão apresentadas
as ocorrências mais comuns de referências por tipos de material referenciado. algumas observações listadas abaixo são
fruto de ocorrências em artigos de periódicos submetidos à publicação.
Para a padronização dos títulos dos periódicos nas referências é utilizado como guia o LocatorPlus 1 , fonte de consulta
da National Library of Medicine, que disponibiliza, na opção Journal Title, o título e/ou a abreviatura utilizada. em
algumas fontes, o título já vem padronizado (PubMed, lilacs e Medline). Caso não seja utilizada a forma padrão dê
preferência, informá-lo por extenso evitando utilizar uma abreviatura não padronizada que dificulte sua identificação.
Para a indicação de autoria, incluem-se os nomes na ordem em que aparecem na publicação até seis autores,
iniciando-se pelo sobrenome seguido de todas as iniciais dos pré-nomes separando cada autor por vírgula (1). no
caso da publicação apresentar mais de seis autores, são citados os seis primeiros; utiliza-se vírgula seguida da expressão
et al. (2). Quando o sobrenome do autor incluir grau de parentesco – filho, sobrinho, Júnior, neto - este deve ser
subsequente ao último sobrenome: João dos santos de almeida filho - almeida filho Js, José rodrigues Junior -
rodrigues Junior J.
Para padronização de títulos de trabalhos, utilizam-se letras minúsculas em todo o período, com exceção da primeira
palavra que começa, sempre, com letra maiúscula. fogem à regra nomes próprios: nomes de pessoas, nomes de ciências
ou disciplinas, instituições de ensino, países, cidades ou afins, e nomes de estabelecimentos públicos ou particulares.
EXEMPLOS DE REfERÊNCIAS EM PERIÓDICOS
1. Artigo com até seis autores
Kakuda Jt, stuntz M, trivedi V, Klein sr, Vargas hi. objective assessment of axillary morbidity in breast cancer
treatment. am surg 1999; 65: 995-8. obs.: usar 995-8, não usar 995-998.
2. Artigo com mais de seis autores
zheng h, takahashi h, Murai y, Cui z, nomoto K, Miwa s, et al. Pathobiological characteristics of intestinal
and diffuse-type gastric carcinoma in Japan: an immunostaining study on the tissue microarray. J Clin Pathol
2007 Mar;60(3):273-7.
1 Disponível em: (http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&PaGe=first).
Brazilian Journal of Cancerology 2011; 57(3): 431-459
445

3. Artigo cujo autor é uma Instituição
utilizar o nome da instituição indicando entre parênteses o país quando for uma instituição pública (a) no caso
de uma instituição particular utiliza-se somente o nome da instituição. observar a hierarquia (b) à qual a instituição
está subordinada para sua perfeita identificação (não utilizar direto: secretaria de atenção à saúde. De onde?).
4. Artigo com autoria de múltiplas organizações
incluem-se todas. (a) instituto nacional de Câncer (Brasil). encontro internacional sobre rastreamento de Câncer
de Mama. revista brasileira de cancerologia 2009 abr.-jun.; 2 (55): 99-113. (b) Brasil. Ministério da saúde. secretaria
de atenção à saúde. Departamento de atenção Básica. Coordenação nacional de saúde Bucal. Projeto sB Brasil 2003:
condições de saúde bucal da população brasileira 2002-2003: resultados principais. Brasília, 2004b. [acesso em abr
2004]. Disponível em:
5. Autor com indicação de parentesco em seu nome
Mattes rD, Curram Jr WJ, alavi J, Powlis W, Whittington r. Clinical implications of learned food aversions in
patients with cancer treated with chemotherapy or radiation therapy. Cancer 1992; 70 (1): 192-200.
6. Artigo sem indicação de autoria
Pelvic floor exercise can reduce stress incontinence. health news 2005 apr;11(4):11.
7. Artigo com indicação de seu tipo (revisão, abstract, editorial)
facchini luiz augusto. aBrasCo 30 anos: ciência, educação e prática com compromisso social. [editorial] Cad
saúde Pública [periódico na internet]. 2010 Jan [citado 2010 ago 23] ; 26(1): 4-4. Disponível em: .
8. Artigo publicado num suplemento de periódico
nascimento af, Galvanese atC. avaliação da estrutura dos centros de atenção psicossocial do município de são
Paulo, sP. rev saude Publica 2009; 43 suppl.1: 8-15.
9. Artigo publicado na parte de um número
fukuzawa M, oguchi s, saida t. Kaposi's varicelliform eruption of an elderly patient with multiple myeloma. J
am acad Dermatol. 2000 May;42(5 Pt 2):921-2.
10. Artigo publicado sem indicação de volume ou número do fascículo
schwartz-Cassell t. feeding assistants: based on logic or way off base? Contemp longterm Care. 2005 Jan:26-8.
11. Artigo publicado com paginação indicada em algarismos romanos
nagpal s. an orphan meets family members in skin. J invest Dermatol. 2003;120(2):viii-x.
12. Artigo contendo retratação ou errata publicadas, a referência deve conter a indicação da publicação das mesmas
Mokdad ah, Marks Js, stroup Df, Gerberding Jl. Correction: actual causes of death in the united states, 2000.
JaMa. 2005 Jan 19;293(3):293-4. erratum for: JaMa. 2004 Mar 10;291(10):1238-45.
13. Artigo com publicação eletrônica anterior à versão impressa
Bicalho PG, hallal PC, Gazzinelli a, Knuth aG, Velásquez-Meléndez G. atividade física e fatores associados em
adultos de área rural em Minas Gerais, Brasil. rev saude Publica [acesso 2010 ago 23]. Disponível em: Publicado 2010.
epub 30-Jul-2010. doi: 10.1590/s0034-89102010005000023.
14. Artigo provido de DOI
Caldeira aP, fagundes GC, aguiar Gn de. intervenção educacional em equipes do Programa de saúde da família para
promoção da amamentação. rev saúde Pública 2008;42(6):1027-1233. doi: 10.1590/s0034-89102008005000057.
15. Artigo no prelo
Barroso t, Mendes a, Barbosa a. analysis of the alcohol consumption phenomenon among adolescents: study
carried out with adolescents in intermediate public education. rev latino-am enfermagem. in press 2009.
EXEMPLOS DE REfERÊNCIAS EM LIVROS E OuTRAS MONOGRAfIAS
16. Livro
hoppenfeld s. Propedêutica ortopédica: coluna e extremidades. rio de Janeiro: atheneu; 1993. 294 p.
17. Livro com indicação de editor, organizador, coordenador
Bader MK, littlejohns lr, editors. aann core curriculum for neuroscience nursing. 4th. ed. st. louis (Mo):
saunders; c2004. 1038 p.
446 Brazilian Journal of Cancerology 2011; 57(3): 431-459

18. Livro editado por uma Instituição
World Cancer research fund (usa). food, nutrition, physical activity and prevention of cancer: a global perspective.
Washington (DC): american institute for Cancer research; 2007.
19. Quando o autor do capítulo é o autor do livro, referência de capítulo de livro
ferreira sa. nervos proximais do membro superior. in: ____. lesões nervosas periféricas diagnóstico e tratamento.
são Paulo: santos; 2001. p. 35-48.
20. Livro sem indicação de autoria
hiV/aiDs resources: a nationwide directory. 10th ed. longmont (Co): Guides for living; c2004. 792 p.
21. Anais de conferências
harnden P, Joffe JK, Jones WG, editors. Germ cell tumours V. Proceedings of the 5th Germ Cell tumour Conference;
2001 sep 13-15; leeds, uK. new york: springer; 2002.
22. Trabalho apresentado em conferências
Christensen s, oppacher f. an analysis of Koza's computational effort statistic for genetic programming. in: foster
Ja, lutton e, Miller J, ryan C, tettamanzi aG, editors. Genetic programming. euroGP 2002: Proceedings of
the 5th european Conference on Genetic Programming; 2002 apr 3-5; Kinsdale, ireland. Berlin: springer; 2002.
p. 182-91.
23. Legislação
Dispõe sobre a regulamentação do exercício da enfermagem. lei no. 7.498, 25 de junho de 1986. Diário oficial
da união. seção i, fls. 9.273-9.275 (Jun 26, 1986). 1986.
24. Teses e dissertações
Verde sMMl. impacto do tratamento quimioterápico no estado nutricional e no comportamento alimentar de
pacientes com neoplasia mamária e suas consequências na qualidade de vida [dissertação]. são Paulo: universidade
de são Paulo; 2007.
9. Tabelas
as tabelas deverão constar em folhas separadas. não enviar as tabelas em forma de imagem, de forma a permitir
sua edição. numerar as tabelas em ordem consecutiva de acordo com a primeira citação no texto e dar um título curto
a cada uma. Definir para cada coluna um cabeçalho abreviado ou curto. Colocar as explicações em rodapés, não no
cabeçalho. explicar, em notas de rodapé, todas as abreviações não padronizadas usadas em cada tabela. Para notas de
rodapé, utilizar numeração romana.
identificar medidas estatísticas de variações, tais como: desvio-padrão e erro-padrão.
não usar linhas internas, horizontais ou verticais.
Constatar que cada tabela esteja citada no texto por sua numeração e não por citação como: tabela a seguir, tabela
abaixo.
se forem usados dados de outra fonte, publicada ou não, obter autorização e agradecer por extenso.
o uso de tabelas grandes ou em excesso, em relação ao texto, pode produzir dificuldade na forma de apresentação
das páginas.
10. Ilustrações
enviar o número requerido de ilustrações ou “figuras”. não são aceitáveis desenhos à mão livre ou legendas
datilografadas. as fotos devem ser digitalizadas, em branco e preto, usualmente de 12 x 17cm, não maiores do que
20 x 25 cm, filmes de raios X ou outros materiais. as letras, os números e símbolos devem ser claros e de tamanho
suficiente, de tal forma que, quando reduzidas para a publicação, ainda sejam legíveis. Colocar os títulos e explicações
abaixo das legendas e não nas próprias ilustrações.
se forem usadas fotografias de pessoas, os sujeitos não devem ser identificáveis ou suas fotografias devem estar
acompanhadas por consentimento escrito para publicação.
as figuras devem ser numeradas de acordo com a ordem em que foram citadas no texto. se uma figura já foi publicada,
agradecer à fonte original e enviar a autorização escrita do detentor dos direitos autorais para reproduzir o material.
a autorização é requerida, seja do autor ou da companhia editora, com exceção de documentos de domínio público.
a rBC é uma publicação em preto e branco e por isso todas as ilustrações serão reproduzidas em preto e branco.
as ilustrações devem ser fornecidas da seguinte forma:
Brazilian Journal of Cancerology 2011; 57(3): 431-459
447

• Arquivo digital em formato .TIFF, .JPG, .EPS, com resolução mínima de:
300 dpi para fotografias comuns
600 dpi para fotografias que contenham linhas finas, setas, legendas etc.
1.200 dpi para desenhos e gráficos
11. Nomenclatura
Devem ser observadas rigidamente as regras de nomenclatura biomédica, assim como abreviaturas e convenções
adotadas em disciplinas especializadas.
os originais em língua portuguesa deverão estar em conformidade com o acordo ortográfico datado de 1º de
Janeiro de 2009.
resUmo Dos reQUisiTos Técnicos pArA A ApresenTAção De mAnUscriTos
antes de enviar o manuscrito por e-mail, para rbc@inca.gov.br, confira se as “instruções para autores” disponível
em www.inca.gov.br/rbc foram seguidas e verifique o atendimento dos itens listados a seguir:
• Submeter o arquivo integral do manuscrito em Microsoft Word 6.0 ou 7.0.
• Usar espaço duplo em todas as partes do documento.
• Começar cada seção ou componente em uma nova página.
• Revisar a sequência: página-título/folha de rosto – título em português, inglês e espanhol; título abreviado; autoria;
resumo e palavras-chave, abstract e key words, resumen e palabras clave; agradecimentos; declaração de conflito de
interesse; declaração de subvenção; texto; referências; tabelas, quadros, figuras com legendas (cada uma em páginas
separadas).
• De três a seis palavras-chave e respectivas key words e palabras clave.
• Referências: numeradas, em sobrescrito, na ordem de aparecimento no texto, corretamente digitadas, e não
ultrapassando o número de 25. Verificar se todos os trabalhos citados estão na lista de referências e se todos os
listados estão citados no texto.
• Apresentar ilustrações, fotos ou desenhos separados, sem montar (20 x 25 cm máximo).
• Incluir carta de submissão disponível nas “Instruções para Autores”. Caso o manuscrito tenha mais que um autor,
cada um deles deverá preencher e assinar a carta e o autor responsável pela submissão deve enviar a mesma digitalizada
em formato .JPG junto com o arquivo do manuscrito para rbc@inca.gov.br.
• Incluir permissão para reproduzir material previamente publicado ou para usar ilustrações que possam identificar
indivíduos.
• Incluir autorização escrita das pessoas nomeadas nos agradecimentos, quando aplicável.
• Incluir documento comprovando a aprovação do trabalho por CEP ou TCLE, quando aplicável.
448 Brazilian Journal of Cancerology 2011; 57(3): 431-459

Carta de Submissão à Revista Brasileira de Cancerologia
Por favor, preencha e envie este formulário juntamente com o original do seu trabalho para o e-mail: rbc@inca.gov.
br. Caso o manuscrito tenha mais que um autor, cada um deles deverá preencher, assinar e encaminhar esta carta para o
autor responsável pela submissão, para digitalizar em formato .JPG e enviar à rBC em anexo, junto com o manuscrito.
Título do manuscrito _____________________________________________________________________
______________________________________________________________________________________
Classificação do manuscrito:
( ) artigo original
( ) revisão sistemática da literatura
( ) relato de Caso/série de Casos
( ) artigo de opinião
( ) resenha
( ) resumo
( ) Carta ao editor
Cada autor deve indicar suas contribuições, marcando com a letra X os campos abaixo:
1. o autor contribuiu:
( ) na concepção e planejamento do projeto de pesquisa
( ) na obtenção e/ou análise e interpretação dos dados
( ) na redação e revisão crítica
2. Conflito de interesses:
( ) o autor não tem conflitos de interesse, incluindo interesses financeiros específicos e relacionamentos e afiliações
relevantes ao tema ou materiais discutidos no manuscrito.
( ) o autor confirma que todos os financiamentos, outros apoios financeiros, e apoio material/humano para esta
pesquisa e/ou trabalho estão claramente identificados no manuscrito enviado para avaliação do “Conselho editorial
da rBC”.
3. agradecimentos:
( ) o autor confirma que as pessoas que contribuíram substancialmente ao trabalho desenvolvido neste texto, mas
que não atendem aos critérios para autoria, foram mencionadas nos “agradecimentos” do manuscrito com a descrição
de suas contribuições específicas.
( ) o autor confirma que todos que foram mencionados nos “agradecimentos” deram sua permissão por escrito
para serem incluídos no mesmo.
( ) o autor confirma que, se os “agradecimentos” não foram incluídos no texto submetido, foi porque não houve
nenhuma contribuição substancial de outros ao manuscrito além dos autores.
4. transferência de Direitos autorais/Publicação
Declaro que em caso de aceitação do manuscrito para publicação, concordo que os direitos autorais a ele passarão
a ser propriedade da rBC, sendo vedada tanto sua reprodução, mesmo que parcial, em outros periódicos, sejam eles
impressos ou eletrônicos, assim como sua tradução para publicação em outros idiomas, sem prévia autorização desta
e, que no caso de obtenção do mesmo, farei constar o competente agradecimento à revista.
autor ___________________________________ assinatura _________________________________
Data ___________________________________ e-mail ____________________________________
Brazilian Journal of Cancerology 2011; 57(3): 431-459
449

InSTRuCCIOnES PARA LOS AuTORES
informAción generAL
la revista Brasileña de oncología (rBC) es una publicación trimestral que tiene como objetivo publicar trabajos
relacionados con todas las áreas de oncología. se aceptan trabajos en Portugués, inglés y español.
rBC adopta los "Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for
Biomedical Publication" [requisitos de uniformidad para Manuscritos enviados a revistas Biomédicas] del Comité
internacional de editores de revistas Médicas (iCMJe) (http://www.icmje.org). el documento original, incluyendo
tablas, ilustraciones y referencias debe seguir estos requisitos.
los manuscritos deben ser inéditos y destinados exclusivamente a rBC, y su presentación simultánea a otro periódico
no está permitida. los conceptos y opiniones expresadas en los artículos, así como la exactitud y procedencia de las
citas son de la exclusiva responsabilidad del (de los) autor(es). los manuscritos que se refieren a partes de la misma
investigación tienen el envío desincentivado por esta revista.
los manuscritos publicados pasan a ser propiedad de rBC, y queda prohibida su reproducción, incluso parcial,
en otros periódicos, como su traducción para su publicación en otros idiomas sin autorización previa de esta.
los manuscritos aceptados para publicación pueden ser modificados para adecuarse al estilo editorial-gráfico de la
revista, sin, entre tanto, cambiar su contenido técnico-científico.
si el manuscrito incluye tablas e ilustraciones publicadas anteriormente por otros autores y otros vehículos, el autor
debe presentar comprobantes de autorización para la reproducción, firmado por los titulares de derechos de estos.
los lectores de las revistas médicas merecen confiar en lo que leyen, a menos que haya una declaración clara de que
el artículo está reeditado por la elección del autor y editor. las bases para esta posición son las leyes internacionales de
derechos de autor, la conducta ética y el uso de recursos de acuerdo con una lógica de costo efectividad.
Cuando parte del material del manuscrito ya haya sido presentado en una comunicación preliminar, en simposio,
congreso etc., este hecho debe ser citado como una nota a pie de página de la portada y una copia del texto de la
presentación debe acompañar el envío del manuscrito.
en el envío de manuscritos o resúmenes de la investigación clínica, ensayos clínicos, investigación básica,
investigación aplicada, investigación de traducción; estudios de laboratorio, estudios epidemiológicos (prospectivos o
retrospectivos); el uso de datos de prontuarios, investigación en base de datos; reporte de casos; entrevistas, cuestionarios,
averiguaciones poblacionales; es obligatoria la inclusión de documento, con número de protocolo, de que todos los
procedimientos propuestos hagan sido evaluados y aprobados por el Comité Ético en investigación Clínica (CeiC)
de la institución a la cual se vinculan los autores o, en la falta de esto, por un otro CeiC indicado por el Comité
nacional de Ética en investigación Clínica del Ministerio de sanidad.
los pacientes tienen derecho a privacidad, hecho que no debe ser infringido sin el consentimiento informado.
la información de identificación personal no debe ser publicada en descripciones escritas, fotografías, genealogías y
reporte de casos, a menos que la información sea esencial para fines científicos y que el paciente (o sus padres o tutor)
otorgue un consentimiento informado por escrito, autorizando su publicación.
Deben se omitir los detalles de identificación, si no son fundamentales, pero los datos del paciente nunca deben
ser alterados o falsificados en un intento de lograr el anonimato. el completo anonimato es difícil de lograr, por eso
es necesario obtener el consentimiento informado si hay alguna duda. Por ejemplo, enmascarar la región ocular en las
fotografías de los pacientes es una protección inadecuada para el anonimato.
rBC, una vez que reconoce la importancia de la difusión internacional, de libre acceso, de información sobre
estudios clínicos, apoya las políticas para el registro de ensayos clínicos de la organización Mundial de la salud (oMs)
y del iCMJe. Por lo tanto, serán aceptados para su publicación sólo artículos de investigación clínica que han recibido
un número de identificación en uno de los registros de ensayos Clínicos por los criterios establecidos por la oMs e
iCMJe, cuyas direcciones están disponibles en el sitio del iCMJe (http://www.icmje.org).
los conflictos de intereses deben ser reconocidos y mencionados por los autores. entre estas situaciones, se menciona
la participación en empresas productoras de los medicamentos o equipos citados o utilizados en el trabajo, así como
sus competidores. también se consideran fuentes de conflicto la ayuda recibida, las relaciones de subordinación en el
trabajo, consultorías etc.
Brazilian Journal of Cancerology 2011; 57(3): 431-459
451

el envío del manuscrito a rBC debe ser por correo electrónico a rbc@inca.gov.br, con el texto completo, tablas,
gráficos, figuras, imágenes, código postal y Consentimiento informado (si aplicable) y de conformidad con los estándares
de la revista. la "Carta de presentación" individual y firmada por cada uno de los autores (modelo disponible en el
http://www.inca.gov.br/rbc) también debe ser encaminada.
proceso De evALUAción De Los mAnUscriTos
la publicación de la obra dependerá del cumplimiento de los estándares de rBC y de la decisión de su Consejo
editorial. el proceso de evaluación comienza con el editor científico que evalúa si el artículo recibido incluye
contribuciones en el campo de la oncología y si es de interés para los lectores. también evalúa si el documento
original está preparado de acuerdo con las instrucciones recomendadas por la revista. los manuscritos considerados
pertinentes, pero en desacuerdo con estas instrucciones, serán devueltos a los autores para los ajustes necesarios, antes
de la evaluación por el Consejo editorial.
la versión aceptada es encaminada para análisis y emisión de la opinión de los miembros del Consejo editorial y/o
Ad Hoc, ambos formados por profesionales de grande conocimiento en diversas áreas de la oncología. en ese proceso,
la confidencialidad y el anonimato serán adoptados para autor(es) y para la junta de opinión. el análisis de la junta
de opinión se realiza con base en el formulario “Parecer do Conselho editorial” [opinión del Consejo editorial],
disponible en las instrucciones para la publicación en rBC en el http://www.inca.gov.br/rbc.
Después de emitir la opinión, el manuscrito es enviado al editor científico que tiene el conocimiento de las opiniones
emitidas y analiza el cumplimiento de los estándares de publicación de la revista y decide sobre la aceptación o no
del artículo, así como las alteraciones solicitadas, proceso sobre el cual tiene plena autoridad de decisión. la opinión
es, entonces, enviada a los autores por correo electrónico.
Después de la evaluación, se puede clasificar los manuscritos como: manuscrito aprobado sin restricciones, que será
encaminado al revisor técnico para su revisión y posterior publicación; manuscrito aprobado con restricciones, que será
enviado al (los) autor(es) con las solicitudes de ajuste a través de correo electrónico. el manuscrito revisado debe ser
presentado nuevamente por el (los) autor(es) a rBC, por correo electrónico, acompañado de una carta informando las
alteraciones realizadas o, si no hay tales alteraciones, presentando motivos que la respalden. Puesto que no hay regreso
del trabajo en cuarenta y cinco (45) días, se considerará que los autores no tienen interés en la publicación; manuscrito
no aprobado, en ese caso el autor recibirá una notificación de recusación por correo electrónico.
el manuscrito aprobado será publicado de conformidad con el flujo y el cronograma del editorial de la revista.
cATegoríA De Los mAnUscriTos
son considerados para su publicación los siguientes tipos de manuscritos:
• Artículos originales - son artículos en que se presentan los resultados obtenidos en investigaciones empíricas o
experimentales originales cuyos resultados pueden ser replicados y/o generalizados. también son consideradas
originales las investigaciones de metodología cualitativa y las formulaciones discursivas de teorización. Como
estructura deben proporcionar: introducción, método, resultados, discusión y conclusión. el máximo es de 20
páginas, incluyendo figuras, tablas, gráficos etc. (no deben ultrapasar 5).
• Revisión de la Literatura – es una revisión sistematizada y actualizada de la literatura sobre un tema específico y que
debe dar al lector una cobertura general de un tema. revisiones narrativas no son aceptadas. Deben ser descritos los
tipos de revisión (integrativa, sistemática, meta-análisis), los métodos y procedimientos utilizados para realizar el
trabajo. la interpretación y conclusión de los autores deben estar presentes. Como estructura deben proporcionar:
introducción, método, resultados, discusión y conclusión. el máximo es de 20 páginas, incluyendo figuras, tablas,
gráficos etc. (no deben ultrapasar 5).
• Reporte de caso/Serie de Casos - es la descripción detallada y el análisis crítico de uno o más casos, típicos o atípicos,
basado en revisión bibliográfica extensa y actualizada sobre el tema. el autor debe presentar un problema en sus
muchos aspectos, su pertinencia. el máximo es de 15 páginas, incluyendo figuras, tablas, gráficos etc. (no deben
ultrapasar 4).
• Artículo de Opinión – es una opinión calificada sobre un tema específico en oncología. No necesita resumen. El
máximo es de 10 páginas, incluyendo tablas, gráficos etc. (no deben ultrapasar 2).
• Reseña - reseña crítica de libros relacionado con el ámbito temático de Oncología, publicado el año pasado. El
máximo es de 4 páginas.
452 Brazilian Journal of Cancerology 2011; 57(3): 431-459

• Resúmenes de disertación doctoral, de tesis, de trabajos que merezcan destaque o que han sido presentados en eventos
de oncología en los últimos 12 meses, a partir de la fecha del resumen - es la información en forma sucinta de trabajo
realizado. Por lo tanto, debe incluir la naturaleza y los propósitos de la investigación y algunas observaciones sobre
la metodología, resultados y conclusiones más importantes. su objetivo es transmitir a los investigadores de forma
rápida y fácil la naturaleza del trabajo, sus características básicas de los logros y el alcance científico afirmado. Deben
contener por lo menos 150 a 250 palabras y seguir los estándares de la revista con respecto a la estructura, forma
y contenido, incluso en relación con los descriptores.
• Cartas al Editor - pueden estar relacionadas con cuestiones editoriales o no, pero deben contener informaciones
relevantes para el lector. en el caso de críticas a trabajos publicados en la edición anterior de la revista, la carta es
enviada a los autores para que su respuesta sea publicada al mismo tiempo. las cartas pueden ser resumidas por los
editores, pero los principales puntos serán mantenidos. el máximo es de 4 páginas.
prepArAción DeL mAnUscriTo
el original debe ser escrito en el verbo en tercera persona del singular, en la voz activa (aBnt.nBr-6028, 2003, p. 2).
el procesador de texto utilizado debe ser el Microsoft Word 6.0 o 7.0, fuente Times New Roman tamaño 12, márgenes
de 30mm en ambos lados, doble espacio en todas las secciones, papel de tamaño a4 (210 x 297mm) y páginas numeradas.
Para permitir una mayor claridad en la exposición del tema y la localización particular de cada ítem, se divide el
texto en partes lógicas, de acuerdo con los temas relacionados.
ejemplo:
introDuCCión (seCCión PriMaria)
Material y MÉtoDo (seCCión PriMaria)
la recogida de datos (sección secundaria)
Variables (sección terciaria)
en la presentación de los títulos de las secciones, hay que destacar gradualmente el tipo y el tamaño de las letras,
señalando que todas las secciones primarias deben estar escritas en la misma manera, así como todas las secundarias
y así sucesivamente.
el texto de cada sección de un documento puede incluir una serie de párrafos que deben ser caracterizados por
las letras minúsculas del alfabeto (a, b, c,...) seguidos de paréntesis, y que precedan inmediatamente la primera
palabra de su texto.
ejemplo:
a) escribir un artículo científico.
b) ilustrar el texto.
principALes orienTAciones AcercA De cADA sección
1. Página de título o portada
Debe contener: a) título del artículo, alternando letras mayúsculas y minúsculas, en portugués, inglés y español; b)
título abreviado de hasta 40 caracteres; c) nombre(s) por extenso del (de los) autor(es). la designación de la autoría debe
basarse en las deliberaciones iCMJe, que considera el autor aquel que contribuye sustancialmente en el diseño o en la
planificación del estudio; en la obtención, en el análisis y/o interpretación de los datos; así como en la redacción y/o
revisión crítica y aprobación final de la versión publicada. los estudios institucionales (de autoría colectiva) y estudios
multicéntricos, los responsables deben tener sus nombres especificados y todos considerados autores deben cumplir
con los criterios arriba mencionados; d) indicar para cada autor, en una nota a pie de página, la categoría profesional,
el más alto grado académico, el (los) nombre(s) del (de los) departamento(s) e institución(es) a que el trabajo debe
ser asignado, correo electrónico, ciudad, estado y país; e) nombre, dirección y teléfono del autor responsable por la
correspondencia sobre el manuscrito; f) descripción de la contribución individual de cada autor en el manuscrito
(ejemplo: .... trabajó en el diseño y redacción final y ...... en la investigación y metodología); g) agradecimientos:
otros colaboradores, que no cumplan los criterios de autoría arriba descritos, deben tener sus nombres referidos en
este ítem, especificando el tipo de colaboración. los autores son responsables de obtener la autorización por escrito
de las personas referidas en los agradecimientos, ya que y puede inferir que están de acuerdo con el contenido del
trabajo; h) declaración de conflicto de intereses (escribir "nada a declarar" o revelar cualquier conflicto); i) para trabajos
subvencionados, identificar el patrocinador y el número del proceso (si hay alguno).
Brazilian Journal of Cancerology 2011; 57(3): 431-459
453

2. Resumen y descriptores (palabras clave)
todos los artículos deben incluir resúmenes estructurados en portugués, inglés y español, acompañados por los
descriptores en sus respectivos idiomas. la terminología para los descriptores debe ser denominada en el artículo como
sigue: Palabras-chave, key words y palabras clave. Cada resumen debe tener al mínimo 150 palabras y al máximo 250,
introducción, objetivo(s), metodología, resultados, conclusión, acompañados de un mínimo de tres y un máximo de
seis descriptores. los descriptores son palabras esenciales que ayudan a la indexación de artículos en bases de datos
nacionales e internacionales. Para determinar los descriptores, es necesario consultar la lista de “Descritores em Ciências
da saúde” [Descriptores en Ciencias de la salud] (DeCs-lilacs- http://decs.bvs.br) preparada por BireMe.
en el resumen no deben ser hechas citas de referencias, tampoco abreviaturas y/o siglas deben ser incluidas, así
como gráficos, tablas o figuras.
en el caso de los resúmenes de los trabajos presentados en eventos de oncología o que merezcan destaque y que
han sido aceptados para su publicación en rBC, es responsabilidad de los autores cumplir con los estándares de la
revista antes de enviarlos, además de la precisión y exactitud del lenguaje.
3. Introducción
la introducción debe ser objetiva con la definición clara del problema estudiado destacando su importancia y las
lagunas en el conocimiento; la revisión de la literatura debe ser estrictamente pertinente al tema del estudio, con el fin
de proporcionar los antecedentes para la comprensión del conocimiento actual sobre el tema y destacar la importancia
del nuevo estudio. Debe contener el (los) objetivo(s) del estudio.
4. Métodos
Debe indicar, de manera objetiva, el tipo de estudio (prospectivo, retrospectivo; ensayo clínico o experimental; si la
distribución de los casos fue aleatoria o no, cualitativa etc.), los métodos empleados, la población estudiada (describir
claramente la selección de los sujetos de los estudios observacionales o experimentales – pacientes o animales de
laboratorio, incluyendo grupos de control, así como de los estudios cualitativos), la fuente de datos y los criterios de
selección o grupo experimental, incluso de los controles. identificar el equipo y los reactivos utilizados. Describir,
también, los métodos estadísticos utilizados y las comparaciones para las cuales cada prueba fue utilizada.
los reportes de ensayos clínicos deben presentar información sobre todos los elementos principales del estudio,
incluyendo el protocolo (población de estudio, intervenciones o exposiciones, resultados - y la lógica de análisis
estadístico), atributos de las intervenciones (métodos de aleatorización, indicación de los grupos de tratamiento) y los
métodos de enmascaramiento.
los autores que enviaren artículos de revisión, deben presentar los procedimientos adoptados para localizar,
seleccionar, obtener, clasificar y sintetizar las informaciones, además de definir los criterios de inclusión y exclusión
de los estudios seleccionados para su revisión.
Cuando experimentos con seres humanos fueren reportados, indicar si los procedimientos seguidos estuvieron de
acuerdo con las normas éticas del Comité de investigación en seres humanos, con la Declaración de Helsinky (última
versión de 2000) y con la resolución 196/96 (res. Cns 196/96). no utilizar los nombres de los pacientes, iniciales o
números de registro, especialmente en el material ilustrativo. en el caso de los experimentos con animales, indicar si
fueron seguidas las normas de la institución, de los Consejos nacionales de investigación o de cualquier ley nacional
sobre el uso y cuidado con animales de laboratorio.
De esta sección, también hace parte la mención del documento, indicando el número de protocolo, del CeiC de
la institución a que se vinculan los autores y que aprobó el estudio.
5. Resultados
Presentar los resultados pertinentes para el objetivo del trabajo y que serán discutidos. sólo los resultados encontrados
deben ser descritos, sin incluir las interpretaciones o comparaciones. Presentar los resultados, tablas e ilustraciones en
una secuencia lógica, teniendo en cuenta que el texto debe complementar y no repetir lo que se describe en las tablas
e ilustraciones. restringir tablas e ilustraciones a las que sean necesarias para explicar el argumento del artículo y para
embasarlo. usar gráficos como una alternativa a las tablas con muchas entradas; no duplicar los datos en gráficos y tablas.
evitar el uso de términos técnicos en estadística, tales como: "random" (lo que implica una fuente de aleatorización),
"normal", "significante", "correlación" y “muestra” de manera no técnica. Definir los términos estadísticos, abreviaturas
y símbolos. en los reportes de casos, las secciones "métodos" y "resultados" se sustituyen por la descripción del caso.
454 Brazilian Journal of Cancerology 2011; 57(3): 431-459

6. Discusión
Debe contener la interpretación de los autores, comparar los resultados con la literatura, relacionar las observaciones
con otros estudios relevantes, indicar las limitaciones del estudio, enfatizar los aspectos nuevos e importantes del estudio
y las conclusiones derivadas, incluyendo sugerencias para futuras investigaciones.
la discusión puede ser redactada junto con los resultados si esa es la preferencia del autor.
no repetir con detalles los datos u otros materiales colocados en las secciones "introducción" o "resultados".
7. Conclusión
la conclusión debe basarse en los resultados encontrados y estar vinculada a los objetivos del estudio. afirmaciones
no calificadas y conclusiones no plenamente respaldadas por los datos no deben constar en esta sección. no hacer
alusiones a estudios que no han sido completados. establecer nuevas hipótesis, cuando éstas fueren claramente
justificadas como tales. recomendaciones, cuando apropiadas, pueden ser incluidas.
8. Referencias
Deben ser numeradas en el texto por números arábigos en sobrescrito (por ejemplo, la extensión de la supervivencia
entre otros1), de manera consecutiva, de acuerdo con el orden en que son mencionadas por la primera vez en el texto
y sin mención de los autores. la misma regla se aplica a las tablas y leyendas. en el caso de la cita secuencial, separar
los números por un guión (por ejemplo, 1-2), cuando intercalados, utilice una coma (por ejemplo: 1,3,7).
las referencias no pueden exceder el número de 25.
las referencias no deben ser incluidas en el resumen. sólo deben constar referencias pertinentes y que de hecho
hagan sido usadas en el estudio.
las referencias deben ser verificadas en los documentos originales. en caso de ser una cita de una referencia
mencionada por otro autor, debe utilizarse el término "apud".
la exactitud de las referencias es responsabilidad de los autores.
las siguientes directrices tienen el objetivo de llevar a los autores ejemplos de referencias presentadas en sus trabajos
para informar su estandarización. se basan en los requisitos de uniformidad para Manuscritos enviados a revistas
Biomédicas: escribir y editar para Publicaciones Biomédicas, estilo Vancouver, formuladas por el iCMJe. serán
presentadas las ocurrencias más comunes de referencias por tipos de material referenciado. algunas observaciones
listadas abajo resultan de ocurrencias en artículos de periódicos enviados para publicación.
Para estandarizar los títulos de los periódicos en las referencias, se utiliza como una guía locatorPlus ; fuente de
consulta de la national library of Medicine [Biblioteca nacional de Medicina], que dispone, en la opción Journal
title [título de Periódico], el título y/o la abreviatura utilizada. en algunas fuentes, el título ya es estandarizado
(PubMed, lilacs y Medline). Caso no sea usada la forma estándar preferida, informar por extenso evitando utilizar
una abreviatura no estandarizada que dificulte su identificación.
Para la indicación de autoría, se incluyen los nombres en la orden en que aparecen en la publicación hasta seis
autores, comenzando por el apellido seguido de todas las iniciales de los nombres separando cada autor por coma (1). si
la publicación presenta más de seis autores, los seis primeros son citados; se usa coma seguida de la expresión et al. (2). si
el apellido del autor incluye grado de parentesco – filho, sobrinho, Júnior, neto [comunes en portugués] – éste debe ser
subsecuente al último apellido: João dos santos de almeida filho - almeida filho Js, José rodrigues Junior - rodrigues
Junior J.
Para estandarizar los títulos de los trabajos, se utilizan letras minúsculas en todo el período, excepto la primera
palabra que comienza, siempre, con mayúscula. rompen la regla nombres propios: nombres de personas, nombres
de las ciencias o disciplinas, instituciones de enseñanza, países, ciudades o similares, y nombres de estabelecimientos
públicos o privados.
EJEMPLOS DE REfERENCIAS EN PERIÓDICOS
1. Artículo con hasta seis autores
Kakuda Jt, stuntz M, trivedi V, Klein sr, Vargas hi. objective assessment of axillary morbidity in breast cancer
treatment. am surg 1999; 65: 995-8. n.: utilizar 995-8, no utilizar 995-998.
2. Artículo con más de seis autores
zheng h, takahashi h, Murai y, Cui z, nomoto K, Miwa s, et al. Pathobiological characteristics of intestinal
and diffuse-type gastric carcinoma in Japan: an immunostaining study on the tissue microarray. J Clin Pathol
2007 Mar;60(3):273-7.
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3. Artículo cuyo autor es una Institución
utilizar el nombre de la institución indicando entre paréntesis el país, cuando es una institución pública (a) si es
una institución privada, se utiliza sólo el nombre de la institución. observar la jerarquía (b) a la que la institución
está sujeta a su perfecta identificación (no se utilizar directamente: secretaria de salud. ¿De dónde?).
4. Artículo con autoría de múltiples organizaciones
se incluyen todas. (a) instituto nacional del Cáncer (Brasil). encontro internacional sobre rastreamento de Câncer
de Mama. revista brasileira de cancerologia 2009 abr.-jun.; 2 (55): 99-113. (b) Brasil. Ministerio de sanidad.
secretaria de salud. Departamento de atención Primaria. Coordinación nacional de salud Bucal. Projeto sB
Brasil 2003: condições de saúde bucal da população brasileira 2002-2003: resultados principais. Brasília, 2004b.
[accedido en abril 2004]. Disponible en:
5. Autor indicando parentesco en su nombre
Mattes rD, Curram Jr WJ, alavi J, Powlis W, Whittington r. Clinical implications of learned food aversions in
patients with cancer treated with chemotherapy or radiation therapy. Cancer 1992; 70 (1): 192-200.
6. Artículo sin indicación de autoría
Pelvic floor exercise can reduce stress incontinence. health news 2005 apr;11(4):11.
7. Artículo con indicación de su tipo (revisión, resumen, editorial)
facchini luiz augusto. aBrasCo 30 anos: ciência, educação e prática com compromisso social. [editorial]
suplemento de salud Pública [periódico en internet]. 2010 ene [citado el 23 de agosto 2010]; 26 (1): 4-4.
Disponible en: .
8. Artículo publicado en un suplemento de un periódico
nascimento af, Galvanese atC. avaliação da estrutura dos centros de atenção psicossocial do município de são
Paulo, sP. rev saude Publica 2009; 43 suppl.1: 8-15.
9. Artículo publicado en la parte de un número
fukuzawa M, oguchi s, saida t. Kaposi's varicelliform eruption of an elderly patient with multiple myeloma. J
am acad Dermatol. 2000 May;42(5 Pt 2):921-2.
10. Artículo publicado sin indicación de volumen o número del fascículo
schwartz-Cassell t. feeding assistants: based on logic or way off base? Contemp longterm Care. 2005 Jan:26-8.
11. Artículo publicado con la paginación indicada en números romanos
nagpal s. an orphan meets family members in skin. J invest Dermatol. 2003;120(2):viii-x.
12. Artículo que contiene retracción o erratas publicadas, la referencia debe contener la indicación de su
publicación
Mokdad ah, Marks Js, stroup Df, Gerberding Jl. Correction: actual causes of death in the united states, 2000.
JaMa. 2005 Jan 19;293(3):293-4. errata para: JaMa. 2004 Mar 10;291(10):1238-45.
13. Artículo con la publicación electrónica anterior a la versión impresa
Bicalho PG, hallal PC, Gazzinelli a, Knuth aG, Velásquez-Meléndez G. atividade física e fatores associados em
adultos de área rural em Minas Gerais, Brasil. rev saude Publica [accedido el 23 de agosto 2010]. Disponible en:
Publicado
2010. epub 30-Jul-2010. doi: 10.1590/s0034-89102010005000023.
14. Artículo proveído de DOI
Caldeira aP, fagundes GC, aguiar Gn de. intervenção educacional em equipes do Programa de saúde da
família para promoção da amamentação. rev saúde Pública 2008;42(6):1027-1233. doi: 10.1590/s0034-
89102008005000057.
15. Artículo en la prensa
Barroso t, Mendes a, Barbosa a. analysis of the alcohol consumption phenomenon among adolescents: study
carried out with adolescents in intermediate public education. rev latino-am enfermagem. en prensa 2009.
EJEMPLOS DE REfERENCIAS EN LIBROS y OTRAS MONOGRAfÍAS
16. Libro
hoppenfeld s. Propedêutica ortopédica: coluna e extremidades. rio de Janeiro: atheneu; 1993. 294 p.
456 Brazilian Journal of Cancerology 2011; 57(3): 431-459

17. Libro con indicación de editor, organizador, coordinador
Bader MK, littlejohns lr, editors. aann core curriculum for neuroscience nursing. 4th. ed. st. louis (Mo):
saunders; c2004. 1038 p.
18. Libro editado por una Institución
World Cancer research fund (usa). food, nutrition, physical activity and prevention of cancer: a global
perspective. Washington (DC): american institute for Cancer research; 2007.
19. Cuando el autor del capítulo es el autor del libro, referencia de capítulo de libro
ferreira sa. nervos proximais do membro superior. in: ____. lesões nervosas periféricas diagnóstico e tratamento.
são Paulo: santos; 2001. p. 35-48.
20. Artículo sin indicación de autoría
hiV/aiDs resources: a nationwide directory. 10th. ed. longmont (Co): Guides for living; c2004. 792 p.
21. Actas de conferencias
harnden P, Joffe JK, Jones WG, editors. Germ cell tumours V. Proceedings of the 5th Germ Cell tumour Conference;
2001 sep 13-15; leeds, uK. new york: springer; 2002.
22. Trabajo presentado en las conferencias
Christensen s, oppacher f. an analysis of Koza's computational effort statistic for genetic programming. in: foster
Ja, lutton e, Miller J, ryan C, tettamanzi aG, editors. Genetic programming. euroGP 2002: Proceedings of
the 5th european Conference on Genetic Programming; 2002 apr 3-5; Kinsdale, ireland. Berlin: springer; 2002.
p. 182-91.
23. Legislación
Dispone sobre la regulación de la Práctica de enfermería. ley n º 7.498, 25 de junio de 1986. Diário oficial de
la unión. sección i, págs. 9.273-9.275 (26 de junio de 1986). 1986.
24. Tesis y disertaciones
Verde sMMl. impacto do tratamento quimioterápico no estado nutricional e no comportamento alimentar de
pacientes com neoplasia mamária e suas consequências na qualidade de vida [disertación doctoral]. são Paulo:
universidad de são Paulo; 2007.
9. Tablas
las tablas deben presentarse en hojas separadas. no enviar las tablas en formato de imagen, para permitir su edición.
numerar las tablas consecutivamente de acuerdo con la primera cita en el texto y asignar un título breve para cada
una. Definir para cada columna una cabecera abreviada o corta. Colocar las explicaciones en notas a pie de página, no
en la cabecera. explicar, en todas las notas a pie de página, todas las abreviaturas no estandarizadas utilizadas en cada
tabla. Para las notas a pie de página, utilice los números romanos.
identificar las medidas estadísticas de variaciones, tales como: desviación estándar y error estándar.
no utilizar líneas internas, horizontales o verticales.
Constatar que cada tabla esté citada en el texto por su número y no por cómo es citada: la siguiente tabla, la tabla
de abajo.
si se utilizan datos de otra fuente, publicada o no, obtener la autorización y agradecer por extenso.
el uso de tablas grandes o en exceso, en relación con el texto puede ocasionar dificultades en la forma de presentación
de las páginas.
10. Ilustracines
enviar el número requerido de ilustraciones o “figuras”. no son aceptables los diseños a mano alzada o subtítulos
mecanografiados. las fotos deben ser escaneadas en blanco y negro, generalmente de 12 x 17 cm, no más grande
que 20 x 25 cm, películas de rayo-X u otros materiales. las letras, los números y los símbolos deben ser claros y lo
suficientemente grandes, para que cuando fueren reducidos para su publicación, todavía sean legibles. Colocar los
títulos y explicaciones debajo de los subtítulos y no en las propias ilustraciones.
si se usan fotografías de personas, los sujetos no deben ser identificables o sus fotografías deben estar acompañadas
por consentimiento escrito para publicación.
las figuras deben ser numeradas de acuerdo con la orden en que fueron citadas en el texto. si una figura ya fue
publicada, agradecer la fuente original y enviar la autorización escrita del titular de los derechos de autor para reproducir
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el material. la autorización es requerida, sea del autor o de la compañía editora, con la excepción de los documentos
de dominio público.
rBC es una publicación en blanco y negro y, así, todas las ilustraciones serán reproducidas en blanco y negro.
las ilustraciones deben ser proveídas en la siguiente manera:
• Archivo digital en formato .TIFF, .JPG, .EPS, con una resolución mínima de:
300 dpi para fotografías comunes
600 dpi para fotografías que contienen líneas finas, setas, subtítulos etc.
1.200 dpi para diseños y gráficos
11. Nomenclatura
Debe ser observada estrictamente la estandarización de nomenclatura biomédica, así como abreviaturas y
convenciones adoptadas por las disciplinas especializadas.
los textos originales en portugués deben estar conforme el acuerdo ortográfico, de 1 de enero de 2009.
resUmen De Los reQUisiTos Técnicos pArA LA presenTAción De mAnUscriTos
antes de enviar su manuscrito por correo electrónico a rbc@inca.gov.br, asegúrese de que las “instruções para autores”
[instrucciones para los autores], disponible en www.inca.gov.br/rbc han sido seguidas y verifique el cumplimiento de
los ítems listados a continuación:
• Enviar el archivo completo del manuscrito en Microsoft Word 6.0 o 7.0.
• Utilizar doble espacio en todas las partes del documento.
• Comenzar cada sección o componente en una página nueva.
• Revisar la secuencia: portada - título en portugués, inglés y español; título abreviado; autoría; resumo y palabras-chave,
abstract y key words, resumen y palabras clave; agradecimientos; declaración de conflicto de interese; declaración de
subvención; texto; referencias; tablas, cuadros, figuras con subtítulos (cada una en páginas separadas).
• De tres a seis palavras-chave y sus respectivas key words y palabras clave.
• Referencias: Numeradas, en sobrescrito, por orden de aparición en el texto, correctamente escrito y que no exceda
el número de 25. Verificar si todos los trabajos citados están en la lista de referencias y si todos los listados son
citados en el texto.
• Presentar ilustraciones, fotografías o dibujos separados, sin (20 x 25 cm máximo).
• Incluir la carta de presentación disponible en la sección “Instruções para Autores” [Instrucciones a los autores]. Si
el manuscrito tiene más de un autor, cada uno debe llenar y firmar la carta y el autor responsable por el envío debe
encaminarla en formato digital .JPG junto con el archivo del manuscrito a rbc@inca.gov.br.
• Incluir los permisos para reproducir material previamente publicado o para usar ilustraciones que puedan identificar
a los individuos.
• Incluir la autorización escrita de las personas referidas en los agradecimientos, cuando aplicable.
• Incluir documento evidenciando la aprobación del trabajo por el CEIC o, cuando aplicable.
458 Brazilian Journal of Cancerology 2011; 57(3): 431-459

Carta de presentación a la Revista Brasileña de Oncología
Por favor, rellene y envíe este formulario junto con el texto original a: rbc@inca.gov.br. si el manuscrito tiene
más de un autor, cada uno debe rellenar, firmar y encaminar esta carta para el autor responsable por el envío, para
transformarla en formato digital .JPG y encaminar a rBC en anexo, junto con el manuscrito.
Título del manuscrito _____________________________________________________________________
______________________________________________________________________________________
Clasificación del manuscrito:
( ) artículo original
( ) revisión sistemática de la literatura
( ) reporte de Caso / serie de Casos
( ) artículo de opinión
( ) reseña
( ) resumen
( ) Carta al editor
Cada autor debe indicar sus contribuciones, anotando con la letra X los campos abajo:
1. el autor ha contribuido:
( ) en el diseño y la planificación del proyecto de investigación
( ) en la obtención y/o análisis e interpretación de datos
( ) en la composición y revisión crítica
2. Conflicto de interés:
( ) el autor no tiene conflictos de interés, incluyendo los intereses financieros específicos y relaciones y afiliaciones
relevantes con el tema o los materiales tratados en el manuscrito.
( ) el autor confirma que todas las financiaciones, otros tipos de apoyos financieros y apoyo material/humano para
esta investigación y/o el trabajo se identifican claramente en el manuscrito enviado para la evaluación del "Consejo
de editorial de la rBC".
3. agradecimientos:
( ) el autor confirma que las personas que han contribuido sustancialmente al trabajo desarrollado en este texto,
pero que no cumplen con los criterios de autoría, han sido mencionados en la sección "agradecimientos" del manuscrito
que contiene la descripción de sus contribuciones específicas.
( ) el autor confirma que todos los que son mencionados en los "agradecimientos" han dado su autorización por
escrito para ser incluidos en esta sección.
( ) el autor confirma que si los "agradecimientos" no fueron incluidos en el texto enviado, fue porque
no hubo una contribución sustancial de otros al manuscrito además de los autores.
4. transferencia de Derechos de autor / Publicación
yo declaro que si el manuscrito es aceptado para su publicación, estoy de acuerdo que los derechos de autor serán
propiedad de rBC, siendo prohibida su reproducción, incluso parcial, en otros periódicos, impresos o electrónicos,
así como su traducción para la publicación en otros idiomas, sin su previa autorización y que, en caso de obtención
de ésta, haré constar el debido agradecimiento a la revista.
autor ___________________________________ firma ____________________________________
fecha ___________________________________ e-mail ____________________________________
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