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Brazil Learns What Works in Antismoking Campaigns: High Taxes and Graphic Photos
The world is slowly learning how to curb smoking, and some countries are showing more success than others. In recent years, Brazil has taken steps that put it at the front of the pack.
Between 1989 and 2001, the fraction of adults who smoke in Rio de Janeiro, Brazil's largest city, dropped from 30% to 21%, compared with a drop in the United States from 25.5% in 1990 to 22.8% in 2001. This decline has been fueled by a comprehensive antitobacco campaign, which includes high taxes and graphic images on cigarette packages.
"Although Brazil has a lot of controversial aspects of health care, we have probably one of the best examples of the changing picture in tobacco consumption over the past years," said Gilberto Schwartsmann, M.D., Ph.D., a professor of oncology at the Federal University in Porto Alegre and head of medical oncology at Hospital Mario Kroeff in Rio de Janeiro.
Worldwide, 450 million people are expected to die from smoking-related causes over the next 50 years. Researchers predict that if half of the current adult smokers could be persuaded to quit, 160 million to 180 million of those deaths could be prevented. Measures that have proven effective include higher cigarette taxes, advertising and promotion bans, consumer information, warning labels, and restrictions on public smoking.
"But of these, cigarette taxes are the most important intervention," said Prabhat Jha, M.D., Ph.D., the Canada research chair in health and development public-health sciences at the University of Toronto. "Higher cigarette taxes induce quitting, reduce consumption, and prevent restarting."
Studies suggest that a 10% increase in price would reduce demand by 4% in rich countries and 8% in developing ones, with demand measured in per capita cigarettes purchased. In the United Kingdom, for example, the government raised cigarette prices approximately 35% between 1990 and 1996, and per capita consumption dropped by nearly 20%.
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Brazil used an increase in cigarette taxes to help recover from economic trouble, raising the price by 70% between 1990 and 1993. Per capita cigarette consumption during that period dropped 25% and has continued to drop for an overall reduction of nearly 45% between 1990 and 2005. (These numbers, of course, do not include the consumption of black-market cigarettes, which may be a significant fraction of those consumed.)
But the opposite can happen as well. The South African government ignored price control options between 1970 and 1989, which caused the real price of cigarettes to drop by approximately 30%. Consumption climbed by a similar percentage.
Most countries' tobacco control efforts do not rely only on taxes. Brazil has outlawed all promotion and advertising of tobacco products except at the point of sale. Descriptions such as light or mild are forbidden, and restrictions have been placed on smoking in some public places.
Cigarette packaging has also changed dramatically in Brazil. Since 2002, each cigarette pack must have a label that gives a telephone number where smokers can call to get help to quit and learn reasons why they should quit. The label also must contain a warning that the product contains more than 4,700 toxic substances and nicotine and that there is no safe concentration for these compounds. And, perhaps most notable, are the graphic images that must be included on the labels depicting some of the health affects of smoking, including spontaneous abortion, premature births, amputations, lung cancer, mouth diseases, impotence, and childhood asthma. Tobacco companies must rotate the labels several times each year to minimize the likelihood that smokers will become immune to them.
A survey of more than 2,000 individuals in 126 Brazilian cities found that 73% of people supported the new packet warnings, and 67% of smokers said they were more likely to quit after having seen the images. The government has been a strong supporter too—it was the second country to sign onto the World Health Organization's Framework Convention on Tobacco Control, the first legally binding treaty focusing on tobacco control measures.
Many of the control measures that Brazil is using, which are laid out in the framework convention, are showing success in other countries as well. What doesn't work in tobacco control, Jha says, are prohibition and efforts to reduce supply.
"As long as there is demand, cutting off one supplier just opens the arena for another source."
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J Natl Cancer Inst 2007 99: 585-586.
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