Smoking prevalence declined in Brazil from 16.2% in 2006 to 9.8% in 2019. That year, the World Health Organization (WHO) recognized Brazil as the second country to adopt the highest level of all MPOWER measures. With a population of approximately 209 million, Brazil is the world’s fifth most populated country and the largest global exporter of tobacco leaf. Despite strong domestic influence from the tobacco industry, the country serves as a model for successful tobacco control. This public health success story was built on advocacy by civil society, government representatives and academia.
Smoking prevalence declined in Brazil from 16.2% in 2006 to 9.8% in 2019. That year, the World Health Organization (WHO) recognized Brazil as the second country to adopt the highest level of all MPOWER measures, measures aimed at reducing demand for tobacco and maintaining high quality surveillance of tobacco use and attitudes, knowledge and behaviors about use.
MPOWER measures address smoke-free environments and tobacco advertising, promotion and sponsorship, among other tobacco demand reduction policies. With a population of approximately 209 million, Brazil is the world’s fifth most populated country and the largest global exporter of tobacco leaf. Despite strong domestic influence from the tobacco industry, the country serves as a model for successful tobacco control.
This public health success story was built on advocacy by civil society, government representatives and academia. National tobacco control advocacy was spearheaded by ACT Promoção da Saúde (ACT Health Promotion) and its allies throughout Brazil, with support from the Campaign for Tobacco-Free Kids.
THE CHALLENGE
In 2006, when ACT was founded, smoking prevalence in Brazil was at 16.2%. Smoking was not prohibited in indoor environments, advertising was allowed at points of sale and there was no consistent policy on minimum tobacco prices and taxes. The tobacco industry used a number of strategies to influence policymaking and avoid regulation, posing a challenge to advocates working to monitor and oppose its tactics. ACT’s mission was to strengthen civil society’s role in public health and advance critical tobacco control policies in accordance with the World Health Organization’s Framework Convention on Tobacco Control.
OUR ROLE
In 2007, ACT initiated its tobacco control project with financial and technical support from the Campaign for Tobacco-Free Kids. Our assistance, which has been ongoing, helped ACT grow into the key non-governmental organization advancing tobacco control policies in Brazil.
The Campaign for Tobacco-Free Kids and ACT supported Brazil’s tobacco control efforts in critical ways:
Providing legal assistance by creating a countrywide network of lawyers working in tobacco control, who have been involved with many legal actions.
Promoting industry accountability by exposing the tobacco industry’s tactics to block public health policies in Brazil and around the world.
Mobilizing international support for advocacy initiatives.
Supporting advocacy research to generate local evidence.
Promoting media advocacy and communications efforts by establishing ACT as a resource on tobacco control issues, conducting trainings and reaching out to journalists, and launching creative campaigns and collaborating with media relations firms, in many cases on a pro-bono basis
RESULTS
In 2009, the state of São Paulo adopted a “smoke-free” law that banned smoking in enclosed public spaces. ACT played an active role in the process of approving and implementing the legislation. Ten years after the law was adopted, the compliance rate in São Paulo was 99.7%, and smoking had decreased from 18.8 % in 2006 to 13.5% in 2019.
Following active advocacy by ACT and its partners, a national smoke-free law, including a ban on tobacco advertising at points of sale, was approved in 2011 and supported by regulations in 2014. New taxes and minimum prices on tobacco products were also adopted in 2011, with periodic readjustments until 2016, as stated in the law. Coordinated advocacy by ACT, National Cancer. Institute and Oswaldo Cruz Foundation was the driving force behind this strong comprehensive law.
In 2012, the National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária, or Anvisa) published a regulation prohibiting additives in tobacco products, but lawsuits filed by tobacco industry representatives blocked the measure. The Supreme Court ultimately ruled in Anvisa’s favor in 2018. However, the decision was not binding, opening the door for other lawsuits that continue to delay the policy’s implementation. Undaunted by this familiar industry tactic, ACT has worked to advance a comprehensive law that would ban tobacco additives through legislation. A bill was approved by the Senate and, at the time of this writing, is pending in the Chamber of Deputies.
In 2018, Brazil ratified the WHO Protocol to Eliminate Illicit Trade in Tobacco Products, joining a group of countries committed to reducing tobacco use by combatting the illegal trade of tobacco. Despite attempted interference by the tobacco industry, the measure was approved with support from civil society. The following year, the industry urged the government to lower tobacco taxes, but the proposal failed following strong opposition from ACT’s coalition.
In 2019, Brazil’s Attorney General’s Office brought a lawsuit against the tobacco industry, requesting that the country’s publicly funded healthcare system, Unified Health System, be reimbursed for expenses paid to treat smoking-related diseases. To support the effort, ACT launched a social media campaign using the hashtag #ContaDoCigarro (“CigaretteBill”).
LESSONS LEARNED
Strategic investments of legal, policy and funding support from international donors can successfully further evidence-based policy and build long-term capacity of a locally lead tobacco control movement. The collaboration between the Campaign for Tobacco-Free Kids and ActBrazil shows that by engaging civil society and mobilizing government officials through continued advocacy it is possible to achieve ambitious public health policy change. Some valuable lessons we have learned include:
The FCTC remains a valuable advocacy tool to define evidence based approaches to reduce smoking.
Local advocates are crucial drivers, but successful adoption of public health policies, requires that they have financial resources and effective technical support. International advocates provide external validation. Working with a well established national coalition that includes representatives in every state strengthened civil society’s role at the state level and nationally.
Public support was reinforced by presenting tobacco control as a human rights and economic priority through a broad coalition and alliance with stakeholders outside of the traditional health community, including journalists’ organizations, a tobacco control lawyers’ network (organized with support from ACT and the Campaign for Tobacco-Free Kids) and associations of small tobacco growers.
Providing the judiciary with confirmed information, in collaboration with academia, helped them strengthen the implementation and enforcement of tobacco control laws.
For the best outcomes, media interventions must go hand-in-hand with policy advocacy.
The tobacco industry must be held accountable using consistent monitoring and public exposure in close collaboration with local partners.