Epidemiological Stagnation of Smoking and the Urgency of new Communication Strategies with Smokers

INTRODUCTION

The National Tobacco Control Policy (PNCT)¹ is a successful public health intervention model. Other non-communicable diseases (NCDs)² prevention and combat programs, such as those related to alcohol and unhealthy nourishment, are treading through the same pathways tobacco control initiatives have taken in lawmaking and regulatory instances and health promotion.

The creation in 2003 of a PNCT governmental commission³ which entailed the adoption of multi-sectoral policies – definition of minimal cigarette prices, improvement of health warning labels on cigarette packs, advertising banning, and smoking bans⁴ in public areas –, provoked a significant reduction in the prevalence of smoking⁵.

However, smoking continues to kill 173 thousand smokers annually, there are 22 million Brazilian smokers still⁶, whose majority smoke daily, mostly in low-income and education groups, potentially affected by severe diseases with social and economic repercussion for their families and society⁷,⁸.

Time-series analyzes of surveys and research revealed concerning epidemiologic data and raised a red flag among managers and investigators. Deceleration and inertia of the percent drop of adult smokers between 2018 and 2024, according to the surveillance system for risk and protective factors for chronic diseases by telephone survey (Vigitel)⁸, may indicate that the effects of the measures implemented so far are no longer as effective as before. The estimates suggest that the goal of prevalence of NCDs of 40% by 2030 will not be achieved⁹.

In addition, the national survey of school health (PeNSE) revealed an increase in the proportion of current smokers among adolescents (6.6% in 2015 to 6.8% in 2019), standing out 16-17 years old girls¹⁰. This growth may have various and combined causes as easy access to buy cigarettes online¹¹ and at sellers per unit¹², social media advertising¹³, weak tax policy which expands affordability and illicit ENDS (electronic nicotine delivery system) sale, already appearing in the statistics – according to the national alcohol and drugs survey 2025, 8.8% of the 14-years old or older population tried this product and 5.6% claimed they used it in the last year¹⁴. A possible outcome of this context was pointed out by the national health survey (PNS): among 18-24-years-old smokers, the prevalence was kept stable between 2013 and 2019 as opposed to the decline observed in older individuals⁵. The availability of illicit tobacco products, 38.6% of the Brazilian market¹⁵, and the growth of smokers during the COVID-19 pandemic¹⁶ are part of this epidemiologic scenario.

PNS revealed a negative variation of 8.8% in the attempt to smoke cessation between 2013 and 2019, mostly in low education groups and in the age range of 40-59 years, where good part of the smokers can be found¹⁷. In addition, PNS observed that, regardless of the increase of visits to the doctor for several causes, the proportion of those who received counseling to quit smoking dropped from 57.1% in 2008 to 51% in 2019, and in this year, health professionals missed the opportunity to guide and encourage ten million smokers¹⁸.

DEVELOPMENT

This epidemiological scenario indicates an urgency and necessity to adopt social marketing-based novel communication strategies to reach the smoker, expand their knowledge, and change their behaviour, strengthening the engagement in smoke cessation¹⁹. The use of digital technologies (SMS, interactive apps, chatbots etc.) is a notable way to encourage smokers in their decision to quit smoking and support cessation treatment programs²⁰. Understandably, they are wide-ranging interventions but require technological development, structure maintenance, and data protection, among others.

Nevertheless, innovative and non-technological solutions have been proven to be effective. Brazil has a recognized experience with health warning labels on cigarette packs²¹. Since 2001, phrases and images required by the National Health Regulatory Agency (Anvisa) present a negative approach (or of losses) about tobacco's impact on health, whose objective is to inform, make the smoker to repel it, in contrast with the alluring graphic elements of cigarette brands. Anvisa's decision held the tobacco industry responsible for producing and printing these health warnings.

Furthermore, evidence suggests that negative health warnings that provoke fear and repulsion should be accompanied by positive behaviors that help the smoker to find ways to overcome their chemical and psychic dependence²². In that line, Canada's experience in enclosing package inserts on smoking cessation is a viable low-cost regulatory alternative for governments, strengthening guiding strategies and encouragement for smokers²³.

Canadian package inserts bring two distinct positive approaches: (1) guidelines on how to quit smoking (on your own or relying on specialized support) that imbue the smokers with the belief they can change their behavior towards a healthier goal (perception of self-efficacy)²⁴; (2) the benefits of quitting that stimulate the belief that behavioral change will reduce the risk of negative health consequences (perception of response efficacy)²⁴ to motivate habits changing. In that line, the literature on inserts presents positive results: more attempts to quit smoking, increased search for treatment services and support during smoking withdrawal²⁵.

Since Brazilian smokers are aware of the tobacco health harms (through educative campaigns and health warnings)⁵, it is likely that communication strategies that highlight the benefits of smoking cessation (reinforcing the perception of response efficacy) and suggest attitudes the smokers can take on their own or health services where they have access to the treatment (promoting the perception of self-efficacy) can help to reverse the epidemiological scenario. In this last hypothesis, it is essential that the service where treatment is provided be disseminated across a larger number of health units and can absorb a large number of smokers with different profiles of nicotine dependence²⁶.

Still, Anvisa would have to deal with the challenges resulting from the implementation of this initiative as monitoring cigarette packs to check whether the inserts are fully enclosed and their simultaneous or rotation distribution as stipulated in Law # 9,294/1996 and a probable resistance of the tobacco industry, including judicialization, as already occurred with other regulatory interventions²⁷.

CONCLUSION

Smoking is a public health problem far from being resolved; it can't be accountable for paying the price of the success of its policy, which can be ephemeral. If a priority is not granted in both the political and lawmaking agenda, nor a recipient of investments in innovation and in effectively-proven experiences, it is possible that future population investigations reflect a reversal of the downward trend of smoking prevalence with impactful and negative social and economic consequences for the entire society.

Adopting novel strategies to communicate with the smoker can be useful. Most of the smokers have low nicotine dependence and claimed they did not have any support or counseling when they tried to quit smoking, as the PNS made clear. Eventually, there is an opportunity window to encourage them to quit smoking with handy daily-life tips and steer them to rely on the public health network.

Inserts added to the package are a cost-effective measure within Anvisa's jurisdiction, supported by Law # 9,782/1999 that ensured the Agency the ability to rule and control tobacco products, and by Law # 9,924/1996 that rules health warnings printed on cigarette packs. Insofar as the existing knowledge goes and the urgency of new educative strategies for smokers, national studies must analyze forms and characteristics of communication with positive approaches suitable to the national smoking population.

• FUNDING SOURCES
  None.

DATA AVAILABILITY STATEMENT

All content underlying the text is contained in the manuscript.

References

• ¹ Meirelles RHS. Os avanços do controle do tabagismo no Brasil [editorial]. Physis. 2023;33:e33SP100. doi: https://doi.org/10.1590/S0103-7331202333SP100.pt
  » https://doi.org/10.1590/S0103-7331202333SP100.pt
• ² Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Análise em Saúde e Vigilância de Doenças Não Transmissíveis. Plano de ações estratégicas para o enfrentamento das doenças crônicas e agravos não transmissíveis no Brasil 2021-2030 [internet]. Brasília (DF): Ministério da Saúde; 2021 [acesso 2025 dez 18]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/doencas-cronicas-nao-transmissiveis-dcnt/09-plano-de-dant-2022_2030.pdf
  » https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/doencas-cronicas-nao-transmissiveis-dcnt/09-plano-de-dant-2022_2030.pdf
• ³ Presidência da República (BR). Casa Civil. Decreto de 1º de agosto de 2003. Cria a Comissão Nacional para Implementação da Convenção-Quadro para o Controle do Tabaco e de seus Protocolos [internet]. Diário Oficial da União, Brasília, DF. 2003 ago 4 [acesso 2025 out 25]; Seção 1:1. Disponível em: http://www.planalto.gov.br/ccivil_03/DNN/2003/Dnn9944.htm
  » http://www.planalto.gov.br/ccivil_03/DNN/2003/Dnn9944.htm
• ⁴ Portes LH, Machado CV, Turci SRB, et al. A política de controle do tabaco no Brasil: um balanço de 30 anos. Ciênc Saúde Colet. 2018;23(6):1837-48. doi: https://doi.org/10.1590/1413-81232018236.05202018
  » https://doi.org/10.1590/1413-81232018236.05202018
• ⁵ Malta DC, Gomes CS, Andrade FMD, et al. Tobacco use, cessation, secondhand smoke and exposure to media about tobacco in Brazil: results of the National Health Survey 2013 and 2019. Rev Bras Epidemiol. 2021;24(Suppl 2):e210006. doi: https://doi.org/10.1590/1980-549720210006.supl.2
  » https://doi.org/10.1590/1980-549720210006.supl.2
• ⁶ Pinto M, Bardach A, Costa MG, et al. Carga da doença e econômica atribuível ao tabagismo no Brasil e potencial impacto do aumento de preços por meio de impostos. Buenos Aires: IECS; 2024. [acesso 2025 fev. 26]. Disponível em: https://ninho.inca.gov.br/jspui/handle/123456789/15986
  » https://ninho.inca.gov.br/jspui/handle/123456789/15986
• ⁷ Bazotti A, Finokiet M, Conti IL, et al. Tabagismo e pobreza no Brasil: uma análise do perfil da população tabagista a partir da POF 2008-2009. Ciênc Saúde Colet. 2016;21(1):45-52. doi: https://doi.org/10.1590/1413-81232015211.16802014
  » https://doi.org/10.1590/1413-81232015211.16802014
• ⁸ Ministério da Saúde (BR), Secretaria de Vigilância em Saúde e Ambiente, Departamento de Análise em Saúde e Vigilância de Doenças Não Transmissíveis. Vigitel Brasil 2006–2024: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal entre 2006 e 2024 [Internet]. Brasília (DF): Ministério da Saúde; 2025 [acesso 2025 dez 15]. 211p. Disponível em: https://svs.aids.gov.br/daent/cgdnt/vigitel/vigitel-2006-2024-brasil.pdf
  » https://svs.aids.gov.br/daent/cgdnt/vigitel/vigitel-2006-2024-brasil.pdf
• ⁹ Malta DC, Gomes CS, Cardoso LSM, et al. Retrocessos no alcance das metas de controle do tabagismo: uma análise de tendências temporais e projeções para 2030. Ciênc Saúde Colet [internet]. 2025 [acesso 2025 dez 15];30(12):e02742025. Disponível em: https://cienciaesaudecoletiva.com.br/artigos/retrocessos-no-alcance-das-metas-de-controle-do-tabagismo-uma-analise-de-tendencias-temporais-e-projecoes-para-2030/19750
  » https://cienciaesaudecoletiva.com.br/artigos/retrocessos-no-alcance-das-metas-de-controle-do-tabagismo-uma-analise-de-tendencias-temporais-e-projecoes-para-2030/19750
• ¹⁰ Szklo AS, Bertoni N. Lei, para que te quero? Dados comparativos da Pesquisa Nacional de Saúde do Escolar (PeNSE) sobre acesso a cigarros por adolescentes. Cad Saúde Pública. 2023;39(2):e00145722. doi: https://doi.org/10.1590/0102-311XPT145722
  » https://doi.org/10.1590/0102-311XPT145722
• ¹¹ Viegas JRR, Szklo AS, Assunção KHR, et al. Publicidade e venda de produtos de tabaco em plataformas digitais de delivery. Rev Bras Cancerol. 2022;68(4):e-142763. doi: https://doi.org/10.32635/2176-9745.RBC.2022v68n4.2763
  » https://doi.org/10.32635/2176-9745.RBC.2022v68n4.2763
• ¹² Szklo AS, Perez CA, Casado L, et al. Single cigarette sales contravene tobacco control policies, Brazil. Bull World Health Organ. 2024;102(11):834-6. doi: https://doi.org/10.2471/blt.24.291807
  » https://doi.org/10.2471/blt.24.291807
• ¹³ Pinto MCM, Riva MPR, Cury LS, et al. A Promoção de novos produtos de tabaco nas redes sociais à luz da pandemia. Rev Bras Cancerol. 2020;66(TemaAtual):e-1108. doi: https://doi.org/10.32635/2176-9745.RBC.2020v66nTemaAtual.1108
  » https://doi.org/10.32635/2176-9745.RBC.2020v66nTemaAtual.1108
• ¹⁴ Universidade Federal de São Paulo. Ministério da Justiça e Segurança Pública. Levantamento nacional de álcool e drogas: caderno temático LENAD III: tabagismo e uso de dispositivos eletrônicos para fumar [internet]. São Paulo: Universidade Federal de São Paulo; 2025 [acesso 2025 dez 18]. Disponível em: https://lenad.uniad.org.br/cadernos-lenad/Caderno-LENAD-III-tabaco-defs.pdf
  » https://lenad.uniad.org.br/cadernos-lenad/Caderno-LENAD-III-tabaco-defs.pdf
• ¹⁵ Szklo AS, Drope J. The cigarette market in Brazil: new evidence on illicit practices from the 2019 National Health Survey. Tob Control. 2024;33(Suppl 2):s128-34. doi: https://doi.org/10.1136/tc-2022-057847
  » https://doi.org/10.1136/tc-2022-057847
• ¹⁶ Malta DC, Gomes CS, Souza Júnior PRB, et al. Factors associated with increased cigarette consumption in the Brazilian population during the COVID-19 pandemic. Cad Saúde Pública. 2021;37(3):e00252220. doi: https://doi.org/10.1590/0102-311x00252220
  » https://doi.org/10.1590/0102-311x00252220
• ¹⁷ Oliveira PPV, Pereira VOM, Stopa SR, et al. Indicadores referentes à cessação do comportamento de fumar no Brasil, Pesquisa Nacional de Saúde, edições 2013 e 2019. Epidemiol Serv Saúde. 2022;31(spe1):e2021388. doi: https://doi.org/10.1590/SS2237-9622202200005.especial
  » https://doi.org/10.1590/SS2237-9622202200005.especial
• ¹⁸ Szklo AS, Martins SR. Smokers who were seen by a doctor or other healthcare provider for any health concern in Brazil: what a missed opportunity to encourage smoking cessation! Public Health. 2023;225:176-81. doi: https://doi.org/10.1016/j.puhe.2023.10.009
  » https://doi.org/10.1016/j.puhe.2023.10.009
• ¹⁹ Centers for Disease Control and Prevention. Health communications in tobacco prevention and control [Internet]. Atlanta: Department of Health and Human Services, 2018 [acesso 2025 dez 25]. Disponível em: https://www.hhs.nd.gov/sites/www/files/documents/DOH%20Legacy/CDC_Tobacco_Control_Best-Practices-Health_Communications-user-guide.pdf
  » https://www.hhs.nd.gov/sites/www/files/documents/DOH%20Legacy/CDC_Tobacco_Control_Best-Practices-Health_Communications-user-guide.pdf
• ²⁰ Prochaska JJ, Benowitz NL. Current advances in research in treatment and recovery: nicotine addiction. Sci Adv. 2019;5(10):eaay9763. doi: https://doi.org/10.1126/sciadv.aay9763
  » https://doi.org/10.1126/sciadv.aay9763
• ²¹ Perez CA, Silva VLC, Bialous SA. Análise da interferência da indústria do tabaco na implantação das advertências sanitárias nos derivados de tabaco no Brasil. Cad Saúde Pública [internet]. 2017 [acesso 2025 maio 25]:33(Suppl 3):e00120715. Disponível em: https://www.scielo.br/j/csp/a/p3dYsRmq7FrgPKsYc8st6BR/?format=pdf⟨=pt
  » https://www.scielo.br/j/csp/a/p3dYsRmq7FrgPKsYc8st6BR/?format=pdf⟨=pt
• ²² Witte K, Allen M. A meta-analysis of fear appeals: implications for effective public health campaigns. Health Educ Behav. 2000;27(5):591-615. doi: https://doi.org/10.1177/109019810002700506
  » https://doi.org/10.1177/109019810002700506
• ²³ Thrasher JF, Osman A, Abad-Vivero EN, et al. The use of cigarette package inserts to supplement pictorial health warnings: an evaluation of the Canadian policy. Nicotine Tob Res. 2015;17(7):870-5. doi: https://doi.org/10.1093/ntr/ntu246
  » https://doi.org/10.1093/ntr/ntu246
• ²⁴ Thrasher JF, Islam F, Davis RE, et al. Testing cessation messages for cigarette package inserts: findings from a best/worst discrete choice experiment. Int J Environ Res Public Health. 2018;15(2):282. doi: https://doi.org/10.3390/ijerph15020282
  » https://doi.org/10.3390/ijerph15020282
• ²⁵ Moodie C. Adult smokers’ perceptions of cigarette pack inserts promoting cessation: a focus group study. Tob Control. 2018;27(1):72-7. doi: https://doi.org/10.1136/tobaccocontrol-2016-053372
  » https://doi.org/10.1136/tobaccocontrol-2016-053372
• ²⁶ Cardoso ARR, Martins LFL, Lima FLT, et al. Impacto da pandemia da Covid-19 sobre o serviço e cuidado à pessoa tabagista no SUS. Physis. 2023;33:e33SP105. doi: https://doi.org/10.1590/S0103-7331202333SP105.pt
  » https://doi.org/10.1590/S0103-7331202333SP105.pt
• ²⁷ Carvalho AP, Dias T. The tobacco industry's interference in the judiciary to invalidate the regulation of additives in tobacco products in Brazil. Tob Induc Dis [internet]. 2025 [acesso 2025 nov 25];23(Suppl1):A754. Disponível em: https://www.tobaccoinduceddiseases.org/The-tobacco-industry-s-interference-in-the-Judiciary-to-invalidate-the-regulation,206822,0,2.html
  » https://www.tobaccoinduceddiseases.org/The-tobacco-industry-s-interference-in-the-Judiciary-to-invalidate-the-regulation,206822,0,2.html

Edited by

• Scientific-editor:
  Anke Bergmann. Orcid iD: https://orcid.org/0000-0002-1972-8777

Publication Dates

• Publication in this collection
  10 Apr 2026
• Date of issue
  2026

History

• Received
  13 Nov 2025
• Accepted
  29 Dec 2025