Compliance with eye and foot preventive care in people with self-reported diabetes in Latin America and the Caribbean: Pooled, cross-sectional analysis of nine national surveys

AIMS

To estimate the proportion of people with self-reported diabetes receiving eye and foot examinations in Latin America and the Caribbean (LAC).

METHODS

Cross-sectional analysis of national health surveys in nine countries. Adults aged 25-64 years with self-reported diabetes. We quantified the proportion who reported having an eye examination in the last two years or a foot examination in the last year. We fitted multilevel Poisson regressions to assess socio-demographic (age and sex) and clinical (oral hypoglycemic medication and insulin treatment) variables associated with having had examinations.

RESULTS

There were 7435 people with self-reported diabetes included in the analysis. In three countries (Chile [64%; 95% CI: 56%-71%], British Virgin Islands [58%; 95% CI: 51%-65%], and Brazil [54%; 95% CI: 50%-58%]), >50% of people with diabetes reported having had an eye examination in the last two years. Fewer participants (<50% across all countries) reported having had a foot examination in the last year, with Ecuador having the lowest proportion (12%; 95% CI: 8%-17%). Older people, and those taking oral medication or insulin, were more likely to have eye/foot examinations.

CONCLUSIONS

The proportion of eye and foot examinations in people with self-reported diabetes across nine countries in LAC is low.

Diabetes mortality: trends and multi-country analysis of the Americas from 2000 to 2019

BACKGROUND

Diabetes has been increasing worldwide and is now among the 10 leading causes of death globally. Diabetic kidney disease (DKD), a complication of poorly managed diabetes, is related to high mortality risk. To better understand the situation in the Americas region, we evaluated diabetes and DKD mortality trends over the past 20 years.

METHODS

We analysed diabetes and DKD mortality for 33 countries in the Americas from 2000 to 2019. Data were extracted from the World Health Organization (WHO) Global Health Estimates and the World Population Prospects, 2019 Revision, estimating annual age-standardized mortality rates (ASMR) and gaps in the distribution of diabetes and DKD mortality by sex and country. Trend analyses were based on the annual average percentage of change (AAPC).

RESULTS

From 2000 to 2019, the overall mortality trend from diabetes in the Americas remained stable [AAPC: -0.2% (95% CI: -0.4%-0.0%]; however, it showed important differences by sex and by country over time. By contrast, DKD mortality increased 1.5% (1.3%-1.6%) per year, rising faster in men than women, with differences between countries. Central America, Mexico and the Latin Caribbean showed significant increases in mortality for both diseases, especially DKD. In contrast in North America, diabetes mortality decreased whereas DKD mortality increased.

CONCLUSIONS

The increase in DKD mortality is evidence of poorly controlled diabetes in the region. The lack of programmes on prevention of complications, self-care management and gaps in quality health care may explain this trend and highlight the urgent need to build more robust health systems based on primary care, prioritizing diabetes prevention and control.

Greater agreement is required to harness the potential of health intelligence: a critical interpretive synthesis

OBJECTIVES

To synthesize existing knowledge on the features of, and approaches to, health intelligence, including definitions, key concepts, frameworks, methods and tools, types of evidence used, and research gaps.

STUDY DESIGN AND SETTING

We applied a critical interpretive synthesis methodology, combining systematic searching, purposive sampling, and inductive analysis to explore the topic. We conducted electronic and supplementary searches to identify records (papers, books, websites) based on their potential relevance to health intelligence. The key themes identified in the literature were combined under each of the compass subquestions and circulated among the research team for discussion and interpretation.

RESULTS

Of the 290 records screened, 40 were included in the synthesis. There is no clear definition of health intelligence in the literature. Some records describe it in similar terms as public health surveillance. Some focus on the use of artificial intelligence, while others refer to health intelligence in a military or security sense. And some authors have suggested a broader definition of health intelligence that explicitly includes the concepts of synthesis of research evidence for informed decision making.

CONCLUSION

Rather than developing a new or all-encompassing definition, we suggest incorporating the concept and scope of health intelligence within the evidence ecosystem.

Effectiveness of a participatory approach to develop school health interventions in four low resource cities: study protocol of the 'empowering adolescents to lead change using health data' cluster randomised controlled trial

INTRODUCTION

Comprehensive local data on adolescent health are often lacking, particularly in lower resource settings. Furthermore, there are knowledge gaps around which interventions are effective to support healthy behaviours. This study generates health information for students from cities in four middle-income countries to plan, implement and subsequently evaluate a package of interventions to improve health outcomes.

METHODS AND ANALYSIS

We will conduct a cluster randomised controlled trial in schools in Fez, Morocco; Jaipur, India; Saint Catherine Parish, Jamaica; and Sekondi-Takoradi, Ghana. In each city, approximately 30 schools will be randomly selected and assigned to the control or intervention arm. Baseline data collection includes three components. First, a Global School Health Policies and Practices Survey (G-SHPPS) to be completed by principals of all selected schools. Second, a Global School-based Student Health Survey (GSHS) to be administered to a target sample of n=3153 13-17 years old students of randomly selected classes of these schools, including questions on alcohol, tobacco and drug use, diet, hygiene, mental health, physical activity, protective factors, sexual behaviours, violence and injury. Third, a study validating the GSHS physical activity questions against wrist-worn accelerometry in one randomly selected class in each control school (n approximately 300 students per city). Intervention schools will develop a suite of interventions using a participatory approach driven by students and involving parents/guardians, teachers and community stakeholders. Interventions will aim to change existing structures and policies at schools to positively influence students' behaviour, using the collected data and guided by the framework for Making Every School a Health Promoting School. Outcomes will be assessed for differential change after a 2-year follow-up.

ETHICS AND DISSEMINATION

The study was approved by WHO's Research Ethics Review Committee; by the Jodhpur School of Public Health's Institutional Review Board for Jaipur, India; by the Noguchi Memorial Institute for Medical Research Institutional Review Board for Sekondi-Takoradi, Ghana; by the Ministry of Health and Wellness' Advisory Panel on Ethics and Medico-Legal Affairs for St Catherine Parish, Jamaica, and by the Comité d'éthique pour la recherche biomédicale of the Université Mohammed V of Rabat for Fez, Morocco. Findings will be shared through open access publications and conferences.

TRIAL REGISTRATION NUMBER

NCT04963426.

Multimorbidity and social determinants of health in the US prior to the COVID-19 pandemic and implications for health outcomes: a cross-sectional analysis based on NHANES 2017-2018

Multimorbidity increases the risk of all-cause mortality, and along with age, is an independent risk factor for severe disease and mortality from COVID-19. Inequities in the social determinants of health contributed to increased mortality from COVID-19 among disadvantaged populations. This study aimed to evaluate the prevalence of multimorbid conditions and associations with the social determinants of health in the US prior to the pandemic.Methods Data from the 2017-18 cycle of NHANES were used to determine the prevalence of 13 chronic conditions, and the prevalence of having 0, 1, or 2 or more of those conditions, among the US adult population aged ≥ 20 years. Multimorbidity was defined as having 2 or more of these conditions. Data were stratified according to demographic, socioeconomic and indicators of health access, and analyses including logistic regression, performed to determine the factors associated with multimorbidity.Results The prevalence of multimorbidity was 58.4% (95% CI 55.2 to 61.7). Multimorbidity was strongly associated with age and was highly prevalent among those aged 20-29 years at 22.2% (95% CI 16.9 to 27.6) and continued to increase with older age. The prevalence of multimorbidity was highest in those defined as Other or multiple races (66.9%), followed in decreasing frequency by rates among non-Hispanic Whites (61.2%), non-Hispanic Blacks (57.4%), Hispanic (52.0%) and Asian (41.3%) groups.Logistic regression showed a statistically significant relationship between multimorbidity and age, as expected. Asian race was associated with a reduced likelihood of 2 or more chronic conditions (OR 0.4; 95% CI 0.35 to 0.57; P < 0.0001). Socioeconomic factors were related to multimorbidity. Being above the poverty level (OR 0.64; 95% CI 0.46 to 0.91, p = 0.013); and a lack of regular access to health care (OR 0.61 (95% CI 0.42 to 0.88, p = 0.008) were both associated with a reduced likelihood of multimorbidity. Furthermore, there was a borderline association between not having health insurance and reduced likelihood of multimorbidity (OR 0.63; 95% CI 0.40 to 1.0; p = 0.053).Conclusions There are high levels of multimorbidity in the US adult population, evident from young adulthood and increasing with age. Cardiometabolic causes of multimorbidity were highly prevalent, especially obesity, hyperlipidemia, hypertension, and diabetes; conditions subsequently found to be associated with severe disease and death from COVID-19. A lack of access to care was paradoxically associated with reduced likelihood of comorbidity, likely linked to underdiagnosis of chronic conditions. Obesity, poverty, and lack of access to healthcare are factors related to multimorbidity and were also relevant to the health impact of the COVID-19 pandemic, that must be addressed through comprehensive social and public policy measures. More research is needed on the etiology and determinants of multimorbidity, on those affected, patterns of co-morbidity, and implications for individual health and impact on health systems and society to promote optimal outcomes. Comprehensive public health policies are needed to tackle multimorbidity and reduce disparities in the social determinants of health, as well as to provide universal access to healthcare.

The rising burden of non-communicable diseases in the Americas and the impact of population aging: a secondary analysis of available data

Background

Public health progress in the Americas has reduced the burden of many infectious diseases, helping more people live longer lives. At the same time, the burden of non-communicable diseases (NCDs) is increasing. NCD prevention rightly focuses on lifestyle risk factors, social, and economic determinants of health. There is less published information on the importance of population growth and aging to the regional NCD burden.

Methods

For 33 countries in the Americas, we used United Nations population data to describe rates of population growth and aging over two generations (1980-2060). We used World Health Organization estimates of mortality and disability (disability-adjusted life years, DALYs) to describe changes in the NCD burden between 2000 and 2019. After combining these data resources, we decomposed the change in the number of deaths and DALYs to estimate the percentage change due to population growth, due to population aging, and due to epidemiological advances, measured by changing mortality and DALY rates. In a supplement, we provide a summary briefing for each country.

Findings

In 1980, the proportion of the regional population aged 70 and older was 4.6%. It rose to 7.8% by 2020 and is predicted to rise to 17.4% by 2060. Across the Americas, DALY rate reductions would have decreased the number of DALYs by 18% between 2000 and 2019 but was offset by a 28% increase due to population aging and a 22% increase due to population growth. Although the region enjoyed widespread reductions in rates of disability, these improvements have not been sufficiently large to offset the pressures of population growth and population aging.

Interpretation

The region of the Americas is aging and the pace of this aging is predicted to increase. The demographic realities of population growth and population aging should be factored into healthcare planning, to understand their implications for the future NCD burden, the health system needs, and the readiness of governments and communities to respond to those needs.

Funding

This work was funded in part by the Pan American Health Organization, Department of Noncommunicable Diseases and Mental Health.

What is the NCD service capacity and disruptions due to COVID-19? Results from the WHO non-communicable disease country capacity survey in the Americas region

OBJECTIVE

This article presents the Americas regional results of the WHO non-communicable diseases (NCDs) Country Capacity Survey from 2019 to 2021, on NCD service capacity and disruptions from the COVID-19 pandemic.

SETTING

Information on public sector primary care services for NCDs, and related technical inputs from 35 countries in the Americas region are provided.

PARTICIPANTS

All Ministry of Health officials managing a national NCD programme, from a WHO Member State in the Americas region, were included throughout this study. Government health officials from countries that are not WHO Member States were excluded.

OUTCOME MEASURES

The availability of evidence-based NCD guidelines, essential NCD medicines and basic technologies in primary care, cardiovascular disease risk stratification, cancer screening and palliative care services were measured in 2019, 2020 and 2021. NCD service interruptions, reassignments of NCD staff during the COVID-19 pandemic and mitigation strategies to reduce disruptions for NCD services were measured in 2020 and 2021.

RESULTS

More than 50% of countries reported a lack of comprehensive package of NCD guidelines, essential medicines and related service inputs. Extensive disruptions in NCD services resulted from the pandemic, with only 12/35 countries (34%), reporting that outpatient NCD services were functioning normally. Ministry of Health staff were largely redirected to work on the COVID-19 response, either full time or partially, reducing the human resources available for NCD services. Six of 24 countries (25%) reported stock out of essential NCD medicines and/or diagnostics at health facilities which affected service continuity. Mitigation strategies to ensure continuity of care for people with NCDs were deployed in many countries and included triaging patients, telemedicine and teleconsultations, and electronic prescriptions and other novel prescribing practices.

CONCLUSIONS

The findings from this regional survey suggest significant and sustained disruptions, affecting all countries regardless of the country's level of investments in healthcare or NCD burden.

Noncommunicable diseases in the Americas: a review of the Pan American Health Organization's 25-year program of work

This article describes progress in tackling noncommunicable diseases (NCDs) in the Americas since the Pan American Health Organization (PAHO) started its NCD program 25 years ago. Changes in the epidemiology of NCDs, NCD policies, health service capacity, and surveillance are discussed. PAHO's NCD program is guided by regional plans of action on specific NCDs and risk factors, as well as a comprehensive NCD plan. Its work involves implementing evidence-based World Health Organization technical packages on NCDs and their risk factors with the aim of achieving the Sustainable Development Goal target of a one third reduction in premature mortality caused by NCDs by 2030. Important advances have been made in the past 25 years in implementation of: policies on NCD risk factors; interventions to improve NCD diagnosis and treatment; and NCD surveillance. Premature mortality from NCDs decreased by 1.7% a year between 2000 and 2011 and 0.77% a year between 2011 and 2019. However, policies on risk factor prevention and health promotion need to be strengthened to ensure more countries are on track to achieving the NCD-related health goals of the Sustainable Development Goals by 2030. Actions are recommended for governments to raise the priority of NCDs by: making NCDs a core pillar of primary care services, using revenues from health taxes to invest more in NCD prevention and control; and implementing policies, laws, and regulations to reduce the demand for and availability of tobacco, alcohol, and ultra-processed food products.

Prioritizing noncommunicable diseases in the Americas region in the era of COVID-19

This article describes the situation of noncommunicable diseases (NCDs) in the Americas, implementation of NCD interventions according to key progress indicators, the impact of COVID-19 on NCD services, and ways to reprioritize NCDs following COVID-19. Information was retrieved from institutional data and through a supplementary scoping review of published articles related to NCDs and COVID-19 in the Americas published April 2020–November 2021. While NCDs account for 80.7% of all deaths in the Americas, implementation of a key set of NCD interventions has been limited, with only three countries reporting implementation of 12 or more of the 19 NCD indicators. By mid-May 2022, the Americas had reported about 29.9% of all COVID-19 cases in the world (154 million of 515 million) and 43.5% all COVID-19 deaths (2.7 million of 6.2 million). This pandemic has hampered progress on NCDs and significantly disrupted services for people who require ongoing care. Adaptive strategies, such as telehealth and mobile pharmacies, have been used to mitigate service disruptions. However, NCD prevention and management must be an integral part of recovering from the COVID-19 pandemic. This will require scaled up efforts to establish/re-establish and enforce policies on NCD risk factors, especially for tobacco control and obesity prevention, as well as greater investment in primary care and expansion of telemedicine and digital health solutions for continuous care for people with NCDs. Lastly, limited data are available on the impact of COVID-19 on NCDs, and hence NCD data and surveillance need to be strengthened.

Reflection on modern methods: years of life lost due to premature mortality-a versatile and comprehensive measure for monitoring non-communicable disease mortality

The analysis of causes impacting on premature mortality is an essential function of public health surveillance. Diverse methods have been used for accurately assessing and reporting the level and trends of premature mortality; however, many have important limitations, particularly in capturing actual early deaths. We argue that the framework of years of life lost (YLL), as conceptualized in disability-adjusted life-years (DALYs), is a robust and comprehensive measure of premature mortality. Global Burden of Disease study is systematically providing estimates of YLL; however, it is not widely adopted at country level, among other reasons because its conceptual and methodological bases seem to be not sufficiently known and understood. In this paper, we provide the concepts and the methodology of the YLL framework, including the selection of the loss of function that defines the time lost due to premature deaths, and detailed methods for calculating YLL metrics. We also illustrate how to use YLL to quantify the level and trends of premature non-communicable disease (NCD) mortality in the Americas. The tutorial style of the illustrative example is intended to educate the public health community and stimulate the use of YLL in disease prevention and control programmes at different levels.

Alcohol Policy Relevant Indicators and Alcohol Use Among Adolescents in Latin America and the Caribbean

OBJECTIVE

This study assessed four alcohol policy indicators and their associations with adolescent alcohol use in Latin America and the Caribbean.

METHOD

A secondary data analysis of nationally representative, cross-sectional data sets (years 2007-2013) from 26 Latin American and Caribbean countries was performed (N = 55,248 13- to 15-year-old students). Logistic regression models were used to analyze associations between alcohol policy relevant indicators and alcohol use, adjusting for the country and demographic variables.

RESULTS

In all countries, at least 20% of the students were exposed to alcohol advertisements daily or almost daily, which was associated with a twofold increased risk of current alcohol use and at least monthly heavy drinking. Obtaining alcohol from a shop was associated with a nearly threefold increased risk of at least monthly heavy drinking compared with obtaining alcohol from home, which was the most common way to obtain alcohol. Being denied from purchasing retail alcohol was associated with a decreased risk of at least monthly heavy drinking. About 27% to 53% of the students who had tried to purchase alcohol had been denied. One in four students reported exposure to drink driving in the past 30 days.

CONCLUSIONS

Deficits in alcohol policy indicators were identified in a number of countries. Improving implementation and enforcement of alcohol policies could reduce alcohol use and related burden among adolescents in a number of Latin American and Caribbean countries.

Smoking Trends among Brazilian population - National Household Survey, 2008 and the National Health Survey, 2013

OBJECTIVE

To compare current tobacco smoking prevalence in the Brazilian population and the federal states in adults (aged ≥ 18 years), using the National Household Survey 2008 and National Health Survey, 2013.

METHODS

Using data from two national surveys conducted in 2008 and 2013, the paper examines the current tobacco smoking prevalence in Brazil at the national level and at the federal state level. We calculated the percentage change for the period.

RESULTS

Overall, results show -19% reduction in current tobacco smoking prevalence from 18.5% (2008) to 14.7% (2013). Results also show a significant percentage decline in smoking prevalence across geographic regions and demographic characteristics including gender, race, age and education levels. The decline occurred in all regions, urban and rural areas, and in most states. The reduction was -17.5% for men and -20.7% for women, having occurred in all age groups, with the greatest reduction in the group from 25 to 39 years of age; in all categories of race/color, a higher prevalence was found among the blacks and browns. It also declined in all the levels of schooling, with a higher reduction in lower education levels. In 2013, the prevalence for people with less education was 19.7% and 8.7% for those with college degrees.

CONCLUSION

There was an average reduction of about 19% in tobacco consumption in Brazil and the Brazilian states in both sexes, all ages, and race color. Tobacco consumption in the country is one of the lowest in the world and has declined significantly, which can be attributed to the control policies, regulation, and prevention.

Secondhand smoke exposure at home among one billion children in 21 countries: findings from the Global Adult Tobacco Survey (GATS)

OBJECTIVE

Children are vulnerable to secondhand smoke (SHS) exposure because of limited control over their indoor environment. Homes remain the major place where children may be exposed to SHS. Our study examines the magnitude, patterns and determinants of SHS exposure in the home among children in 21 countries (19 low-income and middle-income countries and 2 high-income countries).

METHODS

Global Adult Tobacco Survey (GATS) data, a household survey of people 15 years of age or older. Data collected during 2009-2013 were analysed to estimate the proportion of children exposed to SHS in the home. GATS estimates and 2012 United Nations population projections for 2015 were also used to estimate the number of children exposed to SHS in the home.

RESULTS

The proportion of children younger than 15 years of age exposed to SHS in the home ranged from 4.5% (Panama) to 79.0% (Indonesia). Of the approximately one billion children younger than 15 years of age living in the 21 countries under study, an estimated 507.74 million were exposed to SHS in the home. China, India, Bangladesh, Indonesia and the Philippines accounted for almost 84.6% of the children exposed to SHS. The prevalence of SHS exposure was higher in countries with higher adult smoking rates and was also higher in rural areas than in urban areas, in most countries.

CONCLUSIONS

A large number of children were exposed to SHS in the home. Encouraging of voluntary smoke-free rules in homes and cessation in adults has the potential to reduce SHS exposure among children and prevent SHS-related diseases and deaths.

Tobacco use among youths--Argentina, 2007 and 2012

Tobacco use is the leading preventable cause of deaths worldwide. The MPOWER package, the six recommended policies of the World Health Organization (WHO) to reverse the tobacco epidemic, strongly recommends monitoring tobacco use trends. Because evidence indicates that smoking addiction often starts before the age of 18 years, there is a need to monitor tobacco use among youths. During 2011, a National Tobacco Control Law was enacted in Argentina that included implementation of 100% smoke-free environments, a comprehensive advertising ban (prohibiting advertising, promotion, and sponsorship of cigarettes or tobacco products through any media or communications outlets), pictorial health warnings, and a prohibition against the sale of tobacco products through any means to persons aged <18 years. To ascertain trends in tobacco use among youths in Argentina, the Argentina Ministry of Health and CDC analyzed data from the Global Youth Tobacco Survey (GYTS) for 2007 and 2012 (the next year that it was administered in Argentina). The findings indicated that the overall proportion of youths aged approximately 13-15 years who reported ever smoking a cigarette declined from 52.0% in 2007 to 41.9% in 2012 with significant decreases among both males and females. In 2012, 52.5% of youths in Argentina reported secondhand smoke (SHS) exposure in their homes and 47.5% in enclosed public places in the 7 days preceding the survey. Increased public education and tobacco control efforts will be important to discouraging tobacco use and decreasing SHS exposure among youths in Argentina.

Tracking MPOWER in 14 countries: results from the Global Adult Tobacco Survey, 2008–2010

Background:

The World Health Organization (WHO) MPOWER is a technical package of six tobacco control measures that assist countries in meeting their obligations of the WHO Framework Convention Tobacco Control and are proven to reduce tobacco use. The Global Adult Tobacco Survey (GATS) systematically monitors adult tobacco use and tracks key tobacco control indicators.

Methods:

GATS is a nationally representative household survey of adults aged 15 and older, using a standard and consistent protocol across countries; it includes information on the six WHO MPOWER measures. GATS Phase I was conducted from 2008–2010 in 14 high-burden low- and middle-income countries. We selected one key indicator from each of the six MPOWER measures and compared results across 14 countries.

Results:

Current tobacco use prevalence rates ranged from 16.1% in Mexico to 43.3% in Bangladesh. We found that the highest rate of exposure to secondhand smoke in the workplace was in China (63.3%). We found the highest ‘smoking quit attempt’ rates in the past 12 months among cigarette smokers in Viet Nam (55.3%) and the lowest rate was in the Russian Federation (32.1%). In five of the 14 countries, more than one-half of current smokers in those 5 countries said they thought of quitting because of health warning labels on cigarette packages. The Philippines (74.3%) and the Russian Federation (68.0%) had the highest percentages of respondents noticing any cigarette advertising, promotion and sponsorship. Manufactured cigarette affordability ranged from 0.6% in Russia to 8.0% in India.

Conclusions

Monitoring tobacco use and tobacco control policy achievements is crucial to managing and implementing measures to reverse the epidemic. GATS provides internationally-comparable data that systematically monitors and tracks the progress of the other five MPOWER measures.

Global Adult Tobacco Survey data as a tool to monitor the WHO Framework Convention on Tobacco Control (WHO FCTC) implementation: the Brazilian case

The Global Adult Tobacco Survey (GATS) was conducted in Brazil to provide data on tobacco use in order to monitor the WHO FCTC implementation in the country. It was carried out in 2008 using an international standardized methodology. The instrument included questions about tobacco use prevalence, cessation, secondhand smoke, knowledge, attitudes, media and advertising. Weighted analysis was used to obtain estimates. A total of 39,425 interviews were conducted. The prevalence of current tobacco use was 17.5%, (22.0%, men; 13.3%, women). The majority of users were smokers (17.2%) and their percentage was higher in rural areas (20.4%) than in urban areas (16.6%). About 20% of individuals reported having been exposed to tobacco smoke in public places. Over 70% of respondents said they had noticed anti-smoking information in several media and around 65% of smokers said they had considered quitting because of warning labels. About 30% of respondents had noticed cigarette advertising at selling points and 96% recognized tobacco use as a risk factor for serious diseases. Data in this report can be used as baseline for evaluation of new tobacco control approaches in Brazil, vis-à-vis WHO FCTC demand reduction measures.

A snapshot of the striking decrease in cigarette smoking prevalence in Brazil between 1989 and 2008

OBJECTIVE

To evaluate the differences in cigarette smoking prevalence rates in Brazil between 1989 and 2008.

METHODOLOGY

We calculated absolute and relative differences in smoking prevalences, overall and stratified by gender, age, place of residence, educational level and birth cohort. Data were obtained from random samples from two National Household Surveys (1989,n=39,969; 2008,n=38,461). GLM models were specified to obtain estimates and assess whether differences in proportions of smokers differed by categories of the stratification variables.

RESULTS

Adjusted absolute and relative differences in smoking prevalence rates between 1989 and 2008 were, respectively, -12.4% and -41.0%. Individuals aged 15-34 years and those with 9 or more years of education presented larger relative declines than their counterparts (p(s)≤0.001). After stratification by birth cohort, men presented larger reductions than women, only in the absolute scale (p(s)≤0.001), with the exception of the youngest birth cohort (i.e.,1965-1974).

CONCLUSIONS

In Brazil, several tobacco control measures have been adopted since 1986, in particular increasing taxation of tobacco products and strong health warnings, which may have contributed to the marked decline in smoking prevalence. It is important to understand the evolution of the tobacco epidemic to propose new actions to prevent initiation and encourage cessation among those who started/continued smoking.