Global Health Checkup: Seven Steps to Tackle NCDs in Brazil

by Dr. Kelly Henning, Bloomberg Philanthropies Public Health team lead

This is the first post in a series by Dr. Henning reflecting on her visits throughout the year ahead to Brazil, Vietnam, China, Indonesia, Philippines, Pakistan, Bangladesh and India to see first-hand the successes and challenges our partners face in tackling noncommunicable diseases (NCDs) and injuries in their communities

Brazil, a country known for its spectacular coastline, football prowess, and vibrant culture, has also become known in the public health community for its progressive action to prevent noncommunicable diseases.

On the first stop of my “Global Health Checkup,” I was not only wowed by Rio’s sprawling beaches and Brasilia’s magnificent architecture but also by the incredible work public health leaders are doing to help their citizens lead healthier lives. During meetings with the Director-General of the National Cancer Institute (INCA), the President of the Oswaldo Cruz Foundation (Fiocruz), and ACT I learned about their continued research and advocacy and how it can strengthen Brazil’s tobacco control policies as part of the Bloomberg Initiative to Reduce Tobacco Use. While the main focus of my visit was tobacco control, I also learned about the emerging work taking place to curb diet-related diseases like diabetes and hypertension. Many of those who have blazed the trail on tobacco control are now also doing the same for sugary drinks and junk food. Here are my top seven lessons from the trip:

1. Tobacco Control Works: Brazil has made great strides in implementing MPOWER – the six most effective tobacco control policies. The government of Brazil has:

• Prohibited smoking in enclosed public places;
• Become the first country in the world to ban misleading terms such as “light” and “mild” to describe tobacco products;
• Become the second country in the world to require graphic health warnings on tobacco packs; and
• Raised taxes on tobacco products to an average 79 percent of price.

In 1989, 35 percent of Brazilians were smokers. Thanks in part to these measures and other tobacco control policies, today just 11 percent of Brazilians smoke. This is incredible progress. It means fewer deaths from smoking related causes, less of a burden on the healthcare system to treat smoking-related diseases, and lower exposure to second-hand smoke among Brazilians.

2. Effecting Change Means Taking on Big Industry: Brazil has been a leader in tobacco control and its challenge now will be to build upon its strong foundation to ensure its progress is not undermined, particularly by the massive effort from the tobacco industry to halt progress. For example, it is currently illegal to sell or market e-cigarettes and heated tobacco in Brazil. The tobacco industry is pushing the Brazilian government to lift this ban and allow the sale of these products. While I was in Brasilia, ANVISA, Brazil’s equivalent to the FDA, held a preliminary hearing on that topic. Many of our partners testified at the hearing, sharing the growing evidence on the harms of these products – especially among youth.

We are also seeing the influence of the tobacco industry in the debate over the price of cigarettes. Raising the price of cigarettes is a proven deterrent to smoking. Brazil has implemented tobacco taxes but the price is still too low, so advocates are working to raise the minimum price and increase the tax on tobacco. In response, the tobacco industry has lobbied lawmakers, arguing that increasing the price will fuel the illegal cigarette trade. This argument misses the point – while a tax increase may increase illicit trade, it should be controlled through administrative and enforcement measures. We want to reduce all tobacco use – illegal and legal. We support our partners as they advocate for President Temer to sign the Illicit Trade Protocol.

3. The Legal System Can Drive Change: Brasilia is home to resplendent buildings, including its Supreme Court. The courts have played a vital role in tobacco control in Brazil. In 2012, Brazil banned the use of additives and flavors, including menthol, in tobacco products. For years, an injunction related to a lawsuit by from the tobacco industry prevented the ban from being enforced. However, the Supreme Court recently ruled that the additive ban was constitutional. We are hopeful that soon the policy will be able to be enforced.

4. Support Legislative Solutions: During my visit, I met Senator José Serra, who has been a champion for tobacco control in Brazil throughout his career. Senator Serra has a pending bill that proposes plain packaging of tobacco products, prohibits smoking in cars with children, bans additives and flavors in tobacco products, and strengthens a point-of-sale advertising restriction. We will continue to support our partners as they advocate for this bill.

5. Harness the Power of Community: As a part of Bloomberg Philanthropies’ Partnership for Healthy Cities, the city of Rio de Janeiro is harnessing community leadership to enforce the national tobacco advertising, promotion and sponsorship (TAPS) ban. During my visit, partners of the Bloomberg Initiative to Reduce Tobacco Use visited a local family clinic to learn more about the power of community leaders to reduce smoking.

6. Adequate Food Labeling is Needed: The influx of packaged foods and beverages that are high in sugar, salt, and saturated fat has dramatically changed the diets of Brazilians, leading to a 270 percent increase in the obesity rates of children since 1980. Our civil society partners in Brazil – ACT and IDEC – are collaborating to advocate for evidence-based warning labels on unhealthy foods and beverages; the proposed labels are informed by those currently used in Chile. I was able to see some of their advocacy in action, since my visit coincided with a meeting of Brazil’s Food and Nutrition Security National Council (CONSEA), which is an influential advisory council on food and nutrition policy that is comprised jointly of civil society and government. Through digital advocacy, tabling events (examples below), petitions, and demonstrations our partners educated meeting attendees and policymakers on how the labels can help consumers make informed choices and encourage manufacturers to reformulate towards healthier products.

7. Make Healthy Foods Cheap and Available: I was encouraged to see the amount of fresh, healthy food available at inexpensive prices. Each day I joined colleagues for lunch at “kilo” restaurants, which offer a quality selection of salads, fish, and meats. Fill up your plate and pay by weight – a wholesome lunch that was quick and convenient! It gave me great encouragement that Brazil will be able to curb the overconsumption of processed food and its impact on health through new policy interventions. As a start, Brazil has created exemplary Dietary Guidelines, which encourage eating whole and minimally processed foods with friends and family.

The public health community in Brazil has a lot on its plate this year, but if the past is any indication, advocates will continue to make it easier for all Brazilians to live healthier lives.