Over one billion of the world’s population are smokers, with increasing tobacco use in low-and middle-income countries. However, information about the methodology of studies on tobacco control is limited. We conducted a literature search to examine and evaluate the methodological designs of published tobacco research in Sub-Saharan Africa (SSA) over the past 50 years. The first phase was completed in 2015 using PubMed, Embase, CINAHL, and Cochrane Central Register of Controlled Trials. An additional search was completed in February 2017 using PubMed. Only tobacco/smoking research in SSA countries with human subjects and published in English was selected. Out of 1796 articles, 447 met the inclusion criteria and were from 26 countries, 11 of which had one study each. Over half of the publications were from South Africa and Nigeria. The earliest publication was in 1968 and the highest number of publications was in 2014 (n = 46). The majority of publications used quantitative methods (91.28%) and were cross-sectional (80.98%). The commonest data collection methods were self-administered questionnaires (38.53%), interviews (32.57%), and observation (20.41%). Around half of the studies were among adults and in urban settings. We conclud that SSA remains a “research desert” and needs more investment in tobacco control research and training.

In May 2010, the United Nations (UN) General Assembly unanimously adopted a resolution on non-communicable diseases (NCDs) that called for high-level meetings to address the global burden of NCDs. This paper highlights the growing global burden of NCDs (cardiovascular diseases, cancer, chronic obstructive pulmonary diseases and diabetes), provides a brief historical background on the adoption of the UN NCDs resolution and argues that the resolution provides a remarkable new opportunity for improved international collaboration to address NCDs. Additionally, the paper argues that while the existing World Health Organisation programme on NCDs be continued and expanded, the UN can provide the expanded political leadership that is necessary for multi-sectoral collaboration and can serve as a respected forum for dealing with the issue across numerous key UN agencies.

Symbole de modernité pendant la majeure partie du XXe siècle, la cigarette est depuis une trentaine d’années la cible d’interventions croissantes visant à réduire sa consommation. La lutte contre le tabac bénéficie d’un dispositif sans précédent qui fait office de cas d’école en santé publique, par son ampleur et par l’adhésion qu’il suscite. L’intérêt d’étudier cet objet réside ainsi dans la propriété essentielle de la lutte anti-tabac de relier un dispositif institutionnel et des motivations subjectives. Le dispositif anti-tabac (DAT) a en effet vocation à faire converger les prescriptions normatives d’un ensemble d’institutions et les désirs individuels, et y parvient manifestement dans une certaine mesure. Il permet dès lors d’aborder à la fois un travail sur les sociétés et un travail sur soi. Cette thèse entreprend une analyse sociologique du dispositif anti-tabac au Québec et vise à interroger les modalités et les fins de ce contrôle public de la consommation de tabac, en mettant au jour ses dimensions culturelles, symboliques et politiques. La santé publique apparaissant de nos jours comme lieu central de l’espace politique et social dans les sociétés contemporaines (Fassin et Dozon, 2001 :7), l’utopie d’un « monde sans fumée » se révèle selon nous tout à fait typique des enjeux qui caractérisent la modernité avancée ou « société du risque » (Beck, 2001, [1986]). Après avoir présenté le rapport historiquement ambivalent des pays occidentaux au tabac et ses enjeux, puis problématisé la question de la consommation de substances psychotropes dans le cadre d’une production et d’une construction sociale et culturelle (Fassin, 2005a), nous inscrivons le DAT dans le cadre d’une biopolitique de la population (Foucault, 1976; 1997; 2004b). À l’aune des enseignements de Michel Foucault, cette thèse consiste ainsi en l’analyse de discours croisée du dispositif institutionnel anti-tabac et de témoignages d’individus désirant arrêter de fumer, au regard du contexte social et politique de la société moderne avancée. Le DAT illustre les transformations à l’œuvre dans le champ de la santé publique, elles-mêmes caractéristiques d’une reconfiguration des modes de gouvernement des sociétés modernes avancées. La nouvelle biopolitique s’adresse en effet à des sujets libres et entreprend de produire des citoyens responsables de leur devenir biologique, des sujets de l’optimisation de leurs conditions biologiques. Elle s’appuie sur une culpabilité de type « néo-chrétien » (Quéval, 2008) qui caractérise notamment un des leviers fondamentaux du DAT. Ce dernier se caractérise par une lutte contre les fumeurs plus que contre le tabac. Il construit la figure du non-fumeur comme celle d’un individu autonome, proactif et performant et fait simultanément de l’arrêt du tabac une obligation morale. Par ce biais, il engage son public à se subjectiver comme citoyen biologique, entrepreneur de sa santé. L’analyse du DAT au Québec révèle ainsi une (re)moralisation intensive des questions de santé, par le biais d’une biomédicalisation des risques (Clarke et al., 2003; 2010), particulièrement représentative d’un nouveau mode d’exercice de l’autorité et de régulation des conduites dans les sociétés contemporaines, assimilée à une gouvernementalité néolibérale. Enfin, l’analyse de témoignages d’individus engagés dans une démarche d’arrêt du tabac révèle la centralité de la santé dans le processus contemporain d’individuation. La santé publique apparait alors comme une institution socialisatrice produisant un certain « type d’homme » centré sur sa santé et adapté aux exigences de performance et d’autonomie prévalant, ces éléments constituant désormais de manière croissante des clés d’intégration et de reconnaissance sociale. / Symbol of modernity for most of the twentieth century, smoking has been for the last thirty years the target of increasing interventions to reduce its consumption. Tobacco control benefits from an unprecedented device that acts as a case study in public health, by its scope and the awareness it raises. The interest to study this object then lies in the essential property of tobacco control to bind an institutional device with subjective motivations. The anti-smoking apparatus (ASA) was indeed intended to get the prescriptive requirements of a set of institutions to converge with individual desires, and obviously succeeds to some extent. It thus allows us to address both work on societies and work on oneself. This thesis undertakes a sociological analysis of the anti-smoking apparatus in Quebec and aims at questioning the modalities and purposes of tobacco control by uncovering its cultural, symbolic and political dimensions. Public Health appearing today as the central place of the political and social space in contemporary societies (Fassin and Dozon, 2001: 7), the “smoke-free world” utopia proves to be in our opinion quite typical of the stakes which characterize late modernity or “risk society” (Beck, 2001, [1986]). Having presented the historically ambivalent attitude of Western countries toward tobacco and its stakes, and problematized the issue of substance use within the framework of socio-cultural production and construction (Fassin, 2005a), we situate the ASA in the framework of a biopolitics of the population (Foucault, 1976; 1997; 2004b). In the light of the teachings of Michel Foucault, this thesis thereby consists of the crossed analysis of institutional tobacco control discourse and of testimonies of individuals wishing to quit smoking, with regard to the social and political context of late modernity. The ASA shows the changes at work in the field of public health, themselves characteristics of a reconfiguration of the modes of government of societies. The new biopolitics is indeed aimed at free subjects and undertakes to produce citizens responsible of their biological future, subjects of their own biological conditions optimization. It leans on a “neo-Christian” guilt type (Quéval, 2008) which characterizes such a fundamental levers of the ASA. It is characterized by a struggle against smokers more than against tobacco. It builds the figure of the non-smoker as that of an autonomous, proactive and efficient individual and makes simultaneously quitting smoking a moral obligation. Through this, it engages its audience to subjectify as biological citizens, entrepreneurs of their own health. The ASA in Quebec analysis reveals an intensive (re)moralization of health issues through a biomedicalization of risks (Clarke et al., 2003; 2010), particularly representative of a new way of exercising authority and regulate behaviors in contemporary societies, regarded as a neoliberal governmentality. Finally, the analysis of testimonies of individuals engaged in a process of smoking cessation reveals the centrality of health in the contemporary process of individuation. Public health then appears as a socializing institution producing a certain “type of man” centered on his health and adapted to the performance and autonomy requirements prevailing, these elements now increasingly constituting key-elements of integration and social recognition .

世界衛生組織(WHO)於2003年5月第56屆世界衛生大會通過國際「菸草控制框架公約」 (Framework Convention of Tobacco Control, 簡稱FCTC)，在「禁止菸品廣告、促銷及贊助行為」、「跨國合作管制非法走私菸品貿易」、「管制銷售菸品予未成年人及對弱勢族群的保護」、「研議並追究菸商之法律責任」等各方面皆訂有突破性規範。目前全世界已有超過150國家或簽署、或批准遞交世界衛生組織「菸草控制框架公約」。顯見「菸害防制」議題已經是不分國界、不分種族，21世紀全球一致最重要的公共衛生政策之一。 社會行銷在國外行之有年，強調：「以行銷之概念及技巧，來達到某種特定行為之改變，並改善社會」，而運用於健康議題之社會行銷，則是：「將行銷觀念及技巧系統化，以達到促進健康及減少傷害之行為改變目的」。「菸害防制」之推動，即為運用社會行銷所常見之議題及案例。在台灣，董氏基金會為國內最早推動菸害防制宣導的非營利組織，致力於國內菸害防制工作規劃、教育宣導，並促成相關政策法案制訂及監督執法。1997年推動「菸害防制法」立法(歷經十年)；2000年推動菸品開徵「健康福利捐」、執行「衛生署國民健康局菸害申訴服務中心」、舉辦國際「Quit and Win戒菸就贏」比賽等…董氏基金會推動菸害防制二十餘年，因著社會脈動調整推動策略，其寶貴之實務經驗在在與社會行銷理論相結合。 本研究即希望能收集國內外推動健康議題之社會行銷文獻，以社會行銷之概念，配合個案訪談，分析董氏基金會在推動菸害防制議題上之成效，歸納出活動成果及成功因素，以作為相關組織經營及發展策略之參考方向。 / World Health Organization has adopted the Framework Convention of Tobacco Control (FCTC) in the 56th World Health Assembly in May, 2003. The provisions have breakthrough progress on the fields such as “ban on tobacco advising, promotion and sponsorship”, “cross-country control over tobacco smuggling”, “ban on selling of tobacco to minors”, and “legal liability of the tobacco industry”. Up to date, over 150 countries already signed or ratified the FCTC. This shows that tobacco control is already such an important health policy in 21th century beyond country and race. Social marketing has been popular in other countries for years. The idea is “To change a certain collective behavior and improve the society with the concept and techniques of marketing.” To apply “social marketing” to health issues is to “To change behaviors that promote health and eliminate harm with systematized concept and techniques of marketing.” The promotion of tobacco control is a common topic and case that utilize social marketing theory. In Taiwan, John Tung Foundation (JTF) is the first NGO that advocates tobacco control movement. It has been dedicated to the planning, education and promotion of tobacco control in order to enhance police and legislation and the supervision of law enforcement. In 1997, after ten years of efforts, the Tobacco Hazard Prevention Act was finally passed. In 2000, JTF advocated and successfully lead to the levy of the tobacco health and welfare surcharge, executed the “tobacco complaint center sponsored by Bureau of Health Promotion, Department of health” and sponsored the international Quit & Win cessation campaign. In more than two decades, JTF always modifies its tobacco control strategies with the trend of society. Its invaluable experience is again and again accords with the theory of social marketing. The study aims to collect the literature regarding social marketing of health issues. The author uses the concept of social marketing and case interview to analyze the effects of JTF’s advocacy of tobacco control issues. The performance of its campaign and success factors may be a new guideline for the relevant organizations for their operation and strategy development.

Esta dissertação discute a proposição de políticas geradas por organismos multilaterais e que precisam ser institucionalizadas no âmbito do Estado nacional. Parte-se do fato de que a proposição de políticas é resultante de um processo de disputa entre atores sociais, políticos e econômicos. Nas últimas décadas, a globalização tem modificado a forma de atuação dos Estados nacionais e, conseqüentemente, a elaboração e a implementação de políticas de regulação. Verifica-se que, neste contexto, há uma emergência de organizações internacionais que têm exercido uma influência cada vez maior sobre as relações interestatais e o desenvolvimento do comércio internacional. O objetivo deste trabalho é identificar e analisar os impactos da emergência de instituições e propostas de regulação global sobre as relações estabelecidas entre os atores que atuam no nível nacional/local. Para isso, aborda-se a questão do tabaco enquanto política pública constituída por um fórum internacional, presidido pela Organização Mundial da Saúde (OMS) e que para ser institucionalizada no Brasil precisa passar por um processo de ratificação no âmbito nacional. Verificou-se que, com a proposição de políticas de regulação internacionais, as relações entre os níveis global – local tornam-se mais complexas, devido à emergência de novos atores, esferas e arenas de âmbito global, que passam a tomar decisões que influenciam o nível nacional. Além disso, a emergência desta política a nível nacional provocou algumas mudanças na dinâmica de regulação, até mesmo pela introdução do debate em torno de um tema que provavelmente, sem o apoio da OMS, não seria objeto de uma política de regulação. Esta proposta de regulação permitiu também que novas arenas de discussão e de deliberação fossem constituídas e o fortalecimento de perspectivas ligadas à área da saúde, que antes eram subjugadas pela perspectiva econômica de grupos ligados ao tabaco. Desta forma, a emergência da proposta de regulação a nível nacional acarretou uma mudança na correlação de forças entre os atores nacionais, gerando novas relações entre os atores envolvidos e fazendo com que atores tradicionalmente antagônicos (agricultores e indústrias) se aliassem na defesa da cultura do fumo. / This dissertation discusses the proposition of policies that were generated by multilateral organisms and which need to be institutionalized within the National State. Its key point of departure is that the proposition of policies is resultant from a disputing process among social, political and economical actors. In the last decades, globalization has modified the way National States play roles and, consequently, the elaboration and implementation of regulation policies. It has been verified that within this context, there is an emergence of international organizations that have exercised a major influence over the relationships between national states and the development of the international commerce. The goal of this work is to identify and analyze impacts coming from the emergence of these institutions and proposes of global regulation over relations that were established between actors that act at the national/local level. For this, the study deals with the tobacco issue as a public policy that was constituted by an international forum, presided by the World Health Organization (WHO) and that for being institutionalized in Brazil needs to go through a ratification process within the national sphere. It has been demonstrated that with the proposition of international regulation policy, the relationships among the global – local levels become more complexes, because of the emergence of new actors, spheres and arenas of global field, that come to take decisions for influencing the national level. Besides, the emergence of this policy at the national level provoked some changes in the regulation’s dynamic, even because of the introduction of a debate on a subject, which perhaps would not be object for regulation policy without the support of the WHO. This proposition of regulation allowed, as well, that new arenas for discussion and deliberation could be constructed and the strength of perspectives related to health issues, that earlier were subjugated by the economic perspective coming from groups linked to tobacco. In this way, the emergence of this proposition of regulation at national level has as effects a change in the correlation of forces among national actors, generating new relations between the involved actors and making those actors who are traditionally antagonist (farmers and industries) to join together for defending the tobacco cultivation.

Esta tese inclui dois artigos que têm por objetivo apresentar um panorama das tendências e heterogeneidades do tabagismo nas capitais brasileiras e, assim, oferecer subsídios ao planejamento e avaliação de medidas de controle do tabaco no País. Utilizaram-se os dados da Pesquisa Nacional sobre Saúde e Nutrição (PNSN), e do Inquérito Domiciliar Sobre Comportamentos de Risco e Morbidade Referida de Doenças e Agravos Não Transmissíveis (InqDANT). No primeiro artigo estimou-se a diferença na prevalência de tabagismo em 14 capitais brasileiras entre pessoas de 15 anos ou mais em 1989 (PNSN) e 2002/2003 (InqDANT) relacionando as mudanças observadas às principais medidas de controle do tabaco desenvolvidas no período. O estudo mostrou que o percentual de fumantes diminuiu de 30,2% para 19,4% no período. Entre homens, a prevalência passou de 37,5% para 23,2% (1,1% /ano) e entre mulheres, de 24,3% para 16,5% (0,6% /ano). A avaliação cronológica sugere que as principais medidas de impacto refletidas no decréscimo observado foram a lei que obriga que haja advertências sobre os malefícios do tabagismo nas embalagens e propagandas de cigarros, a restrição e proibição da propaganda de produtos do tabaco e as intervenções relacionadas à proteção ao tabagismo passivo. O declínio da prevalência observado no estudo foi um dos maiores do mundo. No segundo artigo, fez-se uma descrição da situação do tabagismo no Brasil considerando heterogeneidades regionais e de subgrupos populacionais a partir de uma amostra de 24.681 indivíduos de 15 anos ou mais residentes em 16 capitais brasileiras incluídas no InqDANT. A prevalência de tabagismo no gênero masculino variou de 17,0% a 28,2% e no feminino, de 10% a 22,9%. Entre mulheres, menores prevalências foram observadas nas regiões Norte, Nordeste e Centro-Oeste. Este padrão não se repetiu entre homens. Independentemente de gênero, maiores percentuais de fumantes foram encontrados entre pessoas de menor escolaridade e faixa etária 40-49 anos. A cessação média entre homens e mulheres foi de 50%. Os dados indicaram que as políticas públicas de controle do tabaco têm sido efetivas particularmente na indução à cessação de fumar. Contudo, a elevada prevalência em jovens mostrou a importância de reforço a medidas que contenham a iniciação. As heterogeneidades observadas mostraram a necessidade de ações específicas por região. Além dos dois estudos referidos, esta Tese também descreveu novas pesquisas sobre tabagismo utilizando-se dados do InqDANT. Subsequentemente, com base na discussão prévia, delineou-se uma proposta sumária das principais linhas de investigação a serem desenvolvidas no Brasil a fim de subsidiar o Programa Nacional de Controle do Tabagismo e a implantação da Convenção Quadro Para o Controle do Tabaco. / This Thesis includes two papers that aim at describing tobacco use trends and heterogeneity in Brazilian regions and capitals. These data, in turn, aim at supporting tobacco control plan and evaluation. Data from two household surveys The Health and Nutrition National Survey (PNSN) and the Non-Communicable Disease and Self-Perceived Domiciliary Survey (InqDANT) - were used in this study. The first papers objective is to estimate the differences in tobacco use prevalence in Brazilian capitals between 1989 and 2002/2003, and their relationships to tobacco control actions during this period. The percentage of current smokers decreased from 30.2% to 19.4% from 1989 to 2002/2003. The prevalence changed from 37.5% to 23.2% (1.1% /year) in men and from 24.3% to 16.5% (0.6 % /year) in women. The timing of the principal public health actions related to smoking suggests that the declines were the result of the combined effects of cigarette package warning labels, tobacco products advertisement restriction and ban, and restriction of environmental tobacco smoke exposure in public places. The decline in smoking prevalence observed in the present study was one of the highest of the world. On the second paper, we described tobacco use in Brazil and its heterogeneity by region and other characteristics. The study included 24.681 participants selected through a multi-stage sampling strategy of individuals 15 years old or older living in 16 capitals and in the Federal District. The prevalence of smoking was greater in men than in women in all cities. The smoking prevalence ranged from 17.0% to 28.2% in men, and from 10% to 22.9% in women. The highest prevalences in women were found in the South and Southeast regions, a pattern that was not observed in men. Regardless of gender, the highest prevalences of smoking were found in those with lower educational levels and those aged 40- 49 years. Cessation average was approximately 50% in both men and women. These results suggest that tobacco control public policies have been effective, particularly with regard to cessation strategies. However, the high smoking prevalence in the young individuals underscores the importance of reinforcing smoking initiation control measures. The heterogeneity observed in this survey highlights the necessity of tailoring control actions to the different regions. In addition to these two study reports, this Thesis also described possible new studies on tobacco use using InqDANT data. Finally, a description is also presented of important research areas to be developed in Brazil aiming at supporting the National Tobacco Control Program and the Framework Convention on Tobacco Control.

Esta dissertação discute a proposição de políticas geradas por organismos multilaterais e que precisam ser institucionalizadas no âmbito do Estado nacional. Parte-se do fato de que a proposição de políticas é resultante de um processo de disputa entre atores sociais, políticos e econômicos. Nas últimas décadas, a globalização tem modificado a forma de atuação dos Estados nacionais e, conseqüentemente, a elaboração e a implementação de políticas de regulação. Verifica-se que, neste contexto, há uma emergência de organizações internacionais que têm exercido uma influência cada vez maior sobre as relações interestatais e o desenvolvimento do comércio internacional. O objetivo deste trabalho é identificar e analisar os impactos da emergência de instituições e propostas de regulação global sobre as relações estabelecidas entre os atores que atuam no nível nacional/local. Para isso, aborda-se a questão do tabaco enquanto política pública constituída por um fórum internacional, presidido pela Organização Mundial da Saúde (OMS) e que para ser institucionalizada no Brasil precisa passar por um processo de ratificação no âmbito nacional. Verificou-se que, com a proposição de políticas de regulação internacionais, as relações entre os níveis global – local tornam-se mais complexas, devido à emergência de novos atores, esferas e arenas de âmbito global, que passam a tomar decisões que influenciam o nível nacional. Além disso, a emergência desta política a nível nacional provocou algumas mudanças na dinâmica de regulação, até mesmo pela introdução do debate em torno de um tema que provavelmente, sem o apoio da OMS, não seria objeto de uma política de regulação. Esta proposta de regulação permitiu também que novas arenas de discussão e de deliberação fossem constituídas e o fortalecimento de perspectivas ligadas à área da saúde, que antes eram subjugadas pela perspectiva econômica de grupos ligados ao tabaco. Desta forma, a emergência da proposta de regulação a nível nacional acarretou uma mudança na correlação de forças entre os atores nacionais, gerando novas relações entre os atores envolvidos e fazendo com que atores tradicionalmente antagônicos (agricultores e indústrias) se aliassem na defesa da cultura do fumo. / This dissertation discusses the proposition of policies that were generated by multilateral organisms and which need to be institutionalized within the National State. Its key point of departure is that the proposition of policies is resultant from a disputing process among social, political and economical actors. In the last decades, globalization has modified the way National States play roles and, consequently, the elaboration and implementation of regulation policies. It has been verified that within this context, there is an emergence of international organizations that have exercised a major influence over the relationships between national states and the development of the international commerce. The goal of this work is to identify and analyze impacts coming from the emergence of these institutions and proposes of global regulation over relations that were established between actors that act at the national/local level. For this, the study deals with the tobacco issue as a public policy that was constituted by an international forum, presided by the World Health Organization (WHO) and that for being institutionalized in Brazil needs to go through a ratification process within the national sphere. It has been demonstrated that with the proposition of international regulation policy, the relationships among the global – local levels become more complexes, because of the emergence of new actors, spheres and arenas of global field, that come to take decisions for influencing the national level. Besides, the emergence of this policy at the national level provoked some changes in the regulation’s dynamic, even because of the introduction of a debate on a subject, which perhaps would not be object for regulation policy without the support of the WHO. This proposition of regulation allowed, as well, that new arenas for discussion and deliberation could be constructed and the strength of perspectives related to health issues, that earlier were subjugated by the economic perspective coming from groups linked to tobacco. In this way, the emergence of this proposition of regulation at national level has as effects a change in the correlation of forces among national actors, generating new relations between the involved actors and making those actors who are traditionally antagonist (farmers and industries) to join together for defending the tobacco cultivation.

Esta tese inclui dois artigos que têm por objetivo apresentar um panorama das tendências e heterogeneidades do tabagismo nas capitais brasileiras e, assim, oferecer subsídios ao planejamento e avaliação de medidas de controle do tabaco no País. Utilizaram-se os dados da Pesquisa Nacional sobre Saúde e Nutrição (PNSN), e do Inquérito Domiciliar Sobre Comportamentos de Risco e Morbidade Referida de Doenças e Agravos Não Transmissíveis (InqDANT). No primeiro artigo estimou-se a diferença na prevalência de tabagismo em 14 capitais brasileiras entre pessoas de 15 anos ou mais em 1989 (PNSN) e 2002/2003 (InqDANT) relacionando as mudanças observadas às principais medidas de controle do tabaco desenvolvidas no período. O estudo mostrou que o percentual de fumantes diminuiu de 30,2% para 19,4% no período. Entre homens, a prevalência passou de 37,5% para 23,2% (1,1% /ano) e entre mulheres, de 24,3% para 16,5% (0,6% /ano). A avaliação cronológica sugere que as principais medidas de impacto refletidas no decréscimo observado foram a lei que obriga que haja advertências sobre os malefícios do tabagismo nas embalagens e propagandas de cigarros, a restrição e proibição da propaganda de produtos do tabaco e as intervenções relacionadas à proteção ao tabagismo passivo. O declínio da prevalência observado no estudo foi um dos maiores do mundo. No segundo artigo, fez-se uma descrição da situação do tabagismo no Brasil considerando heterogeneidades regionais e de subgrupos populacionais a partir de uma amostra de 24.681 indivíduos de 15 anos ou mais residentes em 16 capitais brasileiras incluídas no InqDANT. A prevalência de tabagismo no gênero masculino variou de 17,0% a 28,2% e no feminino, de 10% a 22,9%. Entre mulheres, menores prevalências foram observadas nas regiões Norte, Nordeste e Centro-Oeste. Este padrão não se repetiu entre homens. Independentemente de gênero, maiores percentuais de fumantes foram encontrados entre pessoas de menor escolaridade e faixa etária 40-49 anos. A cessação média entre homens e mulheres foi de 50%. Os dados indicaram que as políticas públicas de controle do tabaco têm sido efetivas particularmente na indução à cessação de fumar. Contudo, a elevada prevalência em jovens mostrou a importância de reforço a medidas que contenham a iniciação. As heterogeneidades observadas mostraram a necessidade de ações específicas por região. Além dos dois estudos referidos, esta Tese também descreveu novas pesquisas sobre tabagismo utilizando-se dados do InqDANT. Subsequentemente, com base na discussão prévia, delineou-se uma proposta sumária das principais linhas de investigação a serem desenvolvidas no Brasil a fim de subsidiar o Programa Nacional de Controle do Tabagismo e a implantação da Convenção Quadro Para o Controle do Tabaco. / This Thesis includes two papers that aim at describing tobacco use trends and heterogeneity in Brazilian regions and capitals. These data, in turn, aim at supporting tobacco control plan and evaluation. Data from two household surveys The Health and Nutrition National Survey (PNSN) and the Non-Communicable Disease and Self-Perceived Domiciliary Survey (InqDANT) - were used in this study. The first papers objective is to estimate the differences in tobacco use prevalence in Brazilian capitals between 1989 and 2002/2003, and their relationships to tobacco control actions during this period. The percentage of current smokers decreased from 30.2% to 19.4% from 1989 to 2002/2003. The prevalence changed from 37.5% to 23.2% (1.1% /year) in men and from 24.3% to 16.5% (0.6 % /year) in women. The timing of the principal public health actions related to smoking suggests that the declines were the result of the combined effects of cigarette package warning labels, tobacco products advertisement restriction and ban, and restriction of environmental tobacco smoke exposure in public places. The decline in smoking prevalence observed in the present study was one of the highest of the world. On the second paper, we described tobacco use in Brazil and its heterogeneity by region and other characteristics. The study included 24.681 participants selected through a multi-stage sampling strategy of individuals 15 years old or older living in 16 capitals and in the Federal District. The prevalence of smoking was greater in men than in women in all cities. The smoking prevalence ranged from 17.0% to 28.2% in men, and from 10% to 22.9% in women. The highest prevalences in women were found in the South and Southeast regions, a pattern that was not observed in men. Regardless of gender, the highest prevalences of smoking were found in those with lower educational levels and those aged 40- 49 years. Cessation average was approximately 50% in both men and women. These results suggest that tobacco control public policies have been effective, particularly with regard to cessation strategies. However, the high smoking prevalence in the young individuals underscores the importance of reinforcing smoking initiation control measures. The heterogeneity observed in this survey highlights the necessity of tailoring control actions to the different regions. In addition to these two study reports, this Thesis also described possible new studies on tobacco use using InqDANT data. Finally, a description is also presented of important research areas to be developed in Brazil aiming at supporting the National Tobacco Control Program and the Framework Convention on Tobacco Control.

Esta dissertação discute a proposição de políticas geradas por organismos multilaterais e que precisam ser institucionalizadas no âmbito do Estado nacional. Parte-se do fato de que a proposição de políticas é resultante de um processo de disputa entre atores sociais, políticos e econômicos. Nas últimas décadas, a globalização tem modificado a forma de atuação dos Estados nacionais e, conseqüentemente, a elaboração e a implementação de políticas de regulação. Verifica-se que, neste contexto, há uma emergência de organizações internacionais que têm exercido uma influência cada vez maior sobre as relações interestatais e o desenvolvimento do comércio internacional. O objetivo deste trabalho é identificar e analisar os impactos da emergência de instituições e propostas de regulação global sobre as relações estabelecidas entre os atores que atuam no nível nacional/local. Para isso, aborda-se a questão do tabaco enquanto política pública constituída por um fórum internacional, presidido pela Organização Mundial da Saúde (OMS) e que para ser institucionalizada no Brasil precisa passar por um processo de ratificação no âmbito nacional. Verificou-se que, com a proposição de políticas de regulação internacionais, as relações entre os níveis global – local tornam-se mais complexas, devido à emergência de novos atores, esferas e arenas de âmbito global, que passam a tomar decisões que influenciam o nível nacional. Além disso, a emergência desta política a nível nacional provocou algumas mudanças na dinâmica de regulação, até mesmo pela introdução do debate em torno de um tema que provavelmente, sem o apoio da OMS, não seria objeto de uma política de regulação. Esta proposta de regulação permitiu também que novas arenas de discussão e de deliberação fossem constituídas e o fortalecimento de perspectivas ligadas à área da saúde, que antes eram subjugadas pela perspectiva econômica de grupos ligados ao tabaco. Desta forma, a emergência da proposta de regulação a nível nacional acarretou uma mudança na correlação de forças entre os atores nacionais, gerando novas relações entre os atores envolvidos e fazendo com que atores tradicionalmente antagônicos (agricultores e indústrias) se aliassem na defesa da cultura do fumo. / This dissertation discusses the proposition of policies that were generated by multilateral organisms and which need to be institutionalized within the National State. Its key point of departure is that the proposition of policies is resultant from a disputing process among social, political and economical actors. In the last decades, globalization has modified the way National States play roles and, consequently, the elaboration and implementation of regulation policies. It has been verified that within this context, there is an emergence of international organizations that have exercised a major influence over the relationships between national states and the development of the international commerce. The goal of this work is to identify and analyze impacts coming from the emergence of these institutions and proposes of global regulation over relations that were established between actors that act at the national/local level. For this, the study deals with the tobacco issue as a public policy that was constituted by an international forum, presided by the World Health Organization (WHO) and that for being institutionalized in Brazil needs to go through a ratification process within the national sphere. It has been demonstrated that with the proposition of international regulation policy, the relationships among the global – local levels become more complexes, because of the emergence of new actors, spheres and arenas of global field, that come to take decisions for influencing the national level. Besides, the emergence of this policy at the national level provoked some changes in the regulation’s dynamic, even because of the introduction of a debate on a subject, which perhaps would not be object for regulation policy without the support of the WHO. This proposition of regulation allowed, as well, that new arenas for discussion and deliberation could be constructed and the strength of perspectives related to health issues, that earlier were subjugated by the economic perspective coming from groups linked to tobacco. In this way, the emergence of this proposition of regulation at national level has as effects a change in the correlation of forces among national actors, generating new relations between the involved actors and making those actors who are traditionally antagonist (farmers and industries) to join together for defending the tobacco cultivation.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-05-23T13:48:31Z No. of bitstreams: 1 leonardohenriquesportes.pdf: 1936653 bytes, checksum: b3b651640a7c241d88d358f1dc8831c6 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-07-02T11:36:35Z (GMT) No. of bitstreams: 1 leonardohenriquesportes.pdf: 1936653 bytes, checksum: b3b651640a7c241d88d358f1dc8831c6 (MD5) / Made available in DSpace on 2016-07-02T11:36:35Z (GMT). No. of bitstreams: 1 leonardohenriquesportes.pdf: 1936653 bytes, checksum: b3b651640a7c241d88d358f1dc8831c6 (MD5) Previous issue date: 2012-02-27 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / O tabagismo é uma doença epidêmica causada pela dependência da nicotina e acomete quase todos os órgãos do corpo, causando doenças e prejudicando a saúde dos fumantes em geral. Em virtude do impacto negativo do tabagismo na saúde da população mundial, diversas políticas abordam o combate ao tabagismo, com destaque para o Programa Nacional de Controle do Tabagismo (PNCT), que desde 1989 desenvolve ações com o objetivo de reduzir a prevalência de fumantes e a consequente morbimortalidade por doenças tabaco-relacionadas. Se as ações das diferentes políticas que visam o controle do tabagismo forem realizadas de maneira eficaz e eficiente, espera-se reduzir a morbimortalidade devido às doenças relacionadas ao tabaco. O CDC (Centers for disease Control and Prevention), centro de saúde norte-americano de controle e prevenção de doenças, considera 23 categorias de doenças tabaco-relacionadas, estando organizadas em quatro grupos: neoplasias malignas, doenças cardiovasculares, doenças respiratórias e condições perinatais. Dentre todas as doenças tabaco-relacionadas, uma parcela refere-se às condições sensíveis à atenção ambulatorial (ICSAA), as quais representam os agravos à saúde para os quais uma efetiva ação na atenção primária à saúde (APS) diminuiria o risco de hospitalizações. Considerando a importância da realização de pesquisas que relacionem o tabagismo com as ICSAA e que são necessários mais estudos que relacionem as ICSAA com a efetividade dos serviços na APS, esta pesquisa teve a intenção de analisar a situação das políticas voltadas para controle do tabagismo no município de Juiz de Fora/MG através da verificação das ações do PNCT desenvolvidas nas Unidades de Atenção Primária à Saúde (UAPS) da zona urbana do município e do estabelecimento do perfil das ICSAA tabaco-relacionadas no ano de 2008, a fim de servir como uma linha de base para futuros estudos. Para tal, foram entrevistados o coordenador municipal do PNCT e profissionais das 44 UAPS da zona urbana do município acerca das ações de controle do tabagismo desenvolvidas. Além disso, foi feita a descrição estatística das ICSAA tabaco-relacionadas a partir de uma base de dados secundários com informações do Sistema de Informações Hospitalares do SUS (SIH-SUS), referentes ao ano de 2008. Os seguintes aspectos foram considerados na análise das ICSAA tabaco-relacionadas: sexo, idade, grupos de doenças estabelecidas pelo CDC, regiões administrativas de Juiz de Fora, tipo de modelo assistencial adotado pelas unidades e UAPS. Pôde-se observar que há no município ações de promoção da saúde e de tratamento do tabagismo, tendo destaque a capacitação de profissionais para a implementação do tratamento nas UAPS. 40,9% dos entrevistados relataram que, nas UAPS onde atuam, o tratamento para o fumante é ofertado e 88,6% que o tema tabagismo é abordado em salas de espera, grupos e consultas individuais. As ICSAA representaram 17,7% do total de hospitalizações no município, sendo que 43,7% das ICSAA são condições tabaco-relacionadas. Deste grupo, 56,3% corresponderam ao sexo masculino e 23,7% à região leste de Juiz de Fora. Diante disso, o município apresenta o desafio do fortalecimento do controle do tabagismo de forma intersetorial e na atenção primária, podendo este trabalho servir como uma linha de base para futuras avaliações e acompanhamento da evolução da implementação e execução das ações de controle do tabagismo em nível local. A discussão e resultados obtidos poderão servir como instrumento de sensibilização da secretaria municipal de saúde e, assim, como ferramentas de apoio para a formulação de ações estratégicas de saúde para o controle do tabagismo. / Smoking is an epidemic disease caused by nicotine addiction and affects almost every organ of the body, causing disease and impairing the health of smokers in general. Because of the negative impact of smoking on health of the world population, several policies addressing tobacco control, especially the National Program of Tobacco Control (NPTC), which since1989 carries out actions aimed at reducing the prevalence of smokers and consequent morbidity and mortality from tobacco-related diseases. If the actions of the different policies for tobacco control are carried out effectively and efficiently, is expected to reduce morbidity and mortality due to tobacco-related diseases. The CDC (Centers for Disease Control and Prevention), the center of American health control and disease prevention, considers 23 categories of tobacco-related diseases organized into four groups: cancer, cardiovascular diseases, respiratory diseases and perinatal conditions. Among all tobacco-related diseases, a portion refers to ambulatory care sensitive conditions (ACSC), which represent the health problems for which an effective action in the primary health care (PHC) would reduce the risk of hospitalization. Considering the importance of conducting research that relate smoking with ACSC and that more research is needed relating the ACSC to the effectiveness of PHC services, this study intended to analyze the status of policies for tobacco control in Juiz de Fora/MG city by checking the actions of NPTC developed in primary health care units of the urban area and the establishment of the profile of tobacco-related ACSC in 2008 to serve as a baseline for future studies. Thus, respondent was the coordinator of NPTC and local professionals from 44 primary health care units of the urban area about the actions of tobacco control developed. In addition, was made a statistical description of the ACSC tobacco-related from a secondary database with information from the hospital information system for the year 2008. The following aspects were considered in the analysis of tobacco-related ICSA: sex, age, disease groups established by the CDC, administrative regions of Juiz de Fora, type of care model adopted by the units and primary health care units. It was noted municipality'sactions on health promotion and smoking cessation, with a focus on training of professionals for the implementation of treatment in primary health care units. 40.9% of respondents reported that their primary health care units offer treatment for smokers and 88.6% that the smoking issue is approached in waiting rooms, groups and individual consultations.The ACSC accounted for 17.7% of all hospitalizations, with 43.7% of ICSA are tobacco related. Of this group, 56.3% were male and 23.7% for the eastern region of Juiz de Fora city. Thus, the city has the challenge of strengthening tobacco control with intersectoral and primary care approaches. This work may serve as a baseline for future evaluations and monitoring of the implementation progress and enforcement of local tobacco control activities. The discussion and results can serve as a tool for raising awareness of the municipal health secretary and thus as support tools for the formulation of strategic actions of health for tobacco control.