ABC | Volume 112, Nº4, April 2019

FSCLP Statement Oliveira et al 2019: Recommendations for reducing tobacco consumption in Portuguese-Speaking countries Arq Bras Cardiol. 2019; 112(4):477-486 Table 1 – Standardized prevalences by sex in 2015, and annualized difference by sex from 1990 to 2015 according to the sociodemographic index SDI Level Women Standardized Prevalence 2015 Men Standardized Prevalence 2015 Annualized Women Change rate 1990-2015 Annualized Men Change rate 1990-2015 Global 5.4 (5.1-5.7) 25.0 (24.2-25.7) –1.7 (–2.0/ –1·4) –1.3 (–1.5/ –1.2) Angola Low-intermediate 1.6 (0.9-2.6) 14.2 (12.5-16.1) –0.7 (–3.5/2·2) 0.5 (–0.2 /1.3) Brazil Intermediate 8.2 (7.5-9.0) 12.6 (11.8-13.5) –3.3 (–3.9/–2.7) –3.3 (–3.8/–2.9) Cape Verde Low-intermediate 2.5 (1.7-3.6) 9.8 (8.0 -11.7) –0.9 (–3.1/1.3) –0.6 (–1.6/0.6) Equatorial Guinea Low 1.4 (0.9-2.1) 6.9 (5.6-8·4) –1.0 (–3.5/1.3) –0.6 (–1.7/-0.5) Guinea-Bissau Low 1.0 (0.6-1.5) 11.4 (9.4 -13·5) –0.9 (–3.4 /1.6) –0.3 (–1.4/-0.8) Mozambique Low 3.1 (2.5-3.8) 17.2 (14.5-20.1) –1.5 (–2.7/–0.2) –0·5 (–1.5/-0.5) Portugal High-intermediate 12.7 (11.0 -14.8) 24.9 (22.7-27.2) 1.3 (0.4 /2.1) –1.0 (–1.4/–0.6) São Tomé and Principe Low-intermediate 1.0 (0.7-1.5) 6.2 (5.0 -7·3) –1.0 (–3.2/1.3) –0.2 (–1.3/0.9) East Timor Low-intermediate 12.4 (9.8-15.1) 39.8 (37.2-42.5) 4.5 (2.8-6.3) –0.1 (–0.5/0.4) SDI: sociodemographic index. The SDI is the weighted geometric mean of the per capita income, educational level, and total fertility rate. 3 These measures stemmed from adherence to the recommendations by the World Health Organization’s Framework Convention on Tobacco Control (FCTC), 9 such as banning of terms such as ultra-light, light, low tar, and mild or any other terms implying that cigarettes are not so harmful. The PSCs have joined the FCTC at different moments, as discussed below in the section “Legislation.” The percentage of deaths attributed to tobacco use across 195 countries increased from 7.28 (7.01-7.56) million in 2007 to 8.10 (7.79-8.42) million in 2017, an increase of 11.3% (9.1-13.4%), according to the Global Burden of Disease (GBD) study. 1 The same occurred with the DALYs, from 199.80 (188.0‑211.72) million in 2007 to 213.39 (201.16-226.67) million in 2017, a 6.8% increase (4.6-9.0%). A similar trend was observed in regard to ischemic heart diseases, from 1.76 (1.68‑1.83) million deaths in 2007 to 1.93 (1.83-2.02) million deaths in 2017, a 7.8% increase (4.6-11.1%), whereas the DALYs increased from 44.30 (42.42-46.19) million in 2007 to 47.38 (45.12-49.71) million in 2017, a 5.6% increase (2.4‑9.0%). Similar increases were observed in relation to deaths due to ischemic stroke, from 351.19 (326.63-379.84) thousand in 2007 to 399.35 (369.15-433.38) thousand in 2017, a 13.4% (8.6-17.8%) increase, with an increase in DALYs from 8.74 (7.96-9.54) million thousand in 2007 to 10.41 (9.42-11.50) million in 2017, a 19.3% (14.7-23.8%) increase. 1 It is important to note that approximately 80% of the smokers reside in low- and middle-income countries, 10 which represent most of the population of PSCs, where the reported decline in tobacco consumption seen in high-income countries has not been observed. 4 There is already strong evidence of cost-effectiveness and opportunities to treat smoking in primary care because of its wide coverage and close and continuous physician-patient relationship. 11 Considering only those risk factors valued in traditional practice, smoking is the only factor that could be completely abolished in the prevention of cardiovascular diseases (CVDs); however, broadening the spectrum and including man-made ecological and behavioral changes, there are many other factors that can be controlled. In a social environment filled with stressful and frustrating circumstances driven by inequality, with conflicts of interest and fueled by marketing, adherence to the consumption of psychoactive substances like tobacco and alcohol is successful due to the action of these substances in the limbic system (reward circuit), leading to chemical and psychological dependence. This system is part of the evolutionary adaptation process that promoted the preservation of species and is one of the determinants of the repeated relapses observed when the patient intends to quit. 12 Quitting smoking is known to be the most effective measure in the prevention of tobacco-related diseases. However, smoking does not receive the necessary attention during medical consultations, both at an outpatient and inpatient level, to initiate the process of quitting the most frequent preventable cause of CVD and many cancers. 11 Thus, the objective of this article is to provide an instrument to be used by healthcare professionals in their daily practice in the fight against smoking. Epidemiology and physiopathologic mechanisms Table 2 shows the risk attributable to cigarette smoking for some diseases in the PSCs, presented as the percentage of deaths and the percentage of risk attributed to smoking. When smokers and never smokers are compared, the risk of smokers is 2 to 3 times higher for stroke, ischemic heart disease, and peripheral vascular disease; 23 and 13 times higher for malignancy in men and women, respectively; and 12 to 13 times higher for chronic obstructive pulmonary disease. Smokers also have a 2.87 increased risk of death from myocardial infarction compared with nonsmokers. 3 Smoking is also associated with increased blood pressure and related complications like death and decline in renal function. The same applies to abdominal aortic aneurysms, which have an increased risk attributable to smoking, as well as increased aneurysm growth rate when smokers and nonsmokers are compared. Smoking has been associated with cardiac rhythm disorders such as increased frequency 478