ABC | Volume 113, Nº4, October 2019

Updated Updated Cardiovascular Prevention Guideline of the Brazilian Society Of Cardiology – 2019 Arq Bras Cardiol. 2019; 113(4):787-891 6.12. Omega-3 Polyunsaturated Fatty Acids of Plant Origin ALA has shown inconsistent effects on lipid levels. 236,237 A systematic review and meta-analysis of 14 randomized controlled trials with ALA supplementation found no significant influence on TC, LDL-c, or TG and only a minimal effect on HDL-c (a 0.4 mg/dL reduction). 238 Specifically, the effects of linseed on experimental animals range from zero to a slight lipid decrease, and a review suggested a reducing impact on TG due to humans consuming large amounts of linseed oil. 238 Observational studies indicate a modest reduction in the risk for CVD with the consumption of ALA. 238 Data from the Alpha-omega study showed no benefits of ALA supplementation in preventing CVD among individuals who had a prior CVD. More recent data from the Cochrane group meta-analysis suggest that increasing the intake of ALA probably makes little or no difference in all-cause mortality, CV mortality, and coronary events. 232 Its effects on CVA are unclear. However, the authors recognize the low quality of most studies; therefore, further studies on ALA supplementation are necessary to prove or refute its effectiveness in preventing CVD. We can conclude that, at the moment, there is no evidence to recommend ALA supplementation to prevent CVD. Table 3.3 presents the recommendations for ALA consumption and supplementation. 7. Smoking 7.1. Introduction Smoking control in Brazil has been considered as a model, not only for its programming, but for the results, with tobacco use being reduced by at least half when compared to the last decades of the 1900s. Increased cost-effective taxes, a ban on advertising, a ban on indoor use (smoke-free laws), the sale of tobacco products to minors, discussion of the subject in the school curriculum, and warnings and information about Harmful effects of smoking on schools, universities, the media, and on cigarette packs themselves were effective measures to reduce smoking. There are currently over one billion smokers in the world. Brazil is considered one of the countries in the world that has most reduced the prevalence of smokers in the last thirty years. In 1989, about 32% of the population over the age of 15 were smokers, according to the National Health and Nutrition Survey of the Brazilian Institute of Geography and Statistics (IBGE). In 2018, the VIGITEL Survey of the Ministry of Health, through a telephone survey in 27 Brazilian cities, found a frequency of adult smokers over 18 years of age of 10.1%, being higher in males (13.2%) and lower in females (7.5%). The highest frequencies were found in men between the cities of Curitiba and Porto Alegre (17.3%) and São Paulo (15.6%). 239 For the CV system, continued long-term use of tobacco and its derivatives leads to the onset of chronic diseases, which will manifest around 30 years after the start of regular smoking. As most smokers become addicted to nicotine before age 18, the health consequences are disastrous given the long exposure of the body to the harmful components contained in cigarettes. Therefore, prevention is the key to this health catastrophe. Smoking Prevention: Despite worldwide tobacco control efforts, the number of nicotine addicts is still substantial. Effective public policies against the sale, advertising and use of cigarettes in public areas are important tools in primary prevention, as they prevent non-smokers, especially children and adolescents, from being exposed to nicotine. Therefore, the experimentation rate should be reduced in young people under 15 years of age. This initiative will surely reduce the number of potential tobacco users. Primordial prevention of smoking: “Primordial prevention of smoking” is understood to be established before the initiation of smoking. It first identifies the risk factors for smoking, with a wide range from the individual’s own vulnerability, such as the surrounding social determinants. Providing a personalized and continuing education and enabling information exchange requires the formation of a multidisciplinary team. 240 The aim of this team is to work with individuals and their families on the risks of smoking, to outline strategies to prevent them from smoking and to promote health. 241,242 Factors that contribute to starting smoking: 1. Attitudes and beliefs: a study of adolescents 243 showed that 40% of those who had never smoked became experimenters and that 8% had a smoking habit for 4 consecutive years. 244 The lack of a firm decision not to smoke was the strongest predictor of experimenting; 2. Influence of friends and family: the presence of smokers among family and friends is an important predictor of tobacco initiation during adolescence; refusing a cigarette in the face of social pressure is a challenge for most teenagers, and only 44% of them can refuse a cigarette at a party; 245 3. Age: both positive and negative attitudes towards smoking are more pronounced in adolescence; 246 4. False conception: adolescents tend to overestimate the frequency of smoking among adults 247 and to underestimate their own; 248 5. Advertinsing: magazines and movies are main advertising sources promoting adolescent smoking; 6. Nicotine dependence: nicotine is a highly addictive substance, and many individuals develop dependence after a few days or weeks of exposure. 249 Young people are more vulnerable than adullts to nicotine dependence; 250 7. Other risk factors: • Depression: the majority of studies show a relation between the presence of depression and the initiation of smoking, allthough it is not clear if the association is causal; • Poor school performance: missing classes and poor school performance are associated with initiation and continuation of smoking; 251,252,253 • Adverse experiences: separation of parents or divorce, physical emotions; emotional physical, or sexual abuse; growing up among family members who are addicted, mentally ill or imprisoned; 254,255 • Substance abuse: there is a high frequency of smokers among adolescents who use illicit drugs, 256 so every 821