ABC | Volume 113, Nº4, October 2019

Original Article Co-occurrence of Smoking and Unhealthy Diet in the Brazilian Adult Population Priscila Maria Stolses Bergamo Francisco, 1 Daniela de Assumpção, 1 Deborah Carvalho Malta 2 Universidade Estadual de Campinas - Saúde Coletiva, 1 Campinas, SP – Brazil Universidade Federal de Minas Gerais - Escola de Enfermagem, 2 Belo Horizonte, MG – Brazil Mailing Address: Priscila Maria Stolses Bergamo Francisco • Universidade Estadual de Campinas - Saúde Coletiva - Rua Tessália Vieira de Camargo, 126. Postal Code 13083-887, Cidade Universitária Zeferino Vaz, Campinas, SP – Brazil E-mail: primaria@unicamp.br Manuscript received July 30, /2018, revised manuscri´t November 20, 2018, accepted January 23, 2019 DOI: 10.5935/abc.20190222 Abstract Background: Smoking and an inadequate diet are behavioral risk factors that contribute to the majority of deaths and disabilities caused by noncommunicable diseases. Objectives: To estimate the prevalence of the co-occurrence of smoking and inadequate diet and identify associated factors in adults. Methods: A cross-sectional population-based study was conducted with a sample of 28,950 Brazilian adults (18 to 59 years old). Data were obtained fromSistema de Vigilância por Inquérito Telefônico (Vigitel [BrazilianHealth Surveillance Telephone Survey]) in 2014. Independent associations were investigated using Poisson hierarchical regression analysis with 5% significance level. Results: The prevalence of the co-occurrence of smoking and unhealthy eating was 8.6% (95% CI: 7.9–9.3) and was higher among individuals residing in the southern region of the country than in those living in the central western region (PR = 1.50; 95% CI: 1.18–1.89), those with no private health insurance (PR = 1.14; 95% CI: 1.03–1.25), those who drank alcohol abusively (binge drinkers) (PR = 3.22; 95% CI: 2.70–3.85) and those who self-rated their health as fair (PR = 1.65; 95% CI: 1.36–1.99) or poor/very poor (PR = 1.70; 95% CI: 1.18–2.44). The prevalence of both factors was lower among individuals residing in the northeastern region of the country, women, individuals with brown skin color, those with a spouse, the more educated ones and those with overweight or obesity. Conclusion: The more vulnerable segments to the co-occurrence of the risk factors studied were men residing in the southern region of the country, individuals with a lower socioeconomic status and those who reported binge drinking. Interventions addressing multiple behavioral risk factors adapted to specific contexts could have a greater impact on the Brazilian population. (Arq Bras Cardiol. 2019; 113(4):699-709) Keywords: Tobacco Use Disorders; Feeding; Risk Factors; Risk reduction Behavior; Chronic Disease; Adult Health; Health Status Disparities. Introduction Behavioral risk factors are responsible for the majority of deaths due to noncommunicable diseases (NCDs) 1,2 and part of the diseases resulting from these conditions. 3-5 Such factors included smoking, abusive alcohol intake, inadequate diet, physical inactivity, obesity, dyslipidemia, excessive animal fat intake and insufficient intake of fruits and vegetables. 6,7 According to a study conducted in 52 countries, these factors, combined with arterial hypertension, diabetes mellitus and psychosocial stress account for 90% and 94% of the attributable risk of cardiovascular disease among men and women, respectively. 8 The World Health Organization attributes smoking to an estimated six million deaths per year. Insufficient intake of fruits and vegetables corresponds annually to 2.7 million deaths, 31% of ischemic heart diseases, 11% of cerebrovascular diseases and 19% of gastrointestinal cancers in the world. 9 Despite the reduction in the percentage of smokers in Brazil in recent years, 10,11 population-based health surveys have indicated that the prevalence of smoking is greater among adults (40 to 59 years old) and those with a lower education level. 10-12 Moreover, the prevalence of an unhealthy diet is high, 10,13,14 especially among men, adolescents and individuals with a lower education level. 13,14 NCDs have multiple causes that occur simultaneously, resulting in distinct effects. 5 Studies indicate that the accumulation of two or more modifiable risk factors increases the occurrence of NCDs 8,15,16 and cardiovascular diseases 8 and is related to the overall death rate as well as death due to specific causes. 1,2 Risk behaviors are harmful actions that either increase the probability of disease or impede the recovery of health. 17 Therefore, behavioral (modifiable) risk factors are component causes that contribute to increasedmorbidity andmortality rates due to cardiovascular diseases, diabetes mellitus and cancer in adults and seniors. 1,5,15 The greatest impact of exposure to 699