ABC | Volume 113, Nº4, October 2019

Original Article Francisco et al. Smoking and unhealthy diet Arq Bras Cardiol. 2019; 113(4):699-709 Northeast, 31 which may partially explain the present findings regarding the co-occurrence of smoking and an inadequate diet. Moreover, according to the 2008-2009 Family Budget Survey, northeastern and southern Brazil have different profiles in terms food purchase, with greater availability of red meat, processed meats, bacon, soft drinks and alcoholic beverages in the southern region. 32 Regional disparities in the distribution of modifiable risk factors are found in Brazil. 7,13,22,31 In the United States, a study addressing the co-occurrence of five healthy behaviors (not smoking, regular practice of physical activity, not consuming alcohol, maintaining one’s weight and sleeping the recommended number of hours) in the adult population (≥21 years old) found geographic variations in the percentage distribution adjusted for age for the number of grouped factors. 33 Regarding other socio-demographic characteristics, studies indicate that the prevalence of multiple risk factors is higher among young adults, men, individuals with a lower socioeconomic status (lower income and education) and those who live alone. 13,21,34 In the present study, the reduced co-occurrence of risk factors was found with higher education levels. Studies report an association between higher education level and healthy behaviors/health conditions. 10-14,19,21,34 The prevalence of co-occurrence was also lower among those with self-declared brown skin. In the city of Florianópolis (state of Santa Catarina), Silva et al. 13 found a greater occurrence of the accumulation of four risk factors in black adults. In the USA, racial/ethnic differences were found for five behaviors considered. 33 A study analyzing differences in the prevalence of risk factors for chronic diseases according to ethnicity/skin color found that, compared to whites, brown individuals smoked less and consumed fewer fruits, soft drinks and sweets as well as more beans, whole milk and meat with visible fat. 35 No studies were found in the national or international literature on the co-occurrence of smoking and an inadequate diet according to skin color/ethnicity. The prevalence of the co-occurrence of risk factors was higher among individuals without a private health insurance plan. A study involving Brazilian adults found that individuals with private health insurance smoked less, ate better and practiced more physical activity during leisure hours. 36 The Health Ministry has taken several actions for reducing inequalities in the access and offer of healthcare services. The National Health Promotion Policy defends integral care, considering health promotion to be a strategy for organizing the actions and services of the public healthcare system, with a focus on factors that determine the health-disease process, intersectoral actions, social participation and the construction of healthy environments on individual and collective levels. 37 The National Food and Nutrition Policy and the Dietary Guide for the Brazilian Population 38 are important support instruments for the promotion of healthy eating within the Brazilian public health system (SUS, in its Portuguese acronym). The prevalence of the co-occurrence of smoking and inadequate diet was lower among adults with excess weight. The inverse association found after adjustment for socio- demographic characteristics, behavioral factors and health conditions may be partially explained by the fact that smoking exerts an influence on metabolic processes; smokers weigh, on average, 4 kg less than non-smokers due to the increase in the metabolic rate, concomitantly with suppression of appetite. 39 The prevalence of the co-occurrence of risk factors was higher among adults who reported binge drinking, which is a subgroup with greater vulnerability to NCDs. The planning of disease prevention actions should integrate population-based strategies and strategies directed at high-risk subgroups, as both are necessary and work in a synergistic way. 17 In the epidemiology of chronic diseases, the effect of a risk factor depends on the status of the individual for another factor (present/absent). Thus, the presence of two or more modifiable risk factors potentiates the occurrence of NCDs 8,15,16 and shorter time to the emergence of a disease leads to reduced healthy life expectancy. Data from four cohort studies on smoking, physical inactivity and obesity among individuals aged 50 to 75 in European countries revealed the impact of the co-occurrence of behavioral risk factors on the reduction in the expectancy of a healthy life free of chronic diseases. 40 In the present study, the co-occurrence of risk factors was higher among those who did not rate their health positively. The literature describes the association between smoking and a Continuation Arterial hypertension No 22,887 81.7 11.1 0.743 71.1 < 0.001 Yes 6,063 18.3 11.4 65.2 Diabetes mellitus No 27,356 94.9 11.1 0.811 70.9 < 0.001 Yes 1,594 5.1 11.4 53.3 Dyslipidemia No 22,835 83.0 11.1 0.630 70.6 0.029 Yes 6,115 17.0 10.4 67.6 *p-value of chi-square test with Rao-Scott correction. BMI: body mass index 704