Márcia Pinto, co-author of the article “Disease, Social, and Economic Burden of Smoking in Brazil and the Impact of Tax Increases on the Economy and on Reducing Morbidity and Mortality,” published in Cadernos de Saúde Pública, expands on the research findings in this interview. The study, which for the first time included the economic burden on informal caregivers, estimated that smoking caused 174,000 deaths and cost Brazil R$ 153 billion in 2022. The researcher also discusses the role of the illegal cigarette market, tax increase scenarios, and what the ongoing Tax Reform may mean for public health and the country’s finances.
The study used a Markov probabilistic microsimulation model. How does this approach work in practice, and why was it chosen to estimate the burden of smoking in Brazil?
It is a mathematical model that uses hypothetical cohorts to simulate millions of individuals by sex and age. In the hypothetical cohort of smokers, for example, the model simulates the risk for each individual to develop, over one-year cycles from age 35 until the end of life, a type of cancer, pulmonary emphysema, or to experience an episode of acute myocardial infarction or stroke.
And these are not isolated events over a lifetime, as this model allows for estimating the risk of an individual having lung cancer and chronic bronchitis in the same cycle. These risks are derived from the literature; therefore, prior work involves assessing methodological quality to ensure the robustness of the parameters incorporated into the microsimulation.
In addition, case fatality, mortality, and incidence are estimated. Knowing the number of new cases of each tobacco-related disease makes it possible to estimate the total cost of medical care for all individuals. In this case, the cost of treating each disease is estimated.
Given the potential of microsimulation, we have adopted this approach since our first study, also published in Cadernos de Saúde Pública in 2015. This has enabled us to estimate the burden of smoking from the perspective of Brazilian society—that is, by quantifying mortality, morbidity, and both direct and indirect costs, as well as, in this study, the cost of lost productivity among caregivers. In other words, we were able to calculate, for example, the number of new patients with stroke, acute myocardial infarction, and various types of cancer who will require services from the SUS and private health plans annually. Furthermore, this study included new diseases for which the association with smoking is well established in the literature, such as type 2 diabetes mellitus and liver cancer.
The numbers are significant: 174,000 deaths and R$153 billion in annual costs. What surprised the research group the most throughout the study?
I think what was most surprising was precisely the burden on caregivers, which was very high—over R$40 billion. That’s striking. What happens to these caregivers? They have to devote hours to caring for someone, and they’re usually family members who either leave the workforce or reduce their working hours. Family income drops, and it’s also difficult for them to return to the workforce.
So, we are dealing with the care economy, which has proven to be predominantly female, and for this reason, the cost of caregiving is not just a number but involves other issues, such as financial protection mechanisms for these individuals, mental health, and social issues.
At the end of the article, there is a brief mention of the tobacco industry’s impact on the environment. Given the global health and climate change agendas, how important would it be to explore this further in future research?
Environmental issues have been widely debated and researched over the past 30 years. Brazil is the world’s leading tobacco exporter and one of the largest global producers. Studies have already shown that tobacco cultivation is responsible for deforestation and is intensive in the use of pesticides and nitrogen-based fertilizers, which emit nitrates that can contaminate surface and groundwater. Another serious problem is cigarette butts, a major issue in urban areas, on beaches, and in the oceans.
Thus, I believe that measuring the economic burden of these environmental issues is just another layer of this iceberg, which is the burden of tobacco use. I think we should evaluate which high-quality methods and materials can be applied, thereby identifying their environmental impacts in both growing regions and urban areas.
The illicit cigarette market emerges as a central variable in the projected scenarios. How does this market operate in Brazil, and why does it pose such a significant obstacle to tobacco control policies?
The illegal cigarette market is a long-standing problem and makes products more accessible due to lower prices. In Brazil’s case, there are contraband and counterfeit products, as well as those resulting from tax evasion, which occurs when a company fails to meet its tax obligations.
There is always the claim that if the price of cigarettes rises, the illegal market will grow even more, because people will switch to a cheaper product. But this should be interpreted with caution. What I can say is that the illegal market is primarily a matter for law enforcement and for internal and border inspections.
There are studies showing a specific reduction in recent years, but the supply of illegal cigarettes is a reality in the country, with a market share that demands significant action. These studies attribute its persistence to weak law enforcement, a lack of commitment to controlling the cigarette supply chain, the very culture of purchasing illegal products, and a lack of cooperation with Paraguay, the main source of illicit cigarettes for Brazil.
Our study demonstrated that, in scenarios that accounted for the illicit market, the economic benefits of a tax increase would be substantially reduced over a ten-year period, while mortality and morbidity would decline to a lesser extent during that time. Therefore, analyzing the illicit market requires identifying all its dimensions—health, social, economic, and sovereignty, among others—so that its share of the Brazilian market can be progressively reduced.
The article was submitted in January 2025 and addressed the ongoing Tax Reform, which includes cigarettes as a selective tax. In practice, how can this mechanism help reduce the economic and health burden of smoking in the country?
These products will be subject to what we call “sin taxes,” already adopted in several countries. In Brazil, this will be the selective tax scheduled to take effect next year on tobacco products.
Recently, there was an increase in the minimum price per pack, and a new specific tax rate became effective in May and August, respectively. The Brazilian government took this important step, and I hope that starting next year, the selective tax can contribute to a permanent policy of price increases that ensures both increased tax revenue and reduced consumption over the years.
The study indicates that a 50% increase in the price of cigarettes could prevent approximately 145,000 deaths over a ten-year period. How can we translate this data into concrete arguments for public officials and health policymakers?
What the study primarily indicates is that there will be fewer deaths and cases of illness, enabling people to be more productive and enjoy a better quality of life. This is an argument that, in my opinion, reflects what we expect as a society. Price increases are the most cost-effective measure for reducing smoking. So, in addition to reducing mortality and morbidity, they have the potential to increase tax revenue, and in times of fiscal adjustment, I believe this is also an important argument for public officials to consider how the triad of tax increases—price increases—and reduced consumption can benefit Brazilian society.
Article Title: Burden of disease, social and economic aspects of smoking in Brazil and the impact of tax increases on the economy and on reducing morbidity and mortality
Authors: Márcia Pinto, Ariel Bardach, Agustín Casarini, Federico Augustovski, Alfredo Palacios, Natalia Espinola, Marcia Gisele Santos, Kátia Marie Simões e Senna, Ana Clara de Moraes, Vera Luiza da Costa e Silva, Felipe Mendes, Cristiane Galhardo Ferreira Vianna, Ana Paula Leal Teixeira, Andres Pichon-Riviere
Interview: Márcia Pinto
How to cite the manuscript: Pinto M, Bardach A, Casarini A, Augustovski F, Palacios A, Espinola N, Santos MG, Senna KMS, Moraes AC, Silva VLC, Mendes F, Vianna CGF, Teixeira APL, Pichon-Riviere A. Burden of disease, social and economic aspects of smoking in Brazil and the impact of tax increases Taxes for the economy and for reducing morbidity and mortality. Cadernos de Saúde Pública 2026; 42(1):e00002425 doi: 10.1590/0102-311XPT002425