Clarice S. Madruga

How smokers may react to cigarette taxes and price increases in Brazil: data from a national survey

BackgroundDespite being the third largest tobacco producer in the world, Brazil has developed a comprehensive tobacco control policy that includes a broad restriction on both advertising and smoking in indoor public places, compulsory pictorial warning labels, and a menthol cigarette ban. However, tax and pricing policies have been developed slowly and only very recently were stronger measures implemented. This study investigated the expected responses of smokers to hypothetical price increases in Brazil.MethodsWe analyzed smokers’ responses to hypothetical future price increases according to sociodemographic characteristics and smoking conditions in a multistage sample of Brazilian current cigarette smokers aged ≥14 years (n = 500). Logistic regression analysis was used to examine the relationship between possible responses and different predictors.ResultsIn most subgroups investigated, smokers most frequently said they would react to a hypothetical price increase by taking up alternatives that might have a positive impact on health, i.e., they would “try to stop smoking” (52.3%) or “smoke fewer cigarettes” (46.8%). However, a considerable percentage responded that they would use alternatives that would reduce the effect of price increases, such as the same brand with lower cost (48.1%). After controlling for sex age group (14–19, 20–39, 40–59, and ≥60 years), schooling level (≥9 versus ≤9 years), number of cigarettes per day (>20 versus ≤20), and stage of change for smoking cessation (precontemplation, contemplation, and preparation), lower levels of dependence were positively associated with the response “I would try to stop smoking” (odds ratio [OR], 2.19). Young age was associated with “I would decrease the number of cigarettes” (OR, 3.44). A low schooling level was strongly associated with all responses.ConclusionsTaxes and prices increases have great potential to stimulate cessation or reduction of cigarette consumption further among two important vulnerable populations of smokers in Brazil: young smokers and those of low educational level. The results from the present study also suggest that seeking illegal products may reduce the impact of increased taxes, but does not eliminate it.

Contingency management targeting abstinence is effective in reducing depressive and anxiety symptoms among crack cocaine-dependent individuals.

Although contingency management (CM) is effective in promoting abstinence and treatment retention among crack cocaine users who meet the criteria for cocaine dependence, less is known about its off-target effects. In this secondary analysis, we evaluated the impact of CM on depressive and anxiety symptoms in a sample of cocaine-dependent individuals under treatment. Sixty-five crack cocaine users who met the criteria for cocaine dependence were randomly assigned to receive 12 weeks of standard treatment alone (STA; n = 32) or 12 weeks of standard treatment plus CM (STCM; n = 33). The outcome measures of the secondary analysis were depressive and anxiety symptoms assessed with the Beck Depression Inventory-II (BDI-II) and the Beck Anxiety Inventory (BAI). At baseline, 59 (90.8%) of the participants reported at least mild depressive symptoms and 47 (72.5%) reported at least mild anxiety symptoms. The mean BDI-II (24.5 ± 12.1) and BAI (20.7 ± 13.5) scores in the sample as a whole was moderate. After treatment, the reported levels of depressive symptoms (&bgr; = −9.6, p < .05) and anxiety symptoms (&bgr; = −9.9, p < .05) were lower among the individuals receiving STCM than among those receiving STA. This study provides evidence that an STCM intervention targeting crack cocaine abstinence also produces significant reductions in depressive and anxiety symptoms. This low cost intervention also demonstrated significant promise and optimization potential for crack cocaine users in a setting of scarce resources and high mental health comorbidity. Relevance Statement: We found that the prevalence of depressive and anxiety symptoms were extremely high among crack cocaine users, and that, among such individuals, contingency management (CM) reduced depressive and anxiety symptomatology to a greater degree than did standard treatment. Our results suggest that CM targeting crack cocaine abuse can have off-target effects on psychiatric symptomatology.

Commentary on Andreuccetti et al. (2011): The gap between stricter blood alcohol concentration legislation and enforcement in Brazil

Universidade Federal de Sao Paulo, Dept Psiquiatria, Unidade Pesquisa Alcool & Outras Drogas UNIAD, Sao Paulo, Brazil

Association between drug use and urban violence: Data from the II Brazilian National Alcohol and Drugs Survey (BNADS)

Objective To investigate the association of alcohol and cocaine use with urban violence (both as victim and as perpetrator) in a representative sample of the Brazilian population. Method The Second Brazilian Alcohol and Drugs Survey (II BNADS) interviewed 4607 individuals aged 14 years and older from the Brazilian household population including an oversample of 1157 adolescents (14 to 18 years old). The survey gathered information on alcohol, tobacco and illegal substances use as well as on risk factors for abuse and dependence, behaviors associated with the use of substances and the possible consequences, as urban violence indicators. Results Approximately 9.3% of the Brazilian population has been victim of at least one form of urban violence. This proportion increases to 19.7% among cocaine users and to 18.1% among individuals with alcohol use disorders (AUD). Perpetration of violence was reported by 6.2% of the sample. Cocaine use and AUD increased in almost four times the chances of being an aggressor. Being religious and married decreased the chances of being a victim and/or perpetrador of urban violence. Higher education also decreased the chances of involvement in both victimization or perpetration of violence. Both Parallel Mediation Models considering cocaine use as a predictor of urban violence (victimization or perpetration) were valid and alcohol consumption and depressive symptoms were mediators of this relationship. Conclusions This study presents relevant data of interest to Brazil as this country is one of the major consumer market of cocaine and also is among the most violent countries worldwide.

Sociodemographic Characteristics, Patterns of Crack Use, Concomitant Substance Use Disorders, and Psychiatric Symptomatology in Treatment-Seeking Crack-Dependent Individuals in Brazil

ABSTRACT Crack cocaine (crack) dependence is a severe disorder associated with considerable morbidity and mortality, constituting a major public health problem in Brazil. The aim of this study was to improve understanding of the profile of treatment-seeking crack-dependent individuals. We recruited 65 crack-dependent individuals from among those seeking treatment at an outpatient clinic for alcohol and drug treatment in the city of São Paulo, Brazil. Assessments, conducted between August 2012 and July 2014, focused on sociodemographic characteristics, the pattern/history of crack use, treatment history, concomitant substance use disorders, psychiatric symptomatology, and impulsivity. In the study sample, males predominated, as did unemployment, homelessness, and low levels of education. On average, the participants had smoked crack for 10 years. Most had previously been treated for crack dependence. Concomitant DSM-IV diagnoses of dependence on other substances were common, dependence on tobacco and alcohol being the most prevalent. Participants presented significant psychiatric symptomatology and impulsivity, with nearly half of the sample presenting psychotic symptoms, 90% presenting depressive symptoms, and 80% presenting anxiety symptoms. Most treatment-seeking crack-dependent individuals in Brazil are living in extremely poor social conditions and are struggling with the severe, chronic, and comorbid features of this disorder.

Alcohol misuse among women in Brazil: recent trends and associations with unprotected sex, early pregnancy, and abortion

Objective: This study compared the rates of binge drinking (BD) and alcohol use disorder (AUD) reported for 2006 with those reported for 2012, exploring their associations with unprotected sex, early pregnancy, and abortion in a representative sample of women in Brazilian households. Methods: This was a descriptive analysis of data from a cross-sectional study involving randomized multistage cluster sampling of the population ≥ 14 years of age. Weighted prevalence rates and odds ratios were estimated, and serial mediation analysis was performed. Results: A total of 4,256 women were analyzed. The BD prevalence was 35.1% and 47.1% in 2006 and 2012, respectively, a significant increase, especially among women 40-59 years of age. There was no significant difference in AUD prevalence. BD (without AUD) was found to increase the odds of unprotected sex and abortion. The path analysis showed that early pregnancy was a mediator of the relationship between alcohol consumption and abortion. Conclusion: Among women in Brazil, the harmful use of alcohol is increasing, which has an impact on female reproductive health and exposure to risks. There is a need for specific prevention initiatives focusing on alcohol-related behaviors in women.

Prevalence of and pathways to benzodiazepine use in Brazil: the role of depression, sleep, and sedentary lifestyle

Objective: This study aimed to determine the prevalence of benzodiazepine (BZD) use in Brazil and to investigate the direct and indirect effects of alcohol consumption, sedentary lifestyle (SL), depressive symptoms (DS), and sleep dissatisfaction (SD) on BZD use. Methods: The Second Brazilian Alcohol and Drugs Survey (II BNADS) used stratified cluster probabilistic sampling to select 4,607 individuals aged 14 years and older from the Brazilian household population. Results: The lifetime and 12-month prevalence of BZD use was 9.8 and 6.1%, respectively. Older participants (age 40 and older) and women had higher rates. Alcohol use disorder, DS, and SD were significantly more prevalent in BZD users. The parallel multiple mediator model showed a positive direct effect of alcohol consumption on BZD use, with significant positive indirect effects of SL, SD, and DS as simultaneous mediators leading to higher BZD intake. Other statistically significant indirect pathways were DS alone, SD alone, and all of the above except SL. Conclusion: The prevalence of BZD use in Brazil is high compared to that of other countries. Knowledge of the main risk factors and pathways to consumption can guide prevention initiatives and underlie the development of better tailored and effective treatment strategies.

Brazilian cross-cultural adaptation and validation of the List of Threatening Events Questionnaire (LTE-Q)

Objective: To perform a construct validation of the List of Threatening Events Questionnaire (LTE-Q), as well as convergence validation by identifying its association with drug use in a sample of the Brazilian population. Methods: This is a secondary analysis of the Second Brazilian National Alcohol and Drugs Survey (II BNADS), which used a cross-cultural adaptation of the LTE-Q in a probabilistic sample of 4,607 participants aged 14 years and older. Latent class analysis was used to validate the latent trait adversity (which considered the number of events from the list of 12 item in the LTE experienced by the respondent in the previous year) and logistic regression was performed to find its association with binge drinking and cocaine use. Results: The confirmatory factor analysis returned a chi-square of 108.341, weighted root mean square residual (WRMR) of 1.240, confirmatory fit indices (CFI) of 0.970, Tucker-Lewis index (TLI) of 0.962, and root mean square error approximation (RMSEA) score of 1.000. LTE-Q convergence validation showed that the adversity latent trait increased the chances of binge drinking by 1.31 time and doubled the chances of previous year cocaine use (adjusted by sociodemographic variables). Conclusion: The use of the LTE-Q in Brazil should be encouraged in different research fields, including large epidemiological surveys, as it is also appropriate when time and budget are limited. The LTE-Q can be a useful tool in the development of targeted and more efficient prevention strategies.

Amphetamine-type stimulant use and conditional paths of consumption: data from the Second Brazilian National Alcohol and Drugs Survey

Objective: The aim of this study was to estimate nationally representative prevalence rates of amphetamine-type stimulant (ATS) use and to identify consumption-associated factors, proposing a conditional model of direct and indirect consumption paths. Method: Using data from the Second Brazilian National Alcohol and Drugs Survey, this cross-sectional study analyzed a subsample of 3,828 participants between 15 and 64 years old, gathering information on the use of psychoactive substances in a probabilistic sample of the Brazilian household population. Results: Rates of lifetime and last-year ATS use were, respectively, 4.1 and 1.6%. Economically privileged individuals and users of other substances were more at risk for using ATS. The results suggest that higher education decreases the chances of ATS consumption. The conditional model showed that higher income increased ATS use, higher education lowered the odds of such an increase, and cocaine use cancelled that associative effect. Conclusion: Brazil presents high rates of ATS use. Prevention and treatment strategies should focus on the protective effect of higher education levels and should target polydrug use. Knowledge of ATS-associated factors and user profiles is the starting point for developing effective treatments and tailored prevention strategies.

Intimate partner violence trends in Brazil: data from two waves of the Brazilian National Alcohol and Drugs Survey

Objective: To compare intimate partner violence (IPV) prevalence rates in 2006 and 2012 in a nationally representative household sample in Brazil. The associations between IPV and substance use were also investigated. Methods: IPV was assessed using the Conflict Tactic Scale-R in two waves (2006/2012) of the Brazilian Alcohol and Drugs Survey. Weighted prevalence rates and adjusted logistic regression models were calculated. Results: Prevalence rates of IPV victimization decreased significantly, especially among women (8.8 to 6.3%). The rates of IPV perpetration also decreased significantly (10.6 to 8.4% for the overall sample and 9.2 to 6.1% in men), as well as the rates of bidirectional violence (by individuals who were simultaneously victims and perpetrators of violence) (3.2 to 2.4% for the overall sample). Alcohol increased the likelihood of being a victim (odds ratio [OR] = 1.6) and perpetrator (OR = 2.4) of IPV. Use of illicit drugs increased up to 4.5 times the likelihood of being a perpetrator. Conclusions: In spite of the significant reduction in most types of IPV between 2006 and 2012, violence perpetrated by women was not significantly reduced, and the current national rates are still high. Further, this study suggests that use of alcohol and other psychoactive drugs plays a major role in IPV. Prevention initiatives must take drug misuse into consideration.