Original Research

Tobacco smoking prevalence and associated factors among the elderly in the rural area of Rio Grande/RS, Brazil

AUTHORS

name here
Priscila Arruda da Silva
1 PhD, Postdoctoral Researcher *

name here
Rodrigo Dalke Meucci
2 PhD, Professor ORCID logo

name here
Rebeca Luzini
3 Student

name here
Lucas Azevedo Paiva
4 Student

CORRESPONDENCE

*Dr Priscila Arruda da Silva

AFFILIATIONS

1, 2 Federal University of Rio Grande, Postgraduate Programme in Public Health, Rio Grande, Brazil

3, 4 Federal University of Rio Grande, Faculty of Medicine, Rio Grande, Brazil

PUBLISHED

22 November 2019 Volume 19 Issue 4

HISTORY

RECEIVED: 23 June 2018

REVISED: 22 March 2019

ACCEPTED: 9 July 2019

CITATION

Silva PA, Meucci RD, Luzini R, Paiva LA.  Tobacco smoking prevalence and associated factors among the elderly in the rural area of Rio Grande/RS, Brazil. Rural and Remote Health 2019; 19: 4982. https://doi.org/10.22605/RRH4982

AUTHOR CONTRIBUTIONSgo to url

This work is licensed under a Creative Commons Attribution 4.0 International Licence


abstract:

Introduction:  Although tobacco smoking prevalence in the adult Brazilian population is monitored through population-based surveys, the majority of findings come from studies undertaken in urban areas. Therefore, very little is known about tobacco smoking prevalence and associated factors among elderly people living in rural Brazilian areas. As such, this study aimed to assess tobacco smoking prevalence and associated factors among elderly people in the rural area of the municipality of Rio Grande, state of Rio Grande do Sul (RS), Brazil.
Methods:  This was a cross-sectional population-based study conducted with individuals aged 60 years or more residing in the rural area of the municipality of Rio Grande, RS. Tobacco smoking prevalence was calculated according to each category of the independent variables of interest using Fisher’s exact test. Crude and adjusted Poisson regression following a hierarchical analysis model was used to analyze associated factors.
Results:  A total of 13.2% of the elderly people were smokers and 33.8% were former smokers. A total of 66.9% of smokers had smoked for 41 years or more and 14.4% smoked 21 or more cigarettes a day. Following the adjusted analysis, factors associated with smoking were being male (prevalence ratio (PR)=2.23, 95%CI=1.56–3.17), being in the 60–69 year age range (PR=2.65, 95%CI=1.47–4.80), having black/brown skin color (PR=1.99, 95%CI=1.34–2.93) and being single/separated (PR=1.61, 95%CI=1.15–2.25). Practicing the evangelical Christian religion was a protection factor.
Conclusion:  Although the prevalence of tobacco smoking found in this study is similar to that in other national studies with elderly people, tobacco use is still considerable and is among the main causes of avoidable diseases. This study is therefore important because it is the first conducted with elderly people living in the rural area of the municipality. Its findings can become a tool for planning actions or public policies aimed at promoting behavioral changes that reduce risk factors associated with tobacco smoking among the elderly in rural areas.

Keywords:

associated factors, Brazil, elderly, epidemiology, smoking, prevalence, public health.

full article:

Introduction

Tobacco smoking is the leading avoidable cause of diseases and early death in Brazil and worldwide1. It is a public health problem, accounting for the highest morbidity and mortality rates and for some 70% of healthcare expenditure in Brazil, and this trend is increasing2.

Smoking is among the factors that increase the risk of developing diseases at more advanced ages, and rates have been growing rapidly in Brazil3. The need for research focused on this group can be justified by studies that identify elderly people as those who most demand attention from health institutions, because they are the most affected by diseases and morbidities caused by tobacco use, which can compromise their health4,5.

Studies with rural elderly people show high tobacco smoking prevalence, with 22.1% in India, 20.8% in China and 19.1% in the USA6-8. According to a survey specific to tobacco smoking, in Brazil tobacco smoking prevalence is greater in rural areas (20.4%) than in urban areas (16.6%)9. The results are similar to findings for the research studies on smoking in the general population10. These findings may be because elderly people living in rural areas tend to have lower levels of schooling and income, as well as less access to health services9.

Although tobacco smoking among the Brazilian adult population is monitored by surveys such as surveillance of chronic diseases by telephone survey (VIGITEL)11, the data obtained relates to people living in urban areas. Very little is therefore known about tobacco smoking prevalence and associated factors among elderly people living in Brazilian rural areas. As such, the objective of this study is to assess tobacco smoking prevalence and associated factors among the elderly in the rural area of the municipality of Rio Grande, Rio Grande do Sul (RS).

Methods

Study setting

This study is part of a larger study that evaluated the health conditions of the Rio Grande population. Its general objective was to know basic health indicators and the pattern of morbidity and use and access to health services in three population groups living in this area: children aged less than 5 years and their mothers, women of childbearing age (15–49 years) and the elderly (60 years or more).

This was a cross-sectional, population-based study conducted with individuals aged 60 years or more in the municipality of Rio Grande, RS. Located in the southernmost region of the state, 300 km away from the state capital of Porto Alegre, the municipality has an estimated population of 209 378, of whom some 8500 individuals live in its rural areas12.

According to Brazilian Institute of Geography and Statistics data, the rural area of Rio Grande comprised 24 census tracts and approximately 2700 permanently inhabited households. Data collection took place between April and October 2017.

Study sample

Systematic sampling was done of 80% of permanently inhabited households of the rural area of Rio Grande, RS, by drawing a number between 1 and 5. The number drawn corresponded to the household to be skipped. For example, if number 3 was drawn, any household number 3 out of a sequence of five households was not sampled (it was skipped). This procedure ensured that four in every five households were sampled.

In Brazil, as per the WHO definition, an elderly person is considered to be someone who is aged 60 years or more13. As such, all individuals living in the selected households and who were in this age range were eligible to take part in this study and were therefore invited to do so.

Upon acceptance, the supervisor introduced the interviewer who, after the informed consent form had been read and signed, administered the questionnaire corresponding to the age range of the respondent. The head of the household also answered the block of questions about the household. Where an elderly person was unable to answer the questions, the family member or carer in charge of them was interviewed.

At the end of the field work, 4189 households had been identified in the rural area of the municipality of Rio Grande, being 2669 permanent households and 1419 households either unoccupied or with temporary inhabitants (only at weekends/holidays). It was not possible to obtain information from dwellers or neighbors of 101 households, even after three or more attempts.

In the 2669 households that had permanent dwellers, 1351 elderly people were identified, 1131 of whom were included in the sample. A total of 1030 elderly people were interviewed.

The number of elderly people interviewed is sufficient to examine estimated tobacco smoking prevalence of 15%, with a 95% confidence level, a margin of error of two percentage points and an additional 10% for losses/refusals. With regard to studying associated factors, this number guarantees minimum statistical power of 80%, taking a prevalence ratio of 1.8 and an exposed/non-exposed ratio of 1:4 to 5:1, and an additional 15% to adjust for confounding factors.

Data collection procedures 

Two instruments were used for data collection. The first, a household questionnaire, was answered by heads of household and assessed family socioeconomic characteristics. The second, specifically for elderly people, assessed aspects related to behavior, health and use of health services. The questionnaires were administered using the Research Electronic Data Capture (REDCap) mobile application on tablet computers14. All interviewers underwent a 40-hour training course.

The variables used in this study were sex, age, skin color, marital status, schooling, religion, work, alcoholic beverage consumption and tobacco smoking (‘never smoked’, ‘former smoker’, ‘smoker’). Smokers were considered to be individuals who reported smoking one or more cigarettes a day for the previous month or longer, and former smokers were taken to be those who had stopped smoking more than a month previously. Tobacco smoking characteristics among elderly smokers and former smokers were ‘smoker for how long (years)’, ‘number of cigarettes/day’, ‘smoked for how long (years)’ and ‘how long ago stopped smoking (years)’.

Data analyses

Data analysis was performed using the Stata v13 statistical software package (StataCorp; http://www.stata.com). First, the proportions of each of the categories of the independent variables of interest were calculated. Second, tobacco smoking prevalence for each of the exposure categories was calculated using Fisher’s exact test.

Crude and adjusted Poisson regression with robust variance was used to analyze associated factors, calculating the prevalence ratios (PRs) and respective 95% confidence intervals (CIs). The adjusted analysis followed a hierarchical model15 with four levels. The first level contained the age, sex and skin color variables, and the second level contained the schooling, marital status and work variables. The third level contained income in quartiles and religion, and the fourth level contained alcohol consumption in the previous week. Variables with p<0.20 were kept in the model and associated variables were considered to be those with p<0.05 in the Wald heterogeneity or linear trend tests.

Ethics approval

This research project was approved by the Federal University of Rio Grande Research Ethics Committee (report no. 51/2017, process no. CAAE 23116.009484/2016-26). All participants signed a free and informed consent form. The confidentiality of all information provided was ensured, as was the possibility of being able to leave the study at any time.

Results

Of the 2669 inhabited households, 1351 elderly people were identified, 1131 were sampled and 1030 responded (losses and refusals 8.9%). The majority of the sample comprised elderly males (55.2%), people in the 60–69 year age range (51.4%), with white skin color (91.6%) and living with a partner (62.1%). Almost half stated having between 1 and 4 years of schooling (48.9%), 33.8% were in the second income quartile and 84.9% did not undertake paid work. More than half stated they were Catholic (55.1%) and 16.7% had consumed alcoholic beverages in the previous week. A total of 33.8% were former tobacco smokers and 13.2% were smokers (Table 1).

Tobacco smoking prevalence was higher among males (17.6%), people aged 60–69 years (18.7%), with black/brown skin color (28.0%), lower income (18.0%), single/separated (22.5%), working (18%) and who had consumed alcohol in the previous week (18.6%). Evangelical Christians smoked less than individuals of other religions or with no religion (Table 1).

The majority of current smokers had smoked for 41 years or more (66.9%) and 47.0% smoked 11 cigarettes or more per day (Table 2). The majority of former smokers had smoked for 31 years or more (29.6%) and had stopped smoking more than 31 years ago (Table 2).

Being male (PR=2.23, 95%CI=1.56–3.17), being aged 60–69 years (PR=2.65, 95%CI=1.47–4.80), having black/brown skin color (PR=1.99, 95%CI=1.34–2.93) and being single/separated (PR=1.61, 95%CI=1.15–2.25) had statistically significant associations with the outcome after adjustment. Individuals with no religion (PR=3.11, 95%CI=1.49–6.49), Catholics (PR=2.42, 95%CI=1.20–4.88) and people of other religions (PR=3.09, 95%CI =1.36–7.01) had greater risk of smoking when compared to evangelical Christians (Table 3).

Table 1:  Tobacco smoking characteristics and prevalence among elderly people living in the rural area of the municipality of Rio Grande, Rio Grande do Sul, Brazil, 2017 (N=1030)

Table 2:  Tobacco smoking characteristics among elderly smokers and former smokers living in the rural area of the municipality of Rio Grande, Rio Grande do Sul, Brazil, 2017

Table 3:  Crude and adjusted analysis of factors associated with current tobacco smoking among elderly people living in the rural area of the municipality of Rio Grande, Rio Grande do Sul, Brazil, 2017 (N=1030)

Discussion

Tobacco smoking among the elderly living in the rural area of Rio Grande, RS is associated with the male sex, being aged 60–69 years, having black/brown skin color and being single/separated, and is also associated with religion.

Tobacco smoking prevalence found in this study (13.2%) is similar to that found in urban areas of the state of São Paulo (12.2%)16 and by the National Household Sample Survey (PNAD)17, which assessed tobacco smoking prevalence in the rural areas of large municipalities (13.1%). These results show that tobacco smoking prevalence rates among elderly Brazilians are lower than those found in Canada (30.7%)18, China (28.4%)5, India (22.1%)6 and the USA (19.4%)19, and higher than those in Poland (9.3%)20, France (8.3%)21 and Italy (7.1%)22.

The lower prevalence found by this study, as well as in other countries, may be the result of legislation and increased taxation on tobacco and monitoring, in addition to educational/preventive policies and measures to scale up smokers’ access to treatment23. Many countries have joined the WHO convention on tobacco control and have adopted stringent policies to protect the population from the adverse effects of cigarettes24.

Brazil has stood out, as an example to the world, in tackling tobacco smoking. Internationally recognized by the Bloomberg Foundation Awards25 for its initiatives in organizing tobacco monitoring and surveillance, Brazil has made a combined effort to reduce the prevalence of tobacco use even further.

The association between males and tobacco smoking among elderly people living in rural areas has been reported by studies conducted in the USA8, India22 and China20. This association is explained by historical and sociocultural factors that placed cigarettes as a symbol of male status and social power, strongly relating them to masculinity and to personal/professional success26,27.

The habit of smoking was found to be most prevalent among elderly people aged 60–69 years, which is similar to prevalence found in other studies6,16,26. This result may arise from the appearance of diseases that lead older people to stop smoking and to adopt healthier behaviors16.

Elderly single/separated people are at greater risk of tobacco smoking16,26. Hypotheses have been raised to explain this association and they highlight that single/separated people tend towards solitude and isolation, thus being more vulnerability in terms of continuing to smoke compared to people who are married or living with a partner and who receive greater social support, which favors giving up smoking28.

The association between skin color and tobacco smoking is as yet little discussed in the literature. However, studies indicate that people with black and brown skin color are more vulnerable to tobacco consumption, because of less favorable socioeconomic conditions, difficulty in giving up nicotine and the scarcity of resources for so doing29.

Tobacco smoking prevalence among evangelical Christians was considerably less than for followers of other religions. Practicing a faith has been said to have a positive effect on some behaviors and favors keeping away from tobacco and other drugs16. As such it is plausible that values and teachings cultivated by the evangelical Christian faith may have greater influence over these behaviors, when compared to other religions, thus favoring self-control and less possibility of harmful conduct30.

This is the first population-based study with elderly people in the rural area of Rio Grande. The findings may be useful for local government managers, as well as serving as the basis for posterior trend analyses and monitoring of tobacco use in rural areas.

The findings show that tobacco smoking is frequent and of long duration and that, therefore, local health services suffer the impacts of diseases associated with tobacco use. Practices intended to encourage people to give up smoking need to be promoted as a means of preventing and/or minimizing the burden of diseases stemming from tobacco smoking. This is particularly important in rural areas, where traditionally access to health services is more difficult. To this end, the need exists to strengthen primary healthcare services, especially the Family Health Strategy, which has 100% coverage of the rural population of the municipality of Rio Grande, RS.

Limitations of this study include its cross-sectional design, which examines predictors and outcomes only at that moment in time and whereby cause/effect cannot be examined; lack of an instrument to assess the degree of nicotine dependence among the elderly people interviewed; and obtaining reported information about tobacco smoking characteristics that may be subject to memory bias.

Conclusion

This article presents the results of a study of a representative sample of elderly people living in the rural areas of a municipality in the far south of Brazil. Tobacco smoking prevalence and associated factors were identified among a population scattered over a huge territory characterized by low population density and places very far from the urban center of the municipality. Tobacco smoking stood out among that population as a relevant public health issue.

Although the prevalence of tobacco smoking found in this study is similar to other national studies with the elderly, tobacco use is still considerable and is among the main causes of avoidable diseases. The importance of this study therefore lies in its being the first conducted with elderly people living in the rural areas of the municipality studied. Its findings can become a tool for planning actions or public policies aimed at promoting behavioral changes that reduce risk factors associated with tobacco smoking among the elderly in rural areas.

references:

1 World Health Organization. WHO report on the Global Tobacco Epidemic, 2011: warning about the dangers of tobacco. 2011. Available: web link (Accessed 12 April 2018).
2 Malta DC, Bernal RTI, Lima MG, Araujo SSC, Silva MMA, Freitas MIF. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Revista de Saúde Pública 2017; 51(Suppl 1): 4s. DOI link
3 Focchesatto A, Rockett FC, Perry IDS. Risk and protective factors for the development of chronic diseases in a rural elderly population in Rio Grande do Sul. Revista Brasileira de Geriatria e Gerontologia 2015; 18(4): 779-795. DOI link
4 Almeida L, Szklo A, Sampaio M, Souza M, Martins LF, Szklo M, Malta DC, Caixeta R. Global Adult Tobacco Survey Data as a tool to monitor the WHO Framework Convention on Tobacco Control (WHO FCTC) implementation: the Brazilian case. International Journal of Environmental Research and Public Health 2012; 9(7): 2520-2536. DOI link, PMid:22851957
5 Monteiro CA, Cavalcante TM, Moura EC, Claro RM, Szwarcwald CL. Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989–2003). Bulletin of the World Health Organization 2007; 85(7): 527-534. DOI link, PMid:17768501
6 Singh A, Ladusingh L. Prevalence and determinants of tobacco use in India: evidence from recent Global Adult Tobacco Survey data. PLoS ONE 2014; 9(12): e114073. DOI link, PMid:25474196
7 Cai L, Wu C, Goyal A, Han Y, Cui W, He J, et al. Multilevel analysis of the determinants of smoking and second-hand smoke exposure in a tobacco-cultivating rural area of southwest China. Tobacco Control 2013; 22(Suppl 2). DOI link, PMid:23708268
8 Bell RA, Arcury TA, Chen H, Anderson AM, Savoca MR, Kohrman T, et al. Use of tobacco products among rural older adults: prevalence of ever use and cumulative lifetime use. Addictive Behaviors 2009; 34(8): 662-667. DOI link, PMid:19361932
9 National Cancer Institute (INCA). Global adult tobacco survey Brazil 2008/National Cancer Institute – Rio de Janeiro. 2010. Available: web link (Accessed 12 April 2018).
10 Xavier MO, Del-ponte B, Santos IS. Epidemiology of smoking in the rural area of a medium-sized city in Southern Brazil. Revista de Saúde Pública 2018; 52(Suppl 1): 10s. DOI link, PMid:30234882
11 Ministry of Health. Risk and protection factors for chronic diseases by telephone survey. Brazil. 2017. Available: web link (Accessed 12 April 2018).
12 Brazilian Institute of Geography and Statistics. (IBGE). Brazilian cities and states. [In Portuguese]. Available: web link (Accessed 10 April 2018).
13 World Health Organization. Active ageing: a policy framework. [In Portuguese]. 2005. Available: web link (Accessed 3 June 2018).
14 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics 2009; 42(1): 377-381. DOI link
15 Victora CG, Huttly SR, Fuchs SC, AOlinto MT. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. International Journal of Epidemiology 1997; 26(1): 224-227. DOI link, PMid:9126524
16 Zaitune MPA, Barros MBA, Lima MG, Cesar CLG, Carandina L, Goldbaum M, et al. Factors associated with smoking in the elderly: a health survey in São Paulo (ISA-SP). Cadernos de Saúde Pública 2012; 28(3): 583-595. DOI link, PMid:22415190
17 Brazilian Institute of Geography and Statistics (IBGE). National Household Sample Survey – Smoking 2008. 2009 Available: web link (Accessed 10 May 2018).
18 Li FX, Robson PJ, Ashbury FD, Hatcher J, Bryant HE. Smoking frequency, prevalence and trends, and their socio-demographic associations in Alberta, Canada. Canadian Journal of Public Health 2009; 100(6): 453-458. DOI link, PMid:20209740
19 Vander Weg MW, Cunningham CL, Howren MB, Cai X. Tobacco use and exposure in rural areas: findings from the Behavioral Risk Factor Surveillance System. Addictive Behavior 2011; 36(3): 231-236. DOI link, PMid:21146318
20 Kaleta D, Usidame B, Dziankowska-Zaborszczyk E, Makowiec-Dąbrowska T, Leinsalu M. Prevalence and factors associated with hardcore smoking in Poland: findings from the Global Adult Tobacco Survey (2009–2010). BMC Public Health 2014; 14: 583. DOI link, PMid:24916122
21 Lugo A, La Vecchia C, Boccia S, Murisic B, Gallus S. Patterns of smoking prevalence among the elderly in Europe. International Journal of Environmental Research and Public Health 2013; 10: 4418-4431. DOI link, PMid:24048208
22 Ferketich AK, Gallus S, Colombo P, Pacifici R, Zuccaro P, La Vecchia C. Hardcore smoking among Italian men and women. European Journal of Cancer Prevention 2009; 18(2): 100-105. DOI link, PMid:19337056
23 Malta DC, Silva Júnior JB. The Strategic Action Plan for the Fight against Noncommunicable Chronic Diseases in Brazil and the definition of global goals for the fight against these diseases by 2025: a review. Epidemiologia e Serviços de Saúde 2013; 22(1): 151-64. DOI link
24 World Health Organization. Report on the Global Tobacco Epidemic, 2015: raising taxes on tobacco. 2015. Available: web link (Accessed 2 February 2018).
25 Bloomberg Philanthropies. Bloomberg Philanthropies Awards for Global Tobacco Control: meet the winning organizations. 2015. Available: web link (Accessed 12 April 2018).
26 Peixoto SV, Firmo JOA, Lima-costa MF. Health conditions and smoking among older adults in two communities in Brazil (The Bambuí and Belo Horizonte Health Surveys). Cadernos de Saúde Pública 2006; 22(9): 1925-1934. DOI link, PMid:16917590
27 Berto SJP, Carvalhaes MABL, Moura EC. Smoking associated with other behavioral risk factors for chronic non-communicable diseases. Cadernos de Saúde Pública 2010; 26(8): 1573-1582. DOI link, PMid:21229216
28 Marinho V, Blay SL, Andreoli SB, Gastal F. A prevalence study of current tobacco smoking in later life community and its association with sociodemographic factors, physical health and mental health status. Social Psychiatry and Psychiatric Epidemiology 2008; 43: 490-497. DOI link, PMid:18385966
29 Viana DA, Rodrigues LR, Tavares DMS. Factors socio-demographic and economic associated with smoking in the elderly population. Brazilian Journal of Psychiatry 2014; 63(3): 220-226.
30 Kelly PE, Polanin JR, Jang SJ, Johnson BR. Religion, delinquency, and drug use. Criminal Justice Review 2015; 40(4): 505-523. DOI link

You might also be interested in:

2021 - Determinants of physical activity level of people living in rural areas according to the transtheoretical model: regression and path analysis

2014 - Hope of rural women caregivers of persons with advanced cancer: guilt, self-efficacy and mental health

2010 - Breast cancer stage at diagnosis and geographic access to mammography screening (New Hampshire, 1998-2004)