Care for smokers in the Unified Health System: an analysis based on information systemsAbstract
This study analyzed the network of health facilities that recorded care for smokers, based on data from the Health Information Systems (HIS) of the Brazilian Unified Health System (SUS). This is an ecological study, using 2024 data, which characterizes procedures related to clinical and behavioral conditions resulting from tobacco use, as well as the regional and state distribution of the services that recorded them. Different types of procedures related to smoking were identified, revealing clear territorial variation. A low number of “promotion and prevention actions” was observed (0.4%), with a predominance of diagnostic imaging procedures (45%), especially in São Paulo and Rio Grande do Sul. Records were concentrated in psychosocial units and Psychosocial Care Centers (CAPS) (48%), while only 14% occurred in Primary Health Care (PHC). Amapá and Roraima did not record procedures for prevention, diagnosis, or treatment of the conditions studied. The findings highlight weaknesses in the organization of the network, possible underreporting of preventive actions, and challenges in coordinating PHC as the main entry point for cessation. The study underscores the importance of qualifying HIS/SUS data and strengthening promotion and prevention initiatives for smokers, especially in regions with lower coverage of tobacco-related services.
Keywords:
Smoking; Smoking cessation; Health Information Systems; Health services; Health policy.
Resumo
Este estudo analisou a rede de estabelecimentos de saúde que registrou atendimentos a fumantes, com bases em dados dos Sistemas de Informação em Saúde (SIS) do Sistema Único de Saúde (SUS). Trata-se de um estudo ecológico, com dados de 2024, que caracteriza procedimentos vinculados a condições clínicas e comportamentais decorrentes do tabagismo, bem como a distribuição regional e estadual dos serviços que os registraram. Identificaram-se diferentes tipos de procedimentos relacionados ao tabagismo, com clara variação territorial. Observaram-se o baixo registro de “ações de promoção e prevenção” (0,4%) e predomínio de procedimentos de diagnóstico por imagem (45%), especialmente em São Paulo e no Rio Grande do Sul. Verificou-se concentração de registros em unidades psicossociais e CAPS (48%), enquanto apenas 14% ocorreram na Atenção Primária à Saúde (APS). Amapá e Roraima não registraram procedimentos para prevenção, diagnóstico ou tratamento das condições estudadas. Os achados evidenciam fragilidades na organização da rede, possível sub-registro de ações preventivas e desafios na articulação da APS como porta de entrada para cessação. O estudo ressalta a importância de qualificar os dados dos SIS/SUS e fortalecer as iniciativas de promoção e prevenção voltadas a fumantes, principalmente em regiões com menor cobertura de serviços relacionados ao tabagismo.
Palavras-chave:
Tabagismo; Abandono do Uso de Tabaco; Sistemas de Informação em Saúde; Serviços de Saúde; Política de Saúde.
Introduction
Smoking still is a major risk factor for various diseases and premature deaths, despite all the efforts of Brazil and several countries around the world in implementing public policies for tobacco control. Worldwide, smoking kills more than seven million people each year. Recognized as a chronic disease since 1996 by the World Health Organization (WHO) and classified as an aggravation resulting from the use of psychoactive substances, in this case nicotine, smoking requires treatment, as well as actions aimed at preventing the initiation of tobacco use (Cavalcanti et al., 2023; WHO, 1996; 2025).
Brazil stands out on the world stage for its pioneering role in actions to combat tobacco. Since late 1980s, the Ministry of Health, through the National Cancer Institute (Instituto Nacional de Câncer - INCA), has been involved in the management and governance of tobacco control in Brazil. This action is carried out through the National Tobacco Control Program (Programa Nacional de Controle do Tabagismo), which articulates a set of comprehensive and intersectoral actions. In 2005, Brazil ratified the Framework Convention on Tobacco Control, which provides, in Article 14, for the adoption of effective measures to promote the cessation of tobacco use, as well as adequate treatment for tobacco dependence (Portes et al., 2018).
In 2020, the Clinical Protocol and Therapeutic Guidelines (PCDT) for Nicotine Dependence were published, and in 2022, guidelines were published for the organization of services and care for smokers within the scope of the Brazilian Unified Health System (SUS) (Brasil, 2020; 2022).
The network of care for smokers aims primarily at smoking cessation, reducing the prevalence of smokers and morbidity and mortality from diseases related to tobacco and its derivatives at all levels of health care in the SUS (Brazil, 2022). Monitoring this network is fundamental for evaluating both the policy of cessation of tobacco use and for monitoring the health demands of tobacco users (Garbelotto et al., 2024). To this end, health information systems are an essential tool when the data reported are of high quality (Ali et al., 2019; Saraiva et al., 2021).
At different levels of care, management can significantly benefit from the recorded data to generate information that supports decision-making, such as the profile of tobacco users served, procedures performed as a result of tobacco use, or the geographical distribution of network points where care was provided. Through this type of analysis, it is possible to optimize the allocation of resources, directing investments to the areas with the greatest demand. Furthermore, data analysis enables the evaluation of the impact of tobacco control policy at different levels of care (Ali et al., 2019).
Tobacco control is a challenge for management, which needs to organize the health care network to develop educational actions that discourage the initiation of tobacco product consumption, ensure treatment for cessation, as well as the diagnosis and treatment of clinical and behavioral conditions resulting from tobacco consumption. Therefore, it is understood that a situational diagnosis of the network is fundamental for responsible planning.
This study aims to investigate the types of procedures recorded in the SUS information systems, associated with clinical and behavioral conditions resulting from tobacco consumption, as well as to characterize the health establishments involved in smoker care and the distribution of these services in the regions of the country, in 2024.
Methodology
This study adopted an ecological approach, using the federative units and geographic regions of the country as units of analysis and the secondary databases from 2024 of the Outpatient Information System (Sistema de Informações Ambulatoriais - SIA/SUS) and the National Registry of Health Establishments (Cadastro Nacional de Estabelecimentos de Saúde - CNES) as data sources, both accessed through the DATASUS portal (DATASUS, 2024a, 2024b).
Based on the 10th revision of the International Classification of Diseases (ICD-10), the following codes for clinical or behavioral conditions resulting from tobacco use were selected: Mental and behavioral disorders due to tobacco use (F17), Toxic effects of tobacco and nicotine (T65.2), Counseling for tobacco abuse (Z71.6), Lifestyle problems related to tobacco use (Z72.0) and Family history of tobacco abuse (Z81.2) (WHO, 1996). The search for these codes in the main ICD field, in the outpatient and psychosocial production databases of the SIA/SUS, allowed us to identify the procedures analyzed in this study.
According to the criteria adopted by the Management System of the Table of Procedures, Medicines and OPM of the SUS (Sistema de Gerenciamento da Tabela de Procedimentos, Medicamentos e OPM - SIGTAP) for coding procedures, the following categories of procedures were created: a) promotion and prevention actions (procedures starting with 01); b) laboratory or clinical diagnosis (procedures starting with 0202); c) diagnostic imaging (procedures starting with 0204, 0205, 0206, 0207); d) clinical procedure (procedures starting with 03); and e) surgical procedure (procedures starting with 04) (DATASUS, 2024c). All establishments that recorded at least one of these procedures were included in the data analysis.
Healthcare facilities that recorded procedures for the selected ICD codes were categorized based on records from two CNES databases, named specialized services and accreditation. Thus, the facilities were characterized as follows: Primary Health Care (PHC - code 159, from the specialized services database); Psychosocial (Code 115, from the specialized services database); Tobacco Control Service (Code 119, from the specialized services database); Dental Specialty Centers (DSC - codes 0401, 0403, 0404, 0405, 0406, from the accreditation database); Psychosocial Care Centers (CPS - codes 0616, 0617, 0618, 0619, 0620, 0635, from the accreditation database). Specialized Rehabilitation Centers (CER - codes 2201, 2202, 2203, 2204, 2205, 2208, 2209, 2210, 2211, from the qualification database); and oncology-qualified units (ONCO - codes 1701, 1702, 1703, 1704, 1705, 1706, 1707, 1708, 1709, 1710, 1711, 1712, 1713, 1714, from the qualification database) (DATASUS, 2024b).
It should be noted that establishments without classification in the specialized services or qualification database were characterized under the category "Others"; the same establishment may receive more than one characterization. Furthermore, even though the nature of primary health care work does not classify it as specialized care, primary health care units have a code in the CNES specialized service database.
The data were processed and analyzed using R software (version 4.4.0), through tabulation, cross-referencing, and descriptive analysis procedures (R Core Team, 2025). To assess the independence between the disease studied and the type of procedure, Fisher's exact test was performed.
Results
In 2024, 10,411 procedures related to clinical or behavioral conditions resulting from tobacco use were registered in the SUS, the most frequent being: tobacco use (53%) and mental and behavioral disorders due to smoking (39%).
Looking at the regions, the Southeast region registered the highest percentage of procedures due to tobacco use (61.3%), while the Central-West region had the highest percentage of procedures related to mental and behavioral disorders due to smoking (56.7%) (Table 1). Considering the production presented by the states, in Ceará, Paraná, Santa Catarina, and Maranhão, more than 70% of the registered procedures were linked to the condition: mental and behavioral disorders due to smoking. In Minas Gerais and Pernambuco, more than 70% of the procedures were linked to the illness of tobacco use. In Amapá and Roraima, no procedures were registered for the prevention, diagnosis, or treatment of the conditions studied (Table 1).
Distribution of the number of procedures related to clinical and behavioral conditions resulting from tobacco use, by diseaseª, according to federative units and geographic regions. Brazil, 2024
When classified by type of procedure, it can be observed in Table 2 that 45% of the 10,411 procedures related to clinical and behavioral conditions resulting from tobacco use, recorded in 2024, were diagnostic imaging procedures, 35% clinical procedures, 19% laboratory or clinical diagnostic procedures, less than 1% surgical procedures, and only 0.4% were promotion and prevention actions.
Distribution of procedure categories, according to federative units and geographic regions. Brazil, 2024
The identified promotion and prevention actions were recorded only in the states of Minas Gerais, Rio de Janeiro, São Paulo, Santa Catarina, the Federal District, and Mato Grosso. In contrast, it is noteworthy that diagnostic imaging procedures related to clinical and behavioral conditions resulting from tobacco use were performed in 18 of the 27 federative units (Table 2).
In 2024, 906 health facilities were identified in Brazil that recorded at least one procedure related to clinical and behavioral conditions resulting from tobacco use. Of these, 48% are characterized as having a psychosocial classification service or are qualified as CAPS, 14% as APS, 7% are qualified in oncology, and 3% are qualified as CEO or CER (Table 3).
Distribution of the number of health facilities that performed at least one procedure related to clinical and behavioral conditions resulting from tobacco use, by facility typeª, according to federative units and geographic regions. Brazil, 2024
In the North, Northeast, and South regions, less than 10% of the health facilities identified were characterized as APS, and more than 30% were characterized as CAPS. While in Pará, Pernambuco, Espírito Santo, Rio de Janeiro, and the Federal District, at least 10% of the identified facilities were classified as CEO. It is observed that the health facilities that recorded procedures related to clinical and behavioral conditions resulting from tobacco use in the SUS characterized as Oncology are concentrated in the states of the Southeast region, especially in São Paulo and Minas Gerais (Table 3).
Table 4 shows that approximately 75% of health establishments that registered procedures related to clinical and behavioral conditions resulting from tobacco use in the SUS in 2024 did not have a service classification for tobacco control (119), and in the North Region this percentage reached 84% of establishments. The states that concentrated the largest volume of health establishments with a service classification for tobacco control were São Paulo, Rio de Janeiro, Mato Grosso and Minas Gerais.
Distribution of the number of health facilities that performed at least one procedure related to clinical and behavioral conditions resulting from tobacco use, by classification of the tobacco control serviceª, according to federative units and geographic regions. Brazil, 2024
The results of a bivariate analysis between clinical and behavioral conditions resulting from tobacco use and the type of procedure indicate that the observed association is statistically significant (Fisher's exact test p-value <0.001). No promotional or preventative actions were recorded for the ICD corresponding to tobacco abuse counseling. For mental and behavioral disorders due to tobacco use, a high concentration of clinical procedures was observed, with 64% of the 6,697 diagnostic procedures recorded being linked to tobacco use illness (Table 5).
Distribution of the number of procedures related to clinical and behavioral conditions resulting from tobacco use, by type of procedure, according to the diseases studiedª. Brazil, 2024
Discussion
This study, by identifying the health facilities that recorded care for smokers, provided an overview of the health services that have absorbed the demand for procedures related to tobacco use in Brazil. Differences were evidenced in the distribution of these services among the regions of the country, as well as the predominance of diagnostic procedures and a low supply of promotion and prevention actions.
According to the results, most of the procedures recorded (more than 60%) were diagnostic, that is, procedures related to the consequences of smoking, rather than actions for prevention and cessation of smoking. A very small number of procedures due to counseling for tobacco abuse were recorded. Although this may represent underreporting or lack of awareness of this classification, it may also represent low adherence to WHO guidelines for integrating counseling at primary care points and may signal weaknesses in the articulation of the care network (Cavalcanti et al., 2023). This finding suggests the need for proactive strategies to strengthen the network, such as training primary health care teams for the correct recording of these actions, and integrating smoking cessation with other strategic programs for health promotion and prevention of chronic diseases.
In addition, approximately 75% of the health facilities that recorded the procedures discussed here did not have a service classification for smoking cessation. This may indicate that much of the care provided to these users is carried out in units not formally qualified for smoking cessation, which may compromise the standardization of prevention actions, as well as the monitoring of the care network for smoking cessation treatment.
Encouraging tobacco users to be approached and encouraged to quit at all points in the health care network, and not just in primary health care, as well as being guided on how to obtain treatment in the SUS, should be understood as strategic for the National Tobacco Control Program. It is also questioned whether the reason for performing diagnostic imaging procedures due to tobacco use might be related to an informal screening strategy. As smoking is one of the main risk factors for several diseases, it is possible that these procedures are being used to identify lung or neck neoplasms, as well as other diseases, such as cardiovascular diseases and chronic obstructive pulmonary disease (COPD) (Pereira et al., 2024). According to Pinto and colleagues, 78% of lung cancer deaths are attributable to smoking, as are 80% of laryngeal cancer deaths, 57% of mouth and pharyngeal cancer deaths, and 74% of COPD deaths (Pinto et al., 2019).
The distribution of the 906 establishments reveals a strong concentration in establishments characterized as psychosocial (48%) and a small participation of primary health care (14%). Although CAPS (Psychosocial Care Centers) are strategic for managing chemical dependency, primary health care is recommended as the entry point for managing tobacco use, reducing access barriers, given the capillarity of this point of care in the network (Camilo et al., 2024). On the other hand, the greater concentration of actions in CAPS and specialized services may indicate that tobacco dependence is being managed more reactively than preventively, often linked to already established mental and behavioral disorders, as shown by the high percentages in states such as Ceará, Paraná, and Santa Catarina.
Another aspect that deserves highlighting refers to the territorial distribution of services. The absence of procedure records in states such as Amapá and Roraima may indicate regional inequalities, reflecting structural weaknesses in network coverage or possible limitations in filling out information systems, which reinforces the need for professional training regarding the completion of SUS information systems (Ali et al., 2019).
Given this scenario, public policies are needed to guarantee equal and effective access to healthcare for smokers, as well as government support in training healthcare professionals to better serve these users and record the procedures performed. Furthermore, promoting effective communication about health services, considering the reality and needs of smokers, contributes to a more appropriate allocation of resources. This approach enables the provision of more specialized care and encourages improvements in the implementation of smoking cessation programs, reducing the prevalence of smokers and the incidence of tobacco-related diseases.
The limitations of this study should be considered. Because it is based on secondary data from the SUS information systems, which are administrative in nature and not surveillance-related, they are subject to underreporting, inadequate coding, and the absence of individual clinical variables. However, the national scope of these systems and the combined use of SIA/SUS and CNES are useful evidence for planning. Furthermore, obtaining information from these systems is fundamental to stimulating the qualification of data, to contribute to the monitoring of the health care network.
In terms of practical implications, the findings reinforce the urgency of investments in the qualification of records, since incomplete, inconsistent, or inaccurate information can lead to erroneous analyses and, consequently, to inadequate management decisions, and in the expansion of counseling, prevention, and cessation actions. The expansion of community strategies in PHC may be a promising path to broaden access and ensure greater effectiveness of tobacco control policies in Brazil.
Further studies integrating qualitative and quantitative analyses are recommended, capable of exploring organizational, cultural, and structural barriers that hinder the full implementation of current guidelines. Strengthening a coordinated network, guided by health surveillance and supported by quality data, is essential to reduce the burden of morbidity and mortality associated with smoking and consolidate Brazil's historical commitment to tackling this disease.
Acknowledgements
This article was published with resources from the Sustentabilidade Project of PNCT, coordinated by the Tobacco Control Division (Divisão de Controle do Tabagismo - DITAB) of the Prevention and Surveillance Coordination (Coordenação de Prevenção e Vigilância) of the National Cancer Institute, with support from Vital Strategies, Bloomberg Philanthropies, and the Center for Studies, Research and Technological Development in Public Health (Centro de Estudos, Pesquisa e Desenvolvimento Tecnológico em Saúde Coletiva - Cepesc) of the State University of Rio de Janeiro (UERJ).
Note
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Reviewers:
Ligia Devoglio and Jeane Tomazelli
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All research data are available in this text.
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Editor:
Jane Russo
All research data are available in this text.
