Niveles De Ingreso Y Prevalencia De Tabaquismo En América Latina: Revisión Sistemática Y Metaanálisis

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Niveles De Ingreso Y Prevalencia De Tabaquismo En América Latina: Revisión Sistemática Y Metaanálisis NÚMERO TEMÁTICO SOBRE ECONOMÍA DEL CONTROL DEL TABACO EN LAS AMÉRICAS Pan American Journal Revisión of Public Health Niveles de ingreso y prevalencia de tabaquismo en América Latina: revisión sistemática y metaanálisis Ariel Bardach,1 Herney Andrés García Perdomo,2 Ruth Amanda Ruano Gándara1 y Agustín Ciapponi1 Forma de citar Bardach A, García Perdomo HA, Ruano Gándara RA, Ciapponi A. Niveles de ingreso y prevalencia de tabaquismo en América Latina: revisión sistemática y metaanálisis. Rev Panam Salud Publica. 2016;40(4):263–71. RESUMEN Objetivo. Determinar la relación entre la prevalencia de consumo actual de tabaco y los niveles de ingresos monetarios de fumadores en América Latina y el Caribe (ALC). Métodos. Se realizó una búsqueda sistemática en bases de datos incluyendo MEDLINE, EMBASE, CENTRAL, SOCINDEX y LILACS. Se incluyeron estudios de ALC publicados desde enero 1989 hasta diciembre de 2015. Se realizaron análisis de subgrupos planeados por década calendario de los datos, país, riesgo de sesgo, sexo y grupos de edad. Resultados. De un total de 1 254 estudios evaluados por texto completo se incluyeron 29 artículos, de los cuales 25 fueron incorporados en metaanálisis. Todos los estudios incluidos fueron de corte transversal o de vigilancia, la mayoría provenientes de Brasil y de México. Un bajo nivel de ingresos se asoció con una mayor prevalencia de tabaquismo activo (odds ratio [OR] 1,62; intervalo de confianza de 95% [IC95%] 1,34–1,96) con respecto al nivel alto (referencia). Se observó una tendencia de efecto dosis-respuesta: nivel medio de ingresos (OR 1,23; IC95% 1,00-1,52) y nivel bajo de ingresos (OR 1,64; IC95% 1,17-2,30). Esta asociación fue mayor en hombres (OR 2,22; IC95% 1,77-2,78) que en mujeres (OR 1,6; IC95% 1,11-2,47). Conclusiones. Se observó una relación inversa entre el nivel de ingresos y la prevalencia de consumo de tabaco. Se requieren mayores esfuerzos para determinar esta relación en poblacio- nes especiales como adolescentes o embarazadas. Esta investigación puede ser útil para los decisores políticos al mejorar las estrategias de control del tabaco y para caracterizar cuestiones de equidad en la salud pública. Palabras clave Uso de tabaco; equidad; economía de la salud. El tabaquismo constituye la principal como por el consumo indirecto de ciga- años de vida ajustados por discapacidad causa de muerte prevenible en el mundo. rrillos (tabaquismo pasivo) (1, 2) y, para (AVAD) que se pierden cada año a conse- Aproximadamente seis millones de personas el período 2010-2050, se proyectan alre- cuencia del consumo de tabaco aún es mueren por consecuencias relacionadas dedor de 400 millones de muertes por demasiado alta (6). con fumar, tanto por el consumo directo enfermedades atribuibles, sobre todo Además de este importante impacto cáncer de pulmón, enfermedad respira- en términos de muerte y morbilidad, el 1 Centro Cochrane Argentino, Instituto de Efectividad toria crónica y enfermedad cardiovascu- tabaquismo impone una significativa Clínica y Sanitaria (IECS-CONICET). La corres- lar (3, 4). Se estima que la mayoría de las carga económica: se estima que genera pondencia se debe dirigir a Ariel Bardach. Correo muertes se producirán en países de bajos un costo a nivel mundial superior a los electrónico: [email protected] 2 Hospital Universitario del Valle, Universidad del y medianos ingresos (5). En América La- USD (dólares estadounidenses) 500 mil Valle, Cali, Colombia. tina y el Caribe (ALC), la proporción de millones cada año (7), principalmente Rev Panam Salud Publica 40(4), 2016 263 Revisión Bardachetal.•NivelesdeingresoyprevalenciadetabaquismoenAméricaLatina por costos directos en el sistema de salud temprana de quienes sostienen los hoga- Dos investigadores independientes re- y por productividad perdida. res. Un análisis anterior había revelado visaron por título y resumen todos los El consumo de tabaco en poblaciones que los fumadores de bajos ingresos estudios identificados. Los desacuerdos con bajo nivel de ingresos se relaciona tenían peores resultados de las enferme- se resolvieron por consenso del equipo con una mayor frecuencia de enferme- dades relacionadas con el tabaco y que la de revisión. Se obtuvo el texto completo dades asociadas y los pacientes tienen proporción del gasto en tabaco fue de todos los artículos considerados po- menor acceso a los servicios de salud, mayor entre los hogares de bajos ingre- tencialmente incluibles. Dos investigado- además de menores posibilidades de sos, con el consiguiente impacto en su res independientes evaluaron el texto comprar medicamentos (8-10). La mayor finanzas (16). completo de aquellos artículos seleccio- incidencia de tabaquismo (comienzo del El principal objetivo del presente estu- nados para evaluar si cumplían con los hábito) se da en hombres de países de dio fue evaluar la asociación entre la pre- criterios de inclusión. Las discrepancias ingreso bajo y medio, pero la prevalen- valencia de tabaquismo y los niveles de se resolvieron por consenso del equipo cia del tabaquismo es mayor entre los ingresos económicos en ALC. de revisión. Si los datos de los estudios países de ingreso medio-alto (8, 9). incluidos fueron poco claros o insuficien- De acuerdo a un modelo epidemioló- MÉTODOS tes, se consultó con el autor. Si no fue re- gico ampliamente citado, en las primeras suelto en la consulta con el autor, entonces etapas de la epidemia, el consumo de El presente metaanálisis de estudios el artículo fue excluido. En el anexo 1 se tabaco y las enfermedades relacionadas observacionales sigue la guía MOOSE muestran las estrategias de búsqueda predominan en los hombres y tiene una para su reporte (18). Se incluyeron estu- empleadas. difusión limitada entre las mujeres, cual- dios publicados o reportados entre enero Para recolectar la información deta- quiera sea el tipo de país (10). Luego, la de 1989 y diciembre de 2015, que cum- llada antes se utilizó una hoja de cálculo prevalencia masculina disminuye con plieran dos criterios. El primero fue el basada en la web. Un primer revisor ex- una reducción del retraso de la inciden- reporte nivel de ingreso valorado a tra- trajo los datos de los estudios incluidos, cia de la enfermedad en los hombres, ves de mediciones directas (ingreso por y un segundo los comprobó. Se incluye- mientras que las mujeres siguen una pro- hogar, unidades de salario mínimo, línea ron los siguientes datos: continente y gresión similar, aunque de proporciones de pobreza). Se excluyeron la situación país, fecha de publicación, sexo, defini- menores. Según esta evolución, las socie- laboral o el nivel educativo como varia- ción actual de tabaquismo, prevalencia dades de mayores ingresos son las invo- bles sustituto. Cuando en el estudio se porcentual de tabaquismo, fechas de lucradas al inicio, ya que son más reportaban más de dos categorías de ni- reclutamientos, odds ratio (OR) de la abiertas a la incorporación de nuevos vel de ingreso, se seleccionó una catego- asociación entre nivel de ingreso y taba- hábitos, para luego ser alcanzadas por ría media para su comparación con el quismo, unidad monetaria, ingresos del las sociedades de menores ingresos. Sin nivel más alto y más bajo de ingreso. El fumador y de la familia, número de ci- embargo, dado que varía la dinámica se- otro criterio fue el reporte de prevalencia garrillos por día, manejo de las varia- gún el ingreso, se ha recomendado des- de tabaquismo actual. Se incluyeron to- bles confusoras y ajustes, edad en cribir la epidemia en los países en das las definiciones utilizadas por los au- categorías, tipo de diseño epidemiológi- desarrollo mediante un análisis de hom- tores y se las categorizó en una etapa co del estudio, escenario rural o urbano, bres y mujeres por separado (11). posterior. Se consideraron estudios refe- grupos de poblaciones especiales (em- Durante las últimas décadas, un consi- ridos tanto a población general como a barazadas, trabajadores), tipo de mues- derable cuerpo de evidencia ha descrito grupos específicos (grupos regionales, treo (probabilístico o no), educación en una asociación inversa entre la condición etnias, grupo etario, entre otros). categorías, etnia y religión. social y el tabaquismo (12-16). En estos Se realizó una búsqueda sistemática en Se incluyeron estudios epidemiológicos estudios, la pobreza y el consumo de ta- múltiples bases de datos, incluidas MED- observacionales, de vigilancia, cuasi expe- baco se midieron con diversas herramen- LINE, EMBASE, CENTRAL, SOCINDEX rimentales y las ramas control de estudios tas; sin embargo, el nivel de ingresos fue y LILACS. Se evaluó la literatura gris experimentales. La calidad metodológica señalado con frecuencia como un factor mediante el contacto personal con los au- de los estudios se evaluó mediante una he- con una asociación clara y fuerte con la tores principales, agencias de control ta- rramienta elaborada sobre la base de la pobreza. báquico, páginas web específicas, lista de verificación STROBE (20), el Ma- En una revisión sistemática previa conferencias con los investigadores prin- nual Cochrane para Revisiones Sistemáti- (17), se halló una fuerte asociación inver- cipales. La estrategia empleada puede cas de Intervención (21) y dos documentos sa entre la prevalencia de tabaquismo y encontrarse en la información suplemen- metodológicos: Sanderson et al. (22) y menores ingresos en la mayoría de las taria en línea. Fowkes y Fulton (23). Se elaboró un algo- zonas geográficas del mundo, para am- ritmo para estimar el riesgo de sesgo para bos sexos y en todos los grupos
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