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SMAD. Revista eletrônica saúde mental álcool e drogas

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SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) vol.17 no.4 Ribeirão Preto out./dez. 2021 



Nursing perceptions and experiences regarding smoking bans in a psychiatric hospital



Renata Marques de OliveiraI; Antonia Regina Ferreira FuregatoII

IUniversidade Federal de Minas Gerais, Escola de Enfermagem, Belo Horizonte, MG, Brazil
IIUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil

Corresponding author




OBJECTIVE:to learn about the experience of nursing professionals in the implementation of the smoking ban in a psychiatric hospital.
METHOD: a qualitative study was carried out with 73 nursing professionals from a psychiatric hospital in São Paulo's countryside, using Grounded Theory as a methodological reference and Symbolic Interactionism as a theoretical reference. There were 1260 hours of participant observation with field diary records. The data were analyzed from the open, axial and selective coding.
RESULTS: different facets of the smoking ban were observed, such as insecurity, pessimism, resistance and boycott, especially in the private internment unit. However, many nursing professionals supported the ban when they saw the benefits to patients.
FINAL CONSIDERATIONS: the process of implementing the smoking ban was accompanied by difficulties, but it proved to be a viable intervention. Professionals who were initially against the ban began to support it.

Descriptors: Smoking; Nursing; Smoking-Free Policy; Hospitals, Psychiatric; Psychiatric Nursing.




Over time, smoking has been accepted and encouraged, especially in psychiatric hospitals, as a way to control the behavior of psychiatric patients. This is a controversial issue due to the anti-smoking legislation in force in several countries and the scientific evidence that indicates the damage of smoking(1-3).

In Brazil, Law 12.546/2011 and Decree 8262/2014 established the prohibition of tobacco smoke in closed collective environments(4-5). In addition to the federal legislation, some states strengthen control by means of State Anti-Smoking Laws, such as Minas Gerais (Law No. 18,552/2009), Rio de Janeiro (Law No. 5517/2009), Rio Grande do Norte (Law No. 9423/2010), Rio Grande do Sul (Law No. 13,275/2009) and São Paulo (Law No. 13,541/2009)(6-10).

From the experience as professors, inserted in the mental health services, conflicts have been observed due to the smoking ban, since there is no consensus among professionals about this measure. This personal perception coincides with reports of recent studies conducted in Australia and Iran(11-12). In this context, the dilemma reigns: what is the limit between the legislation and the right of patients to decide if they want to quit smoking?

The smoking ban has led professionals to question the autonomy, dignity and right of people with mental disorders to be treated free of discrimination. Some argue that the restriction of smoking is inhuman and cruel because it provides additional stress to the person with mental disorder hospitalized(3,11-12).

Although federal legislation (Law No. 12,546/2011) has been published for almost a decade(4), smoking remains neglected in many mental health services. Unlike in the general population, in psychiatric hospitals non-smokers are the exception(13). According to national and international scientific literature, 60 to 70% of people admitted to psychiatric hospitals are smokers(14-16).

Tobacco damage to the psychiatric population involves somatic comorbidities, decreased life expectancy (around 25 years), worsening psychiatric symptoms, increased risk of suicide, stigma and deprivation of basic needs (food, hygiene products and clothing) due to the purchase of cigarettes(17-21).

In addition to people with mental disorders, tobacco smoke harms health professionals, in view of the proximity of contact, promoting frequent and intense passive exposure to smoking of patients. Thus, nursing professionals, who work in psychiatric hospitals, require special attention. Researchers from Spain, Australia and the United States have dedicated themselves to this theme(12,22-23).

Based on the controlled descriptors in health sciences "smoking" and "psychiatry", an initial consultation was conducted at the Virtual Health Library (VHL) in order to know the main perspectives investigated in this theme (the research did not intend to subsidize an integrative literature review). From this search, 20 articles in Portuguese were identified. It was observed, when reading the abstracts, that in none of them was considered the perspective of health professionals exposed to secondhand smoke, which increased the interest in this theme. This study aims at filling this gap in the national scientific literature.

The PICO strategy was used to define the guiding question of the study, which presents four elements that guide the writing of the study questions. It is recognized as an effective strategy to improve the quality of scientific research, since the problem is better delimited(24). The guiding question was elaborated from three components of the acronym PICO: P (population/population = nursing professionals), I (intervention/intervention = implementation of the smoking ban) and O (outcome/disclosure = experiences/survivors). Therefore, this study was based on the following question: "How do nursing professionals experience smoking prohibition in a psychiatric hospital?".


To learn about the experience of nursing professionals in the implementation of the smoking ban in a psychiatric hospital.



Ethical aspects

Study approved by the Research Ethics Committee of the Ribeirão Preto School of Nursing, University of São Paulo (nº 016/2018). The participants signed two copies of the Consent Form.

Theoretical-methodological reference and type of study

To answer the question, a qualitative study was carried out with Grounded Theory as a methodological reference and Symbolic Interactionism as a theoretical reference.

The Grounded Theory, with the perspective of Symbolic Interactionism, applies to this study, since it aims to investigate people's perception of a given situation. The object of interest is the behavior of people(25-26).

Consolidated Criteria for Reporting Qualitative Research (COREQ) were respected.

Study scenario

Psychiatric hospital of São Paulo countryside, with philanthropic administration and capacity for 215 beds (127 psychiatric beds in the Unified Health System, 60 psychiatric beds in private ward and 28 private beds in clinical ward).

Data sources

In order to obtain an accurate picture of the situation, as many reports as possible, containing the perceptions and behaviors in relation to the smoking ban were sought, including nurses and Nursing Technicians from all hospitalization units, day and night duty. There were 73 nursing professionals (13 nurses and 60 technicians). Seven were excluded from medical leave, nine were hired less than three months ago and one refused to participate.

Data collection

Participant observation was used, chosen as the method of data collection, because it is indicated when little is known about a given phenomenon or when topics related to taboos and cultural processes are investigated(27).

One of the authors of the study inserted himself in the routine, together with the other professionals of the Nursing, in order to experience the prohibition of smoking. This procedure started two months before the ban, which allowed investigating the perceptions and behaviors of Nursing before and during the implementation of the ban.

The data was collected between January and October 2018, totaling 1260 hours of observation divided into 42 weeks. Each insertion in the hospital lasted six hours, alternating the periods (morning, afternoon and night), throughout the week, in order to ensure contact with all the shifts.

Observations were made in all environments where there was the presence of nursing professionals (nurses' room, hospitalization units, meeting rooms, reception, cafeterias, patio). Records were kept in a field diary in which the date and content observed (formal and informal conversations, tone of voice, impressions of the researcher in relation to events, attitudes and behaviors) were inserted.

Data analysis

After several readings of the field diary, the analysis was carried out according to the following steps: 1) open coding (initial organization of categories and subcategories); 2) axial coding (integration of categories from the identification of the main problem according to the participants' perception) and 3) selective coding (delimitation of a single central category with the integration of the concepts in causal conditions, phenomenon, context, intervening conditions, strategies and consequences)(26,28).

The lines of the nurses with "E" and the technicians of Nursing with "T" were identified. The results were discussed based on publications on the topic.



The participants were predominantly women with an average age of 39.8 years. They had been working in Nursing for an average of 12 years, working in the psychiatric hospital for six years.

The interpretation of the data was guided by Symbolic Interactionism, as a theoretical reference, considering that attitudes and behaviors are motivated by the meaning that the phenomenon has for each person(29).

The impressions recorded in the field journal allowed interpreting the opinions and behavior of nursing professionals regarding the smoking ban. By following the Grounded Theory(28), the theoretical model was built around the central category (phenomenon) "Experiencing smoking prohibition in a psychiatric hospital" with the following aspects: 1) Causal conditions; 2) Context; 3) Intervening conditions; 4) Strategies of action/interaction and 5) Consequences (Figure 1).

Causal conditions: "There is a law to be followed"

In December 2017, the Tobacco Commission, composed of doctors, nurses, psychologists, social workers, pharmacist and occupational safety technician, announced that the smoking ban would begin in March 2018, in compliance with Law No. 12,546/2011. On the date disclosed, the cigarettes were returned to relatives.

With the disclosure of the date of implementation of the ban, this issue became present and recurrent among nurses and nursing technicians, both in formal and informal conversations. As it represented a significant change in hospital norms and routine, the first reaction was resistance to the new/unknown.

The resistance of nurses and nursing technicians was explicit through speeches with a pessimistic content, showing an insecurity in the face of change: It will not work, it has been tried before (T4); How will it be? (T30); Poor residents who only have this pleasure in life! (E1)

The belief in self-medication of psychiatric symptoms from smoking became evident: Patients will go to work (E6); they will get more aggressive (T5); they will use more medicine (T15).

Context: "The implementation of the ban"

In the first days of the ban, nurses and nursing technicians were questioned in the public hospitalization units about the lack of cigarettes. In the female psychiatric unit, there was more resistance than in the male unit. However, verbal management was sufficient in situations where the team was questioned.

In the residents' unit, even though they had been advised about the intervention, they insisted for a few days on forming a line, after breakfast, waiting for the first cigarette of the day. Every professional who passed by was questioned: "Dude, what about the cigarettes?". There were also some who asked for cigarettes as a reward after tidying up the beds, sweeping the patio, etc. For not receiving the retribution, some presented a regressive behavior, making beaks and verbalizing "being in bad shape" of the Nursing professional.

As the days went by, most residents did not mention the subject and conditioned behavior (for example, queuing up to order cigarettes) was forgotten.

The success of the withdrawal of cigarettes in the residents' unit has generated the same questioning throughout the hospital, which is exemplified by: Is the ban working or are they smoking in hiding? (E7)

Although residents were one of the most mentioned concerns before the implementation of the ban, it was surprising the acceptance of this public: The residents, who I thought would be more difficult, are very cute. (T42)

Conditions involved: "Boycott"

Unlike the public units, there was intense resistance in the private sector. At the beginning of the prohibition, a patient from the private unit was transferred to the clinical unit, because a few days before the beginning of the prohibition, he presented a severe respiratory condition. Even in the face of the risk of death, nursing technicians were heard with paternalistic discourse: Poor guy! He smoked all his life, what good is it to take [the cigarette] out now? (T18); Look how sad he is! He looks like a bird in a cage (T20); At this point in life, the greatest benefit is to remain smoking (T33).

Three days after the prohibition began, a doctor in the private ward recorded on file that he authorized a patient to smoke five cigarettes a day, justifying that he was agitated and aggressive due to abstinence. The doubts about the ethical aspects of this conduct had repercussions among Nursing professionals as detailed below.

Among nursing professionals, there was a division between those who were in favor of prohibition and those who were against. In this sense, there were professionals who complied with the medical prescription and others who refused. In those days, it was very common to hear, from those who were against, arguments similar to the ones exemplified: It's easy for you to talk because you don't smoke (E13); it's medical order. If the doctor is saying that you have to quit smoking... (T3).

The intervening conditions started to be perceived more frequently, from the second week after the beginning of the prohibition, perhaps because the professionals got used to the presence of the researcher. In informal conversations, the nursing professionals of the private unit hoped that the experience of the prohibition would not be successful.

During a shift, there was a dialogue between two nurses, who supposed that, at that moment, the researcher would not be attentive to them. In order to ensure that they would not draw attention, they used a low tone of voice: I have arranged with Dr. K. [private unit psychiatrist] that we will play dead when we see a smoking patient (E8); Me too. We are living a lie! (E2).

In order to press for an end to the ban, some Nursing professionals from the private unit, articulated to the interdisciplinary team, informed the Tobacco Commission that there were patients requesting discharge from hospital due to the ban and that there had been an increase in the number of mechanical restraints although there was no formal record of this data. The researcher did not have the same perception.

A nurse acknowledged that the resistance of private unit professionals was related to financial interests: How do you beat the professionals of the private [unit] face to face if the management itself supports them? You can't be inflexible and think you don't have the financial issue involved because the hospital is still a company for the board of directors. (E10).

Despite the success of the ban in public units, some difficulties arose in these sectors from the moment it was identified that there were employees and visitors donating cigarettes to the hospitalized people. The offer happened even without them asking and a Nursing Technician was seen offering cigarettes to a person who had never smoked.

Some residents reported that a nurse technician was smoking in hiding during their working hours and offered them cigarettes as a way of not being reported.

The boycott also came from patients in the private ward, who brought cigarettes to the hospital when they returned from weekend outings, hidden in their underwear or introduced into the anus. Even professionals in favor of the ban could not act in this situation due to the lack of ethical support to carry out this type of magazine.

Nursing professionals, from the private unit, argued that the smoking ban had brought more risks. They mentioned the risk of falling because they saw people smoking over the toilet in order to exhale the smoke through the window: That night I saw S. on top of the toilet smoking. Then she fell down and hit her head. This ban is going to kill the patients (E5).

A nurse technician put out a fire in a bathroom trash can due to improper disposal of bituca (cigarette butt). Besides the risks of falling and fire, the risk of explosion was also perceived (there were patients and employees who smoked hiding near the oxygen network) and of nicotinic intoxication (a Nurse technician distributed hidden cigarettes, including for patients using nicotine patch).

Strategies of action/interaction: "Valuing abstinence"

At the beginning of the implementation of the ban, it was common to see professionals making patients aware of the risks of smoking. As the days went by, it was noted that a group of nurses and nursing technicians adopted a different strategy, starting to value the benefits of abstinence as a compliment to the change in skin color, highlighting the lower occurrence of respiratory symptoms and decreased anxiety: N., have you noticed that you are no longer coughing the same way before? (T40); How beautiful your skin looks after you quit smoking! (T1); J., who would have thought! You' re even calmer! (E3).

The statement of the Nursing technician praising the skin change was directed to a patient of the female unit, who always showed herself vain. The strategy was so effective that she suggested to the family to use the money destined to the cigarettes to buy face cream.

It was perceived that many nurses and nursing technicians were open to dialogue. This attitude was fundamental for those patients who accepted the ban without resistance.

A strategy realized by the Nursing professionals, from the residents unit, was an educational action (lecture) about smoking. This moment was positive, because some residents were able to identify cigarette losses in their own organism (risk of leg amputation, aggravated cataract). As motivation, the action was finished with the questioning: "Cigarette prisoners?" In this activity, the Nursing professionals showed photos of people, known to them, who had stopped smoking before the ban in order to awaken the feeling of being able as much as the other.

Consequences: "Positive and negative"

During the ten months of observation of the phenomenon "Experiencing smoking ban in a psychiatric hospital", positive and negative consequences were identified.

Among the positive consequences, it was observed that some patients reported a desire to maintain abstinence, after discharge from hospital, because they discovered during hospitalization that quitting smoking was less difficult than they had imagined. Nursing professionals, who supported the prohibition, tried to motivate the others regarding the benefits of abstinence: The hardest was once. The hardest is the first two weeks without the cigarette. You will be able to go without [smoking] (T23).

Another positive consequence was the change of opinion of some professionals. Those who initially did not support the ban changed their attitude by observing the acceptance and improvement of patients. During the on-call passages, they scored the lowest occurrence of aggressiveness, the improvement of conviviality and the lowest use of cough syrups: I'm sure the hospital is spending less on syrup. (E12) It's a wonder. There are no more those fights (T55).

It was noted that the negative consequences were due to the conditions involved (resistance of private unit professionals and boycott of some groups).

The resistance of the professionals of the private unit was so expressive that, 15 days after the implementation of the ban, the Tobacco Commission defined that the patients of this unit, authorized to smoke by the medical team, would be conducted by Nursing to the external area of the hospital three times a day, at 9:30 a.m., 3:30 p.m. and 8:30 p.m.

This exception generated conflicts due to the inflexibility of patients. When it was raining or there were other priority demands in the unit, the nursing professionals could not meet the agreed smoking schedules. Professionals were humiliated and harassed by patients in these situations. Some Nursing Technicians were found to be emotionally affected, reporting a desire to leave the duty station: I'm still here because I need the job. If I could, I wouldn't come back (T39).

Conflicts between members of the interdisciplinary team occurred when nursing professionals took a stand against accompanying patients on the sidewalk to smoke and identified the risks of leakage and running over: Authorize smoking under the supervision of Nursing? I'm sorry, but we work for health and not for sickness. (T58); Do I take patients on the sidewalk to smoke? Let the doctor go! What if he runs away and gets run over? (T32); We have patients dependent on nursing care who end up without the care because nursing needs to take other patients to smoke (E4).

With some nurses and nursing technicians refusing to take patients to smoke on the sidewalk, the doctor took patients to smoke at certain times.

Due to pressure from professionals and patients, three months after the beginning of the ban, the smoking commission and the hospital administration have defined the suspension of the ban in the private unit.

The end of the ban in the private unit had repercussions in the public units. Patients who did not mention tobacco started asking for cigarettes when they found butts on the floor.

With this movement, cigarettes gradually became more and more present in the hospital, even if hidden. As a consequence, there was an increase in fights, the exchange of belongings (slippers, clothes, hygiene products, and radio) and sexual relations motivated by hidden cigarettes.



The theoretical model that was built for the phenomenon "Experiencing smoking prohibition in a psychiatric hospital" allowed the identification of different facets of the experience of nurses and nursing technicians.

The causal condition of the theoretical model presented here was Law No. 12,546/2011(4), which imposes the prohibition of tobacco smoke in collective environments. Although the law was formulated almost a decade ago, one can see the difficulty of professionals in the psychiatric hospital in accepting it. Two months before its implementation, pessimistic and unsafe nurses and nursing technicians were found.

Studies conducted in mental health services in Australia, England and Iran have shown that the conflicts professionals face in the face of smoking bans do not differ from the Brazilian experience, suggesting a supremacy of tobacco culture(1,12,30).

Approximately half of the professionals at the Iranian psychiatric hospital did not consider the ban feasible and 87% said it was not fair to impose smoking cessation during hospitalization(11). Australian mental health professionals agreed that quitting smoking should be choice not imposition(12).

The insecurity of nursing professionals can be understood by thinking that they have been, throughout history, fundamental for the perpetuation of the smoking culture, since they have always been assigned the function of controlling the behavior of patients. In this scenario, the use of cigarettes as a "bargaining chip" emerged(1-3).

Part of the professionals' insecurity was justified by the fear of increased aggressiveness of smokers, showing that they believe in the theory of self-medication of psychiatric symptoms. This theory, together with the idleness characteristic of medical-centered mental health services, has contributed to the consolidation of tobacco as part of the culture of mental health services(1-3).

Two possibilities for addressing this cultural issue would be the disclosure of scientific evidence, contrary to the theory of self-medication, and the implementation of the smoking ban concomitantly with proposals for socialization and strategies for relieving patients' stress(3).

Regardless of culture, the human being has a natural resistance to change. Pessimism and insecurity, therefore, observed before prohibition, were expected. However, resistance to change is not always negative. It can bring contributions as it promotes openness to dialogue, not allowing innovation to remain superficial(31). It is important that managers be aware of this phenomenon so that they do not give up the implementation of the legislation in the face of the first difficulties.

From the implementation of the ban, there were nursing professionals surprised with the acceptance of patients admitted to public units. Similar fact was identified in an Australian study conducted in Residential Therapeutic Services(1). When comparing the opinion of nursing professionals in psychiatric hospitals before and after smoking bans, Australian and Canadian studies identified an increase in the percentage of people in favor of intervention(32-33).

The residents, mentioned as the main argument against prohibition, were those who showed less resistance, indicating that many smoked because they were conditioned to this habit. This leads to questioning the belief that smoking is the only pleasure of psychiatric patients, as addressed in a literature review(2).

Besides the effectiveness of the ban with the residents, some patients, interned in the acute sector, were discharged from hospital willing to remain abstinent, as identified in an Australian study, which showed that 39% of patients reduced the amount of cigarettes after discharge and 9% stopped smoking definitively(32).

Among other positive results, Nursing professionals noticed an improvement of the conviviality (less aggressiveness) between the patients and an improvement of the respiratory symptoms.

The perception of the decrease in aggressiveness is similar to that found in a study conducted in a psychiatric hospital in England. When comparing before and after the ban, episodes of physical violence against professionals decreased from 58% to 20%(34).

The main difficulties were the boycotts manifested through colludes, omissions and disrespect attitudes to the norm. Similarly, an English study reported protests, by patients and professionals, with 322 notifications of hidden cigarettes. The patients admitted to hide the cigarettes in their own bodies because they were advised, by professionals, at the hospital admission(34). Other English studies reported cigarettes hidden by patients and donations by visitors(30,34).

The boycott situations observed occurred mainly in the private unit. In fact, the professionals in this sector were the most resistant to the prohibition and this is the main differential of this study, since there were no studies in the scientific literature that showed the divergence of acceptance of the prohibition when comparing public and private units.

The greater resistance of the professionals in the private unit was motivated by fear of discharge on request in the unit that concentrated most of the hospital's economic income. This leads to reflect that the main concern was with financial interests. Thus, the bioethical principle of beneficence was not preserved, because it was not thought of the good that prohibition could provide to smokers. Likewise, the boycotts disrespected the non-maleficence, because an evil was generated to the smokers from the omission of the professionals and hidden offer of cigarettes to them(3). In addition, the climate of insecurity and the dispute between professionals generated a not very productive climate in the institution.

The liberation of smoking, in the private unit, at pre-established times, had as consequence the increase of disagreements among patients due to the dispute for cigarettes and the commercialization of these products in exchange for clothes, hygiene products or sex.

Studies in Canada and England have shown that when smoking is allowed, there are more incidents due to patient behavior(33-35). English studies, conducted in psychiatric hospitalization units, showed that the conflicts occurred in the "breaks" in which smoking was allowed(35-36).

Among the successful strategies, used by Nursing professionals to deal with hospitalized smokers, an educational action for awareness, dialogue and the use of praise/encouragement were highlighted. When researching studies that address smoking interventions in the psychiatric population, the focus on biological interventions, such as nicotine patch and drugs, is observed. Counseling, educational actions, motivational interview and therapeutic communication are little mentioned(32,37-38).

This study brought important discussions about the experience of nursing professionals, facing the smoking ban, in a Brazilian psychiatric hospital.


The inclusion of 73 participants made it difficult to take a deeper approach to the phenomenon, since it was necessary to divide the time so that everyone could be contemplated in observation.

Contributions to the Nursing area

The reflections are expected to contribute to the formation of future professionals and to the continuing education of nurses who reproduce, today, in mental health services, behaviors of former asylums contrary to anti-smoking legislation. Future studies may bring more direct results by focusing on nursing interventions for tobacco control in the psychiatric population and ongoing education strategies to address the issue with nursing professionals.


Final considerations

The smoking ban in a philanthropic psychiatric hospital that attends to UHS and private hospitalizations was experienced by all the staff and sectors of this service.

A theoretical model was built around the phenomenon "Experiencing smoking prohibition in a psychiatric hospital" from which different facets of smoking prohibition were observed, such as insecurity, pessimism, resistance, boycott and acceptance by many professionals when they verified the benefits of the intervention for patients.

Before the implementation of the ban, insecurity was observed in professionals motivated by myths related to the increase of aggressiveness with nicotinic abstinence.

Differences were observed between the attitudes and behaviors of professionals in public and private detention units, showing that concern for financial interests may interfere with the success of the prohibition.

The process of implementing the smoking ban was accompanied by a series of difficulties, but it showed that the procedure is feasible. Nursing professionals who were initially against the ban began to support it due to the benefits resulting from the suppression of tobacco use in psychiatric hospitalization units.





Corresponding author:
Renata Marques de Oliveira

Received: Oct 21st 2020
Accepted: Jan 5th 2021



Author's contribution
Study concept and design: Renata Marques de Oliveira, Antonia Regina Ferreira Furegato.
Obtaining data: Renata Marques de Oliveira.
Data analysis and interpretation: Renata Marques de Oliveira, Antonia Regina Ferreira Furegato.
Statistical analysis: Renata Marques de Oliveira, Antonia Regina Ferreira Furegato.
Drafting the manuscript: Renata Marques de Oliveira, Antonia Regina Ferreira Furegato.
Critical review of the manuscript as to its relevant intellectual content: Antonia Regina Ferreira Furegato.
All authors approved the final version of the text.
Conflict of interest: the authors have declared that there is no conflict of interest.

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Corresponding author:
Renata Marques de Oliveira

Received: Oct 21st 2020
Accepted: Jan 5th 2021



Author's contribution
Study concept and design: Renata Marques de Oliveira, Antonia Regina Ferreira Furegato.
Obtaining data: Renata Marques de Oliveira.
Data analysis and interpretation: Renata Marques de Oliveira, Antonia Regina Ferreira Furegato.
Statistical analysis: Renata Marques de Oliveira, Antonia Regina Ferreira Furegato.
Drafting the manuscript: Renata Marques de Oliveira, Antonia Regina Ferreira Furegato.
Critical review of the manuscript as to its relevant intellectual content: Antonia Regina Ferreira Furegato.
All authors approved the final version of the text.
Conflict of interest: the authors have declared that there is no conflict of interest.

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