Correlation between tobacco control policies and tobacco prevention in Mexico: a sub-national analysis

This study aims to determinate the correlation between tobacco control policies (TCP) and the prevalence of tobacco use in the 32 Mexican states during the 2016-2017 period. This is an ecological study that measured TCP by the Tobacco Control Scale (TCS) which assigns a score (0-100) based on the level of these component's implementation: price, prohibition in public spaces, expenditures of public information campaigns, publicity prohibitions, health warnings, and treatments. We analyzed the associations between the TCS scores and prevalence of tobacco use extracted from the National Survey of Drug, Alcohol and Tobacco Consumption using Spearman correlations. Prevalence of daily smokers is negatively correlated with global TCS scores for adolescents (p = 0.026). Price showed similar negative correlations with daily prevalence in adolescents (p = 0.003), adults (p = 0.040), men (p < 0.006), and women (p = 0.040). Many Mexican states need to improve on tobacco control policies, especially targeting a key population: adolescents.

The Challenges of Tobacco Fiscal Policy Implementation in Mexico From the Perspective of Key Actors

INTRODUCTION

Raising tobacco taxes is considered the most effective strategy to avoid smoking initiation and discourage its use, especially among vulnerable groups. However, few low- and middle-income countries have adopted high tobacco taxes. Raising taxes is, therefore, an opportunity to strengthen and accelerate tobacco control. The objective of this study is to analyze the barriers and facilitators to the tobacco tax increase in Mexico.

AIMS AND METHODS

Based on the Governance Analytical Framework, data were generated through 17 in-depth interviews with key intersectoral actors for fiscal policy. The interviews were transcribed and coded according to Hufty's theory of governance.

RESULTS

Robust scientific evidence, intersectoral coordination, and the presence of "champions" boosted progress in tobacco control (facilitators). The main barriers were the incomplete implementation of the World Health Organization-Framework Convention on Tobacco Control (WHO-FCTC) and MPOWER package and lack of commitment ("political will") by government decision makers and legislators, misinformation about the effects of tobacco taxes, and strong tobacco industry interference.

CONCLUSIONS

Robust evidence is necessary but not sufficient to advance the implementation of the MPOWER (WHO-FCTC) actions. To achieve tobacco tax increases and public policies that protect people from unhealthy products in general, the implementation of policies or legal frameworks against industry interference in the development of public policies is imperative.

IMPLICATIONS

By analyzing the barriers and facilitators to increasing the tobacco tax in Mexico, this study identifies two key messages: (1) The need to sensitize legislators and the general population to the problem of smoking not only through epidemiological data but also through testimonies that highlight the life experiences and adversities faced by people who smoke. (2) The need for a regulatory framework to prevent industry interference in public affairs and conflicts of interest. The same framework could be very useful for public health policies to control the consumption of ultra-processed food products or alcohol.

Latin America and the Caribbean Code Against Cancer 1st edition: Tobacco and nicotine-related products, secondhand smoke, and alcohol and cancer

Tobacco, secondhand smoke (SHS), and alcohol, all carcinogens, are leading preventable cancer risk factors in Latin America and the Caribbean (LAC). Since 2000, smoking and SHS exposure have significantly decreased in the region. Yet alcohol consumption remains high. The entry of nicotine-related products such as electronic cigarettes (e-cigs) threatens achievements made in tobacco control and chronic diseases prevention, including cancer. E-cigs use is likely associated with smoking initiation among adolescents who had never smoked and dual use with combustible tobacco products. Therefore, the LAC Code Against Cancer recommends to the public actions they can take to reduce their risk of cancer: 1. Don't smoke or use any type of tobacco. If you do, quitting is possible, with professional help if needed. Don't use e-cigarettes either, as they lead to tobacco use. 2. Make your home a smoke-free place. Respect and promote laws that ensure smoke-free spaces to protect our health. and 3. Avoid drinking alcoholic beverages. This helps prevent several types of cancer. The Code recommends to policymakers a package of cost-effective policies based on the MPOWER and SAFER to prevent cancer at the population level. It also recommends that primary care health professionals: 1. Ask all their patients and their families whether they smoke or vape, inform them about the harms of smoking and vaping, and promote tobacco and nicotine related products cessation strategies among users. 2. Inform about the harms of exposure to SHS, especially among children, and promote smoke-free environments, and 3. Prevent alcohol use by their patients and their families, use tools to assess use, intensity, and frequency, and apply brief counseling intervention to support alcohol abstinence in primary care.

Eventos de vida estresantes y su efecto en la conducta suicida en mujeres durante la pandemia por Covid-19 en México

OBJETIVO

Analizar la estructura factorial, la validez convergente y divergente de la Escala Columbia de Severidad Suicida (CSSRS) y el Cuestionario de Eventos de Vida Estresantes (EVE) y medir la asociación entre EVE y conducta suicida (CS) en mujeres mexicanas durante la pandemia por Covid-19. Material y métodos. Se usaron datos de 2 398 mujeres que participaron en un estudio multicéntrico, realizado en México entre mayo y octubre de 2021. La información se recolectó mediante un cuestionario en línea que incluyó la CSSRS y el EVE. Se hizo un análisis factorial confirmatorio para valorar el ajuste de los modelos.

RESULTADOS

El modelo final mostró asociación entre los EVE y la CS, y tuvo a la violencia como variable central. Dicho modelo presentó un ajuste adecuado (CFI = 0.950, IFI = 0.950, MFI = 0.975, RMSEA = 0.031, CI RMSEA = 0.026-0.036).

CONCLUSIONES

La pandemia por Covid-19 evidenció la necesidad de crear e implementar estrategias que promuevan el cuidado de la salud mental, reduzcan la exposición a la violencia y faciliten los procesos de duelo para prevenir la CS en mujeres mexicanas.

Consumo de tabaco y uso de cigarro electrónico en adolescentes y adultos mexicanos. Ensanut Continua 2022

OBJETIVO

Estimar la prevalencia de consumo actual y previo de tabaco y uso de cigarro electrónico en la población adolescente y adulta mexicana en 2022. Material y métodos. Se utilizó la Encuesta Nacional de Salud y Nutrición Continua 2022 para estimar la prevalencia de consumo de tabaco fumado y uso de cigarro electrónico, considerando variables sociodemográficas.

RESULTADOS

El 4.6% de los adolescentes reportó fumar actualmente y 3.7% reportó fumar en el pasado. De los adultos, 19.5% fuma actualmente y 17.8% fumó en el pasado. El consumo de tabaco fue mayor en las áreas urbanas y metropolitanas, en comparación con las rurales y se encontraron diferencias por nivel educativo y región. El 2.6% de adolescentes y 1.5% de adultos reportaron usar cigarros electrónicos. Conclusión. El tabaquismo continúa siendo un problema de salud pública en México. Es prioritario acelerar la implementación completa del Convenio Marco de la Organización Mundial de la Salud para el Control del Tabaco.

Patrones de consumo de alcohol en adolescentes y adultos mexicanos: Ensanut Continua 2022

OBJETIVO

Caracterizar los patrones de consumo (actual y excesivo) de alcohol en adolescentes y adultos mexicanos. Material y métodos. Se analizó información de la Encuesta Nacional de Salud y Nutrición Continua 2022 (Ensanut Continua 2022) representativa a nivel nacional y regional. Se estimaron las prevalencias de consumo de alcohol actual y consumo excesivo de alcohol en los últimos 12 meses y 30 días.

RESULTADOS

En adolescentes, las prevalencias de consumo actual de alcohol, excesivo en los últimos 12 meses y 30 días fueron de 20.6, 13.9 y 5.2%. En adultos, las prevalencias de consumo actual de alcohol, excesivo en los últimos 12 meses y 30 días fueron 55.5, 40.4 y 19.1%. Las prevalencias fueron mayores en hombres que en mujeres, con diferencias significativas en adultos. En adolescentes, las prevalencias fueron mayores a mayor edad, nivel socioeconómico y en aquellos sin estudios. En adultos, las prevalencias fueron mayores a menor edad, mayor nivel socioeconómico y escolaridad, y en áreas metropolitanas. Conclusión. Estos resultados muestran la necesidad de fortalecer las acciones de implementación, seguimiento y protección ofrecidas por la estrategia SAFER para prevenir y reducir el consumo nocivo de alcohol en adolescentes y adultos.

Health, economic and social burden of tobacco in Latin America and the expected gains of fully implementing taxes, plain packaging, advertising bans and smoke-free environments control measures: a modelling study

OBJECTIVE

To investigate the tobacco-attributable burden on disease, medical costs, productivity losses and informal caregiving; and to estimate the health and economic gains that can be achieved if the main tobacco control measures (raising taxes on tobacco, plain packaging, advertising bans and smoke-free environments) are fully implemented in eight countries that encompass 80% of the Latin American population.

DESIGN

Markov probabilistic microsimulation economic model of the natural history, costs and quality of life associated with the main tobacco-related diseases. Model inputs and data on labour productivity, informal caregivers' burden and interventions' effectiveness were obtained through literature review, surveys, civil registrations, vital statistics and hospital databases. Epidemiological and economic data from January to October 2020 were used to populate the model.

FINDINGS

In these eight countries, smoking is responsible each year for 351 000 deaths, 2.25 million disease events, 12.2 million healthy years of life lost, US$22.8 billion in direct medical costs, US$16.2 billion in lost productivity and US$10.8 billion in caregiver costs. These economic losses represent 1.4% of countries' aggregated gross domestic products. The full implementation and enforcement of the four strategies: taxes, plain packaging, advertising bans and smoke-free environments would avert 271 000, 78 000, 71 000 and 39 000 deaths, respectively, in the next 10 years, and result in US$63.8, US$12.3, US$11.4 and US$5.7 billions in economic gains, respectively, on top of the benefits being achieved today by the current level of implementation of these measures.

CONCLUSIONS

Smoking represents a substantial burden in Latin America. The full implementation of tobacco control measures could successfully avert deaths and disability, reduce healthcare spending and caregiver and productivity losses, likely resulting in large net economic benefits.

Colours, capsules and concept flavour names on cigarette packs appeal to youth in Mexico

BACKGROUND

Flavoured cigarettes are popular in Mexico. We examined how cigarette packaging design features used to communicate flavour influence perceptions of appeal, harm, perceived interest and pack preference among Mexico City residents.

METHODS

We conducted an experimental survey. Participants aged 13-34 years were randomly assigned to one of three conditions, viewed packs with systematically manipulated design features (colour, capsule image and flavour name) and answered questions on appeal, perceived harm, perceived interest and pack preference. Data were analysed using mixed effects and conditional logistic regression.

RESULTS

1500 adolescents and 950 adults participated. Regardless of flavour, cigarette packs with a background colour and capsule image were more appealing to adolescents (OR=13.19, 95% CI 11.53 to 15.10; OR=1.68, 95% CI 1.45 to 1.88) and adults (OR=4.18, 95% CI 3.73 to 4.69; OR=1.66, 95% CI 1.49 to 1.85) than packs without. Among adolescents, 'Tropical Burst' named packs were more appealing (OR=1.43, 95% CI 1.20 to 1.72) than packs without a flavour name and among adults, 'Arctic Air' named packs were more appealing (OR=1.20, 95% CI 1.02 to 1.14). Adolescents and adults reported a preference for trying packs that displayed a flavour name, background colour or capsule image (b=0.104, b=0.702, b=1.316, p<0.001 and b=0.126, b=0.619, b=0.775, p<0.001).

CONCLUSIONS

Colours and flavour capsule images appeal to adolescents and adults in Mexico. Mexico should consider adopting plain packaging to reduce appeal and interest.

Disparities in self-reported exposure to tobacco marketing among youth and young adults from low-socioeconomic status neighbourhoods in Mexico City

Exposure to tobacco marketing is positively associated with smoking initiation and behaviours. There is limited literature examining disparities among reported exposure in low- and middle-income countries. This study sought to fill this gap with a survey among 1427 adolescents and 889 adult smokers in Mexico City in 2020. Data were analysed using chi-square and hierarchical regression models. Two-thirds of adolescents noticed cigarette pack displays in stores. Participants from low- and mid-socioeconomic status (SES) neighbourhoods were more exposed to tobacco marketing than their counterparts through several channels. After addressing the shared variance among participants from the same household nested in neighbourhood SES level and controlling for gender, adolescent non-smokers and adult smokers who noticed pack displays were more likely to be susceptible to smoking (OR = 1.8, 95% CI 1.4-2.4) and to smoke more (OR = 1.7, 95% CI 1.21-2.47); adult smokers who noticed tobacco marketing at more places were less likely to be certain about smoking risks (OR = 0.9, 95% CI 0.8-0.9). The results suggest that the tobacco industry targets youth and individuals from low-SES neighbourhoods through several channels. Greater exposure to tobacco marketing was associated with increased susceptibility to smoking and decreased risk perception. These findings support a comprehensive ban on tobacco marketing in Mexico.

Measurement invariance of the GAD-5 Generalized Anxiety Disorder Scale in a Mexican general population sample

The primary objective of this study was to evaluate the measurement of invariance by sex, age, and educational level of an online version of the Generalized Anxiety Disorder Scale in a five-item version (GAD-5). Configural, metric, scalar, and strict invariance were evaluated using data from 79,473 respondents who answered a mental health questionnaire during the COVID-19 pandemic in Mexico. The sex variable was classified as male or female; age was categorized as minors, youth, young adults, adults, and older adults; and educational level was divided into basic, upper secondary, higher, and graduate education. To test for configural invariance, confirmatory factor models were constructed. For metric invariance, equality restrictions were established for the factor loadings between the construct and its items; for scalar invariance, equality restrictions were established between the intercepts; strict variance implied the additional restriction of the residuals. Statistical analysis was performed in R software with the lavaan package. The results show that with respect to sex, age, and educational level, configural and metric measurement invariance was confirmed (ΔCFI < 0.002; ΔRMSEA < 0.015). However, with respect to scalar and strict invariance, the results showed significant differences regarding the fit model (ΔCFI > 0.002; ΔRMSEA > 0.015). We conclude that the GAD-5 presents configural and metric invariance for sex, age, and educational level, and scalar invariance for sex and age groups. However, the scale does not demonstrate strict invariance. We discuss the implications and suggest that this result could be related to the evaluation of sociodemographic variables.

Beneficios del impuesto a los cigarros en México: análisis por sexo y quintil de ingreso

Objetivo.

Estimar los beneficios económicos y en salud, por sexo y por quintil de ingreso, del incremento de los precios de los cigarros mediante impuestos en México.

Métodos.

Con un modelo de costo-efectividad extendido (ECEA, por su sigla en inglés) se estimaron los beneficios distributivos en mujeres y hombres con un escenario de incremento del precio de los cigarros de 44% (de 56,4 pesos mexicanos [MX$] a MX$81,2 por cajetilla), como resultado de triplicar el impuesto específico actual (de MX$0,49/cigarro a MX$1,49/cigarro). El modelo se calibró con fuentes oficiales de información nacional

Resultados.

Con el incremento del impuesto de un peso por cigarro, cerca de 1,5 millones de fumadores abandonarían el consumo (351 300 mujeres y 1,1 millón de hombres). Así, se evitarían aproximadamente 630 000 muertes prematuras atribuibles al tabaco. La reducción de la carga de enfermedad permitiría ahorros para el sector salud cercanos a MX$42 800 millones y evitaría que más de 250 000 personas (entre ellas, 50 200 mujeres fumadoras) cayeran en situación de pobreza. Además, se recaudarían MX$16 200 millones adicionales por año, de los cuales el quintil más bajo aportaría menos de 3% (1% en el caso de las mujeres de menores ingresos).

Conclusiones.

La epidemia de tabaquismo tiene patrones claramente diferenciados entre mujeres y hombres y reflejan un componente de género. Si bien los beneficios del impuesto al tabaco en México tendrían magnitudes relativas al estado actual de la epidemia en cada caso, estos podrían contribuir a un objetivo más amplio de justicia social mediante la reducción de las inequidades de género.

Progress and challenges in tobacco control policies in Mexico, 2003-2017: an approach using the Tobacco Control Scale

The study aims to assess the implementation of tobacco control policies in Mexico from 2003 through 2017 using the Tobacco Control Scale (TCS). The TCS is a research tool widely used in the European region. It facilitates assessment of tobacco control policy implementation based on six cost-effective interventions: tobacco taxes, smoke-free policies, advertising bans, public spending on the information campaign, health warnings, and smoking cessation treatment, reflecting results in a total score between 0 and 100. From 2003 through 2017, Mexico's total score improved from 24/100 to 55/100, with substantial progress in raising tobacco taxes, 11 subnational smoke-free laws, and with placement on cigarette packs of large health warnings with pictograms. Progress in tobacco control policies implemented in this period corresponds with a decrease in smoking prevalence across Mexico. This tool is useful for monitoring tobacco policy implementation in low- and middle-income countries and be used for advocacy purposes to enforce and improve tobacco control legislation.

The fallacy of science is science: the impact of conflict of interest in vaping articles

Objective.

To explore the association between reporting conflict of interest (COI) and having a positive outcome toward vaping in scientific articles.

Methods.

A cross-sectional study that analyzed a sample of 697 articles published between 2017 and 2020 regarding vaping. Information on the reporting of COI, type of COI (no conflict, conflict with the tobacco industry, pharmaceutical industry, or other), and country of publication were collected. To explore the association between reporting COI and having a positive result for vaping, two logistic regression models were fitted, both adjusted by country of publication.

Results.

From 88 articles that reported COI, 23 reported COI with the tobacco industry, 44 with the pharmaceutical industry, and 21 reported another type of conflict. We found that reporting any type of COI increased by 4.7 times the odds (OR 4.70; 95% CI [2.89, 7.65]) of having a positive result for vaping. Additionally, compared to other countries, manuscripts published in England had 2 times higher odds (OR 2.40; 95% CI [1.16, 4.98]) of reporting a positive result for vaping. Reporting COI with the tobacco and pharmaceutical industries increased the odds of favorable results by 29 times (OR 29.95; 95% CI [9.84, 90.98]) and 2 times (OR 2.87; 95% CI [1.45, 5.69]), respectively.

Conclusions.

In scientific articles, reporting COI and having positive results for vaping are highly associated. COI should be considered and caution should be exercised when using data for policy-making.

Practice, barriers, and facilitators of healthcare providers in smoking cessation in Mexico

OBJECTIVE

To assess the clinical practice, barriers, and facilitators in promoting smoking cessation in primary healthcare clinics in Mexico City.

MATERIALS AND METHODS

A mixed method design was used. Surveys (n = 70) and semi-structured interviews (n = 9) were conducted with health personnel involved in smoking cessation clinics.

RESULTS

Quantitative data revealed that physicians were more likely than nurses to 1) ask patients if they smoke (57.9% vs 34.5%, p = .057), 2) ask patients if they are interested in quitting smoking (65.7% vs 26.9%, p = .003), 3) provide advice to quit smoking (54.3% vs 29.2%, p = .056), and 4) assess whether pharmacotherapy is needed (21.9% vs 10%, p = .285). Qualitative data showed that nurses were more likely than physicians to report lack of resources to refer patients to smoking cessation services, lack of pharmacotherapy availability, and lack of provider training in smoking cessation. Reported barriers include lack of motivation among patients, lack of time for assessment, long appointment wait times, and lack of training. Reported facilitators include existence of smoking cessation programmes and pharmacotherapy at no cost to the patient, and having a multidisciplinary team.

CONCLUSIONS

Due to numerous barriers, smoking cessation interventions are partially implemented in primary care clinics in Mexico City. A restructuring of services is necessary, and nurses should be given a more prominent role.

Cambios en los patrones de consumo de alcohol y tabaco antes y durante la pandemia de Covid-19. Ensanut 2018 y 2020

Objetivo. Examinar los cambios en la prevalencia de con­sumo de alcohol y tabaco antes y durante la pandemia de Covid-19 en México. Material y métodos. Se utilizaron datos de las Ensanut 2018 y 2020 para adolescentes y adultos y se obtuvieron prevalencias de consumo actual y excesivo de alcohol y de fumadores actuales y exfumadores. Resul­tados. El consumo de alcohol en mujeres incrementó de 33.5% en 2018 a 42.5% en 2020, mientras que en los hom­bres no hubo cambios significativos. En el mismo periodo, la prevalencia de consumo excesivo de alcohol disminuyó de 11.1 a 5.5% en mujeres y de 36.7 a 18.3% en hombres. La prevalencia de mujeres fumadoras disminuyó de 9.5 a 7.2%. En adolescentes, no se encontraron diferencias significativas en la prevalencia de consumo de alcohol y tabaco. Conclusión. El consumo de alcohol y tabaco continúa siendo elevado en adolescentes y adultos mexicanos. Urge la implementación de las medidas SAFER y MPOWER para abatir sinérgicamente estas epidemias.

Tobacco Taxes as the Unsung Hero: Impact of a Tax Increase on Advancing Sustainable Development in Colombia

Objective: Tobacco taxes are a well-established cost-effective policy to prevent Noncommunicable Diseases. This paper evaluates the expected effects of a tobacco tax increase on the Sustainable Development Goals in Colombia. Methods: We use microsimulation to build an artificial society that mimics the observed characteristics of Colombia's population, and from there we simulate the behavioral response to a tax increase of COP$4,750 (an increase that has been discussed by policy makers and legislators) and the subsequent effects in all SDGs. Results: The tobacco tax hike reduces the number of smokers (from 4.51 to 3.45 MM smokers) and smoking intensity, resulting in a drop in the number of cigarettes smoked in Colombia (from 332.3 to 215.5 MM of 20-stick packs). Such reduction is expected to decrease premature mortality, healthcare costs, poverty and people facing catastrophic expenditure on healthcare, to increase health, income and gender equity, and to strengthen domestic resource mobilization even in the presence of illicit cigarettes. Conclusion: Tobacco taxes are an effective intervention for public health and a powerful instrument to advance on the 2030 Sustainable Development Agenda. Relevance: A comprehensive analysis of the impact of tobacco taxes on all areas of Sustainable Development is missing in the empirical literature. Such perspective is needed to break the barriers for further tobacco tax increases by gathering wider societal support, especially from stakeholders and key decision makers from development areas other than health. SDG Nr: SDG3 (health), SDG 1 (no poverty), SDG 4 (education), SDG 5 (gender equality), SDG6 (water), SDG10 (inequality), SDG12 (responsible production and consumption), SDG17 (partnerships).

Achievements, challenges, priorities and needs to address the current tobacco epidemic in Latin America

Most Latin American countries have signed and ratified the FCTC, although implementation has been uneven. Countries across the region were relatively quick to adopt mandatory smoke-free workplace policies, but regional progress in other areas has been slower. In taxation, for example, Uruguay and Brazil have made considerable progress while Paraguay and Bolivia have relatively weak policies. More recently, the region is grappling with challenges regulating novel tobacco and nicotine products. Market share for flavor capsule cigarettes in Latin America is the highest in the world; electronic cigarettes and heated tobacco products are, for the most part, dissimilarly regulated; and uptake of these emerging products by adolescents and young adults is on the rise. In examining the needs and challenges in the region, we conclude that the adoption of a strong regulatory framework based on the FCTC and its Protocols is needed to accelerate a positive public health impact. In particular, countries in the region need more consistent progress in implementing FCTC provisions while strengthening regulation of flavored tobacco products, electronic cigarettes and heated tobacco products. Failing to do so threatens to undermine the progress Latin America has made in tobacco use prevention and control.

The distributional effects of tobacco tax increases across regions in Mexico: an extended cost-effectiveness analysis

BACKGROUND

Several studies have shown the beneficial effects of tobacco fiscal policy, but distributional effects have been less examined, especially at the subnational level. The objective of this study is to analyse the distributional effects of a one-peso tobacco tax increase (roughly equivalent to tripling the current excise tax) on health, poverty, and financial outcomes at the subnational level in Mexico.

METHODS

We employ an extended cost-effectiveness analysis that estimates life-years gained, smoking attributable deaths averted, treatment costs averted, number of persons avoiding poverty and catastrophic health expenditures, and additional tax revenues by income group across five regions.

RESULTS

With the one-peso tax increase (or 44% price increase), about 1.5 million smokers would quit smoking across the five regions, resulting in nearly 630 thousand premature deaths averted and 12.6 million life years gained. The bottom income quintile would gain three times more life years gains than the top quintile (ratio 3:1), and the largest gain for the most deprived would occur in the South (ratio 19:1), the region with the highest poverty incidence. Costs averted and additional tax revenues would reach 44.6 and 16.2 billion pesos, respectively. Moreover, 251 thousand individuals would avoid falling into poverty, including 53.2 in the lowest income quintile, and 563.9 thousand would avoid catastrophic health expenditures. Overall, the bottom income group would obtain 26% of the life years gained and 24% of the cost averted, while only paying 3% of the additional tax revenue.

CONCLUSIONS

The most significant gains from a substantial cigarette price increase would be for the poorest 20%, especially in the South, the most impoverished region of Mexico. Therefore, tobacco taxes are an opportunity for governments to advance in equity and towards the achievement of sustainable development goals on non-communicable diseases.

"It's all About the Colors:" How do Mexico City Youth Perceive Cigarette Pack Design

Objectives: Cigarette packs are relevant to branding strategies, designed to appeal to specific groups. There is little research on how pack features increase product appeal among key constituents such as youth in low- and middle-income countries.

Methods: We conducted 10 focus group discussions (FGDs) with adolescents and 5 FGDs with young adult smokers in Mexico City, separated by age, gender, smoking, and socioeconomic status. Participants separated 23 cigarette packs into “appealing” and “unappealing” groups, and were asked to explain their decisions, describing the features that supported their views. FGDs were video-recorded, transcribed in Spanish, translated into English, and subjected to thematic analysis.

Results: Pack groupings did not differ greatly across FGDs; bold, contrasting colors and elements communicating flavor and promotion increased cigarette pack appeal and desire to try. Participants perceived packs with these features to be used by and designed for youth, like themselves.

Conclusion: Our findings reinforce the importance of packaging design in attracting new consumers and maintaining current ones. Mexico should consider stronger tobacco advertising policies that include packaging color and depiction of flavor to reduce product appeal.

Factores asociados con el consumo excesivo de alcohol: Encuesta Nacional de Salud y Nutrición 2020 sobre Covid-19

Objetivo. Conocer la magnitud del consumo excesivo de alcohol (CEA) y su asociación con los factores individuales, familiares y sociales entre agosto y noviembre de 2020 en México. Material y métodos. Con base en los datos de la Encuesta Nacional de Salud y Nutrición 2020 sobre Covid-19, se analizaron 8 595 adultos mayores de 20 años. Se estimaron modelos de regresión logística estratificados por sexo y se obtuvieron razones de momios (RM) con intervalos de confianza al 95% (IC95%). Resultados. El CEA fue de 40.43%; hombres 56.49% y mujeres 25.70%. Los principales factores asociados fueron ser hombre (RM=3.66; IC95%: 3.22,4.12), edad de 20 a 29 años (RM=3.65; IC95%: 2.89,4.63), salir a trabajar durante la pandemia (RM=1.56; IC95%: 1.33,1.81) y tener dos o más escolares en el hogar (RM=1.20; IC95%: 1.03,1.39). Conclusiones. En México, el patrón de CEA es prevalente; por su naturaleza de riesgo y su amplia distribución poblacional, es prioritario implementar intervenciones preventivas individuales y de salud pública.

[Prevalence and psychological factors associated withsuicidal behavior in adolescents. Ensanut 2018-19]

OBJECTIVE

To estimate the prevalence of suicidal behavior and its association with psychological factors in Mexican adolescents.

MATERIALS AND METHODS

Cross-sectional study based on the National Survey of Health and Nutrition (Ensanut 2018-19), with a sample of 17 995 adolescents (10-19 years). Adjusted logistic regression models were estimated, obtaining Odds Ratio (OR) and 95% confidence intervals (95%CI).

RESULTS

Prevalence of suicidal ideation and suicide attempt in Mexico were 5.1 and 3.9%, respectively; the high-est prevalence was in Guanajuato (ideation: 9.0%, attempt: 7.8%). Associated factors. Suicidal ideation: tobacco (OR= 2.26; 95%CI: 1.62-3.16), alcohol (OR= 2.12; 95%CI: 1.65-2.73), depressive symptoms (OR= 6.04; 95%CI: 4.71-7.73), sexual abuse (OR= 6.57; 95%CI: 4.57-9.45). Suicidal attempt: tobacco (OR= 2.17; 95%CI: 1.49-3.15), alcohol (OR= 2.32; 95%CI:1.77-3.03), depressive symptoms (OR= 6.47; 95% CI: 4.91-8.51), sexual abuse (OR= 6.76; 95%CI: 4.60-9.96).

CONCLUSIONS

By increasing suicidal behavior in Mexican adolescents, it is necessary to implement preventive public policies that articulate mental health, addiction and violence programs.

Encodat 2016: Violencia de pareja y uso de tabaco, alcohol y drogas. Nuevos retos para la salud mental

Objetivo. Estimar la prevalencia de violencia de pareja por sexo y su asociación con el uso de tabaco, alcohol y drogas en México. Material y métodos. Estudio transversal de la Encuesta Nacional de Consumo de Drogas, Alcohol y Tabaco 2016, que incluyó a 34 861 personas de 12 a 65 años. Se esti-maron modelos de regresión logística para obtener razones de momios (RM) e intervalos de confianza al 95% (IC95%). Resultados. La prevalencia de violencia de pareja fue de 15.14%; 18.16% en mujeres y 11.89% en hombres. Factores asociados: consumo excesivo de alcohol (RM: 1.64; IC95% 1.38-1.96), consumo de tabaco (RM:1.71;IC95% 1.42-2.07), consumo de medicamentos psicotrópicos sin receta (RM: 3.72; IC95% 1.76-7.88) y consumo de marihuana (RM: 3.06; IC95%: 1.58-5.91). Conclusiones. Los resultados apoyan la necesidad de implementar intervenciones multisectoriales, fortalecer competencias psicosociales para lograr la mejora de la calidad y acceso a los servicios de salud mental y adic-ciones en México.

Implications of household tobacco and alcohol use on child health and women's welfare in six low and middle-income countries: An analysis from a gender perspective

OBJECTIVE

To study the implications of household tobacco and alcohol use on child health and women's welfare using a gender lens in Ethiopia, India, Indonesia, Jordan, Kenya, and Nigeria with varied geographical and cultural characteristics in the pattern of tobacco and alcohol use.

METHODS

We identified child health and women's welfare outcomes that may be impacted by tobacco and alcohol use, with a focus on the crowding-out effects on household resource allocation. For child health indicators, we focussed on engagement in preventative care, nutrition, and responses to acute illness. For women, we focused on access to resources for health-seeking and intimate partner violence (IPV). We used logistic regression to determine the association between household gender tobacco and/or alcohol use on child health and women's welfare, using data from six nationally-representative Demographic and Health Surveys, with each having a sample size of 5000-30,000 households and conducted after 2010.

RESULTS

Children in households where men and women use tobacco are significantly less likely to receive the full schedule of Diphtheria-Pertussis-Tetanus (DPT) vaccine in India, Indonesia, and Jordan (Odds ratio or OR; ORIndia = 0.67, p < 0.001; ORIndonesia = 0.55, p = 0.028; ORJordan = 0.45, p = 0.048), and all basic vaccinations as well as receive appropriate treatment for fever/diarrhoea in India and Indonesia (all basic vaccinations: ORIndia = 0.78, p < 0.001, ORIndonesia = 0.43, p = 0.009; treatment for fever/diarrhoea: ORIndia = 0.65, p < 0.001; ORIndonesia = 0.50, p = 0.038). In most countries, women are significantly more likely to experience IPV when their husband/partner uses tobacco and/or alcohol.

CONCLUSIONS

Across a diverse set of countries with varied cultural characteristics which affect the uptake and use of tobacco and alcohol, tobacco and alcohol use are associated with crowding-out of acute and preventative health-related behaviours and crowding-in of harmful behaviours. This has significant implications for tobacco and alcohol control programmes, and positions tobacco and alcohol control as central to human capital initiatives and in achieving health for all.

The Mexico SimSmoke tobacco control policy model: Development of a simulation model of daily and nondaily cigarette smoking

BACKGROUND

Nondaily smoking has been on the rise, especially in Mexico. While Mexico has strengthened its tobacco control policies, their effects on nondaily smokers have gone largely unexamined. We developed a simulation model to estimate the impact of tobacco control policies on daily and nondaily smoking in Mexico.

METHODS

A previously validated Mexico SimSmoke model that estimated overall trends in smoking prevalence from 2002 through 2013 was extended to 2018 and adapted to distinguish daily and nondaily smoking prevalence. The model was then validated using data from Mexican surveys through 2016. To gauge the potential effects of policies, we compared the trends in smoking under current policies with trends from policies kept at their 2002 levels.

RESULTS

Between 2002 and 2016, Mexico SimSmoke underestimated the reduction in male and female daily smoking rates. For nondaily smoking, SimSmoke predicted a decline among both males and females, while survey rates showed increasing rates in both genders, primarily among ages 15-44. Of the total reduction in smoking rates predicted by the model by 2018, tax policies account for more than 55%, followed by health warnings, cessation treatment, smoke-free air laws, and tobacco control spending.

CONCLUSIONS

Although Mexico SimSmoke did not successfully explain trends in daily and nondaily smoking, it helps to identify gaps in surveillance and policy evaluation for nondaily smokers. Future research should consider appropriate measures of nondaily smoking prevalence, trajectories between daily and nondaily smoking, and the separate impact of tobacco control policies on each group.

Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Ending the global tobacco epidemic is a defining challenge in global health. Timely and comprehensive estimates of the prevalence of smoking tobacco use and attributable disease burden are needed to guide tobacco control efforts nationally and globally.

METHODS

We estimated the prevalence of smoking tobacco use and attributable disease burden for 204 countries and territories, by age and sex, from 1990 to 2019 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study. We modelled multiple smoking-related indicators from 3625 nationally representative surveys. We completed systematic reviews and did Bayesian meta-regressions for 36 causally linked health outcomes to estimate non-linear dose-response risk curves for current and former smokers. We used a direct estimation approach to estimate attributable burden, providing more comprehensive estimates of the health effects of smoking than previously available.

FINDINGS

Globally in 2019, 1·14 billion (95% uncertainty interval 1·13-1·16) individuals were current smokers, who consumed 7·41 trillion (7·11-7·74) cigarette-equivalents of tobacco in 2019. Although prevalence of smoking had decreased significantly since 1990 among both males (27·5% [26·5-28·5] reduction) and females (37·7% [35·4-39·9] reduction) aged 15 years and older, population growth has led to a significant increase in the total number of smokers from 0·99 billion (0·98-1·00) in 1990. Globally in 2019, smoking tobacco use accounted for 7·69 million (7·16-8·20) deaths and 200 million (185-214) disability-adjusted life-years, and was the leading risk factor for death among males (20·2% [19·3-21·1] of male deaths). 6·68 million [86·9%] of 7·69 million deaths attributable to smoking tobacco use were among current smokers.

INTERPRETATION

In the absence of intervention, the annual toll of 7·69 million deaths and 200 million disability-adjusted life-years attributable to smoking will increase over the coming decades. Substantial progress in reducing the prevalence of smoking tobacco use has been observed in countries from all regions and at all stages of development, but a large implementation gap remains for tobacco control. Countries have a clear and urgent opportunity to pass strong, evidence-based policies to accelerate reductions in the prevalence of smoking and reap massive health benefits for their citizens.

FUNDING

Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Genetic Variants in Smoking-Related Genes in Two Smoking Cessation Programs: A Cross-Sectional Study

Previous studies have identified variants in genes encoding proteins associated with the degree of addiction, smoking onset, and cessation. We aimed to describe thirty-one single nucleotide polymorphisms (SNPs) in seven candidate genomic regions spanning six genes associated with tobacco-smoking in a cross-sectional study from two different interventions for quitting smoking: (1) thirty-eight smokers were recruited via multimedia to participate in e-Decídete! program (e-Dec) and (2) ninety-four attended an institutional smoking cessation program on-site. SNPs genotyping was done by real-time PCR using TaqMan probes. The analysis of alleles and genotypes was carried out using the EpiInfo v7. on-site subjects had more years smoking and tobacco index than e-Dec smokers (p < 0.05, both); in CYP2A6 we found differences in the rs28399433 (p < 0.01), the e-Dec group had a higher frequency of TT genotype (0.78 vs. 0.35), and TG genotype frequency was higher in the on-site group (0.63 vs. 0.18), same as GG genotype (0.03 vs. 0.02). Moreover, three SNPs in NRXN1, two in CHRNA3, and two in CHRNA5 had differences in genotype frequencies (p < 0.01). Cigarettes per day were different (p < 0.05) in the metabolizer classification by CYP2A6 alleles. In conclusion, subjects attending a mobile smoking cessation intervention smoked fewer cigarettes per day, by fewer years, and by fewer cumulative pack-years. There were differences in the genotype frequencies of SNPs in genes related to nicotine metabolism and nicotine dependence. Slow metabolizers smoked more cigarettes per day than intermediate and normal metabolizers.

Gender-related beliefs and attitudes about tobacco use and smoking cessation in Mexico

BACKGROUND

While overall trends in tobacco use among men are declining, tobacco use continues to rise significantly among women in developing countries. This study aimed to explore the gender-related beliefs and attitudes about tobacco use and smoking cessation in Mexico, one of the top five Latin America countries with the highest prevalence of tobacco consumption.

MATERIALS AND METHODS

This study was conducted using an explanatory qualitative methods design. Semi-structured interviews were conducted with 14 adults smokers (8 women & 6 men) who visited primary healthcare clinics in Mexico City. Two researchers independently coded the interviews and applied the final codes upon consensus. Inter-rater reliability was assessed for four groups of codewords (92% agreement), based on an ecological model on socio-cultural factors.

FINDINGS

Initiation to smoking in women begins out of curiosity, and in men by imitation. Also, women start using tobacco at an older age compared to men. During maintenance of smoking, women report experiencing loneliness and anxiety about multiple responsibilities, e.g. women reveal that they feel guilty when they smoke due to their maternal role as caregivers. Additionally, some women report that smoking is a symbol of freedom, recalling the media messages associated with promoting tobacco products. Among men, the results show that they smoke for pleasure and to socialize, and consider that women smoke to imitate men and feel powerful. Regarding cessation, women are ambivalent about quitting smoking or not, and men mention not needing professional support. For organizational barriers, women mention the cost of treatment and men, the distance to clinics.

CONCLUSION

Smoking cessation interventions should be proposed from an approach that involves changes in social norms, seeking a more equitable relationship between men and women. Therefore, there must be broad engagement from different sectors and not just at the health sector level.

[Prevalence, proportion and correlates of flavorcapsule cigarette use in Mexico: results fromthe Ensanut 2018-19]

OBJECTIVE

To estimate the prevalence of flavor capsule cigarette, use among Mexicans who are 10 years and older, to determine the proportion of smokers who use flavor capsules, and to characterize the sociodemographic correlates of flavor capsule cigarette use.

MATERIALS AND METHODS

Data came from the National Health and Nutrition Survey 2018-19. The prevalence and proportion of flavor capsule cigarette use were estimated by sex, age, education, and wealth. Poisson models were used to evaluate sociodemographic factors as-sociated with flavor capsule cigarette use.

RESULTS

Among Mexicans,the prevalence of flavor capsule cigarettes use was 6.6%, which is 43% of all smokers. Women, adolescents, and young adults were more likely than other groups to use flavor capsule cigarettes.

CONCLUSIONS

Mexicans report a high prevalence of flavor capsule cigarette use. Banning cigarettes with flavors may reduce the appeal of smoking, particularly for youth and women.

Smoke-Free Air Interventions in Seven Latin American Countries: Health and Financial Impact to Inform Evidence-Based Policy Implementation

INTRODUCTION

Disease burden due to tobacco smoking in Latin America remains very high. The objective of this study was to evaluate the potential impact of implementing smoke-free air interventions on health and cost outcomes in Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, using a mathematical model.

AIMS AND METHODS

We built a probabilistic Monte Carlo microsimulation model, considering natural history, direct health system costs, and quality of life impairment associated with main tobacco-related diseases. We followed individuals in hypothetical cohorts and calculated health outcomes on an annual basis to obtain aggregated 10-year population health outcomes (deaths and events) and costs. To populate the model, we completed an overview and systematic review of the literature. Also, we calibrated the model comparing the predicted disease-specific mortality rates with those coming from local national statistics.

RESULTS

With current policies, for the next 10 years, a total of 137 121 deaths and 917 210 events could be averted, adding 3.84 million years of healthy life and saving USD 9.2 billion in these seven countries. If countries fully implemented smoke-free air strategies, it would be possible to avert nearly 180 000 premature deaths and 1.2 million events, adding 5 million healthy years of life and saving USD 13.1 billion in direct healthcare.

CONCLUSIONS

Implementing the smoke-free air strategy would substantially reduce deaths, diseases, and health care costs attributed to smoking. Latin American countries should not delay the full implementation of this strategy.

IMPLICATIONS

Tobacco smoking is the single most preventable and premature mortality cause in the world. The Framework Convention on Tobacco Control, supported by the World Health Organization, introduced a package of evidence-based measures for tobacco control. This study adds quality evidence on the potential health effects and savings of implementing smoke-free air policies in countries representing almost 80% of the Latin America and the Caribbean population.

Cross-sectional survey for assessing cancer care providers' characteristics and attitudes on smoking cessation in Colombia and Mexico

OBJECTIVE

Cancer care providers' (CCPs) attitudes towards smoking cessation are influenced by many factors, including their smoking status and knowledge. Our objective was to assess CCPs' characteristics, tobacco use and smoking cessation practices in two Latin American cancer centres.

DESIGN

Cross-sectional survey.

SETTINGS

Two urban cancer centres located in Colombia and Mexico.

PARTICIPANTS

A total of 238 CCPs.

MEASURES

Online survey consisted of 28 close-ended questions adapted from the 2012 International Association for the Study of Lung Cancer survey and the Global Adult Tobacco Survey developed by the WHO. Means, frequencies and proportions were reported for each country. Factors associated to providing of smoking cessation treatment or referral at initial visit were evaluated using logistic regression.

RESULTS

Current smoking prevalence was 10.5% and 12.3% among Colombian and Mexican CCPs, respectively. Around three quarters of the Colombian (86.4%) and Mexican CCPs (66.1%) considered to have inadequate training in smoking cessation. Approximately two-thirds of Colombian (67.5%) and Mexican CCPs (63.9%) reported always or most of the time asking patients about tobacco use during the initial visit. In Colombia and Mexico, the most relevant barriers for providing cessation services were (1) difficulties for motivating patients with cancer, (2) patient resistance in quitting smoking, (3) lack of local resources or referral centres for smoking cessation and (4) lack of training in smoking cessation. CCPs appointed at Instituto Nacional de Cancerología were less likely to provide cessation treatment or referral to their patients if they had less than 50% of their time devoted to patient care and were former or current smokers. The regression model for Instituto de Cancerología did not retain statistically significant variables.

CONCLUSION

Our findings highlight an urgent need for assisting Latin American CCPs in their quitting efforts as well as expanding formal smoking cessation training specifically tailored to these professionals for improving patients' cancer prognosis and quality of life.

Smoking trends in Mexico, 2002-2016: before and after the ratification of the WHO's Framework Convention on Tobacco Control

INTRODUCTION

Mexico was the first Latin American country to ratify the Framework Convention on Tobacco Control (FCTC) in 2004, after which it implemented some key FCTC policies (e.g., taxes, smoke-free, pictorial warnings and ad bans). This study assessed trends in the prevalence of current, daily and non-daily smoking in Mexico before and after the implementation of key FCTC policies.

METHODS

Data were analysed from two comparable, nationally representative surveys (i.e., the National Survey on Addictions 2002, 2011 and 2016, and the Global Adult Tobacco Survey 2009 and 2015). The pooled sample comprised 100 302 persons aged 15-65 years. Changes in the prevalence of current, daily and non-daily smoking were assessed.

RESULTS

From 2002 to 2016, the prevalence of current smoking fell 11% in relative terms (from 21.5% to 19.0%). The decrease was registered between 2002 and 2009, and after that, a slight increase was observed (from 16.5% in 2009 to 19% in 2016). The prevalence of daily smoking decreased by about 50% between 2002 and 2016 (from 13.5% to 7.0%) with most of the decrease occurring by 2009. Conversely, the prevalence of non-daily smoking increased by 35% between 2009 and 2016 (from 8.8% to 11.9%).

CONCLUSIONS

Full implementation of the FCTC is necessary to further reduce smoking. Specific interventions may be needed to target non-daily smokers, who now comprise more than half of current smokers in Mexico.

[Correlates of secondhand smoke exposure in public and private settings in Mexico. Encodat 2016.]

OBJECTIVE

To assess the correlates of secondhand smoke exposure (SHS) in public and private settings.

MATERIALS AND METHODS

Data came from the 2016 National Survey of Drug, Alcohol and Tobacco use. Multilevel Poisson models were conducted to evaluate factors associated with SHS.

RESULTS

Having a higher education, being male and being a young adult were associated with higher SHS in bars and restaurants. Men had greater SHS at work, while women and adolescents had greater exposure at home. Adults older than 45 years had higher SHS on public transportation compared to adolescents between 12-17 years old.

CONCLUSIONS

Exposure to SHS remains high and affects the population differentially. To reduce SHS, it is necessary to apply Article 8 of the Framework Convention on Tobacco Control.

Assessing cigarette packaging and labelling policy effects on early adolescents: results from a discrete choice experiment

INTRODUCTION

Cigarette packaging is a primary channel for tobacco advertising, particularly in countries where traditional channels are restricted. The current study evaluated the independent and interactive effects of cigarette packaging and health warning label (HWL) characteristics on perceived appeal of cigarette brands for early adolescents in Mexico.

METHODS

A discrete choice experiment (DCE) was conducted with early adolescents, aged 12-14 years (n=4251). The DCE involved a 3×25 design with six attributes: brand (Marlboro, Pall Mall, Camel), tobacco flavour (regular, menthol), flavour capsule (none, 1 or 2 capsules), presence of descriptive terms, branding (vs plain packaging), HWL size (30%, 75%) and HWL content (emphysema vs mouth cancer). Participants viewed eight sets of three cigarette packs and selected a pack in each set that: (1) is most/least attractive, (2) they are most/least interested in trying or (3) is most/least harmful, with a no difference option.

RESULTS

Participants perceived packs as less attractive, less interesting to try and more harmful if they had plain packaging or had larger HWLs, with the effect being most pronounced when plain packaging is combined with larger HWLs. For attractiveness, plain packaging had the biggest influence on choice (43%), followed by HWL size (19%). Interest in trying was most influenced by brand name (34%), followed by plain packaging (29%). Perceived harm was most influenced by brand name (30%), followed by HWL size (29%).

CONCLUSION

Increasing the size of HWLs and implementing plain packaging appear to reduce the appeal of cigarettes to early adolescents. Countries should adopt these policies to minimise the impact of tobacco marketing.

Trends in cigarette brand preference among Mexican smokers: the rise of Pall Mall

OBJECTIVE

To analyse trends in cigarette brand preference among Mexican smokers during the implementation period of key WHO's Framework Convention on Tobacco Control recommendations.

METHODS

Data came from two nationally representative, comparable surveys, namely the Global Adult Tobacco Survey 2009 and 2015 and the National Survey on Addictions 2011 and 2016. Logistic models were used to estimate the adjusted prevalence of each brand purchased, as well as individual correlates of purchasing the single brand with a large growth over the study period. Multiple linear regressions were also employed to analyse cigarette prices across brands.

RESULTS

Six brand families accounted for about 90% of the cigarette market, with Marlboro clearly dominating all brands at 54%-61%. Only the share of Pall Mall brand, however, registered a rapid increase over the period-from 1% in 2009 to 14% in 2016. Women and younger smokers (15-24 years) were more likely to prefer Pall Mall over other brands. While the typical price segmentation between international (premium) brands and national (discount) brands was observed, the price of Pall Mall is within the range of the latter. Importantly, most varieties of this brand include flavour capsule varieties (FCVs).

CONCLUSIONS

This study suggests that the strong campaign of brand migration, the pricing strategy and the aggressive introduction of FCVs expanded Pall Mall in the Mexican cigarette market. Therefore, better control policies of cigarette contents and taxes that reduce price differentials across brands should be encouraged to promote public health.

Enhancing nicotine replacement therapy usage and adherence through a mobile intervention: Secondary data analysis of a single-arm feasibility study in Mexico

INSTRODUCTION

Nicotine Replacement Therapy (NRT) is an effective treatment for smoking cessation. However, medication usage and adherence remain a challenge that contributes to low smoking cessation rates. In Mexico, 8 in 10 smokers are interested in quitting. However, only 6% of Mexican smokers use medication for smoking cessation. The objective of this study is to assess the feasibility and acceptability of a mobile health (mHealth) intervention to increase usage and adherence of NRT in Mexico.

METHODS

The study involves a secondary data analysis. Forty smokers were recruited to participate in a single-arm pilot study. Participants received an mHealth intervention that uses tablet-based decision support software to drive a 12-week text messaging smoking cessation program and pharmacotherapy support. The intervention allows two-way interactivity text messaging between participants and a tobacco treatment specialist. NRT was offered to participants in accordance with practice guidelines in Mexico. Outcome measures included utilization of NRT, text messaging interactivity with the program, and biochemically verified abstinence at 12 weeks.

RESULTS

Thirty smokers met the criteria for use of NRT. Average age of participants was 38.1 years (SD=10.7), and they were primarily male (56.7%) with at least an undergraduate degree (60%). All participants requested NRT at baseline, and 60% requested a refill at week 4. During the 12-week intervention period, participants sent 620 messages to the program (mean=20.6, SD=18.34) of which 79 messages (12.7%) were related to NRT. Three themes were identified in the messages related to NRT: enthusiasm, instructions, and side effects. At 12 weeks, 40% of participants reported using NRT <75% of the days. Finally, 30% of participants (9/30) were biochemically verified abstinent using intention-to-treat analysis at 12 weeks.

CONCLUSIONS

An mHealth intervention appears to offer a promising strategy to increase usage and adherence of NRT in Mexico. Additional testing as a formal randomized clinical trial appears warranted.

Measuring the illicit cigarette market in Mexico: a cross validation of two methodologies

Objective

To compare two methods to estimate the magnitude of the illicit cigarette trade in Mexico and to contrast these results with tobacco industry figures.

Methods

We used two survey methods: a smoker survey and a discarded pack survey. Data were collected in eight major cities in Mexico between November and December 2017. A total of 2396 face-to-face interviews to adult smokers were conducted and 8204 discarded packs were collected. To determine whether cigarette packs were intended for the Mexican market, we analysed pack features required by Mexican regulations and self-reported brands of the last purchase. Standard statistical tests to compare proportions were employed. Correlates of illicit cigarette use were also analysed.

Results

The share of cigarettes not intended for the Mexican market was 8.8% based on the analysis of discarded packs and 7.6% based on the survey of smokers, that is, the difference was small and only borderline significant overall (p=0.055). Also, both results were lower than those presented by the tobacco industry (16.6%). However, differences across methods were statistically significant for various cities.

Conclusion

Our results suggest that the optimal practice for the study of illicit trade is to cross validate estimates using both the smoker survey and the littered pack survey. If resources are limited, however, our findings indicate that either method could be used because both yield similar overall results, as longs as the potential biases are considered. Also, consistent with findings from other studies, our results suggest that the tobacco industry exaggerates the scope of illicit cigarette trade.

Tobacco control in Mexico: a decade of progress and challenges

Mexico was the first country in the Americas to sign and ratify the World Health Organization's (WHO) Framework Convention on Tobacco Control (FCTC) in 2004. More than a decade later, it is appropriate to evaluate legislative and regulatory progress and the associated challenges; and also, to propose a roadmap to prioritize the problems to be addressed to achieve long-term sustainable solutions. Mexico has made substantial progress in tobacco control. However, regulations have been only weakly enforced. The tobacco industry continues to interfere with full implementation of the WHO-FCTC. As a result, tobacco consumption remains stable at about 17.6%, with a trend upwards among vulnerable groups: adolescents, women and low-income groups. The growing popularity of new tobacco products (electronic cigarettes or e-cigs) among young Mexicans is an increasing challenge. Our review reveals the need to implement all provisions of the WHO-FCTC in its full extent, and that laws and regulations will not be effective in decreasing the tobacco epidemic unless they are strictly enforced.

E-cigarette use and its association with smoking reduction and cessation intentions among Mexican smokers

OBJECTIVE

Evaluate the patterns of e-cigarette use andtheir association with smoking behavior.

MATERIALS AND METHODS

We analyzed data from a population-based representative cohort of adult smokers who participated in the International Tobacco Control Policy Evaluation Surveys in Mexico. The analytic sample (n=760) was restricted to participants who were followed up from wave 6 (2012) to wave 7 (2014-2015). GEE models regressed e-cigarette use at follow-up and changes in cigarettes per day (CPD) between waves, on baseline sociodemographic variables, smoking status (daily, non-daily, quit), e-cigarette trial, and quit intentions.

RESULTS

Smokers who were younger, had a higher income, and had tried e-cigarettes at baseline were more likely to be current e-cigarette users at follow-up. Ecigarette use at follow-up was not associated with a change in CPD over time.

CONCLUSIONS

E-cigarette use does not appear to have promoted smoking cessation or reduction in this sample of Mexican smokers.

[Social factors associated with tobacco and alcohol consumption in Mexican adolescents from populations under 100 000 inhabitants.]

OBJECTIVE

To evaluate the social factors associated with tobacco and alcohol consumption in Mexican adolescents from populations under 100 000 inhabitants.

MATERIALS AND METHODS

Cross-sectional study based on the National Health and Nutrition Survey (Ensanut100k). It included adolescents between 10-19 years. Adjusted logistic regression models were estimated, obtaining Odds Ratio (OR) and confidence intervals 95% (CI95%).

RESULTS

Prevalence of tobacco consumption in the last month was 5.5% (10-14 years= 1.0%, 15-19 years= 11.2%); alcohol consumption 9.3%, and excessive alcohol consumption, 2.8%. Associated factors: smoking, sex (male, OR=6.00, CI95%: 2.89-12.46), age (OR=1.73, CI95%: 1.46-2.04), remunerated work (OR=2.87, CI95%: 1.12-7.34), affiliation to health services (OR=0.26, CI95%: 0.08-0.82); alcohol consumption, (male, OR=5.11, CI95%: 2.38-11.00), age (OR=1.70, CI95%: 1.51-1.92), remunerated work (OR=2.51, CI95%: 1.01-6.24).

CONCLUSIONS

To reduce the consumption of alcohol and tobacco in adolescents, comprehensive prevention strategies must be implemented that consider the individual and social context.

[Evaluation of physical and psychological dependence in Mexican adult smokers, Encodat 2016.]

OBJECTIVE

To evaluate the physical and psychological dependence to tobacco of Mexican smokers and its association with physical, psychological and social factors.

MATERIALS AND METHODS

The 2016 National Alcohol and Tobacco Drug Consumption Survey (n=7 331) was analyzed using the Fagerström nicotine physical dependence scale (FTND) and the short scale of psychological dependence on tobacco (TAPDSc). Bivariate analyzes and generalized ordinal logistic regressions were performed to evaluate the associated factors.

RESULTS

82.3% of daily smokers and 98.8% of occasional smokers reported mild physical dependence, while 47.9 and 37.9% respectively reported moderate psychological dependence. The age of initiation of tobacco use, drug use, high alcohol consumption and high emotional distress were associated with high levels of psychological dependence in all smokers.

CONCLUSIONS

The exclusive use of FTND does not allow to adequately evaluate Mexican smokers. The physical and psychological dependence on tobacco should be assessed with independent and validated scales in this population.

Measuring Smoking Prevalence in a Middle Income Nation: An Examination of the 100 Cigarettes Lifetime Screen

Introduction

Public health surveillance of smoking prevalence is essential in gauging the magnitude of the problem, identifying groups most affected, and evaluating polices. However, little attention has focused on how prevalence is measured, particularly in low-and middle-income countries, where smoking patterns may not mirror those in high-income countries and where the burden of tobacco use is rapidly growing. Mexico provides a unique opportunity to gauge how the questions used to define established smokers can affect prevalence estimates. This study assesses how using the 100-cigarette lifetime question to define smoking status affects estimates of smoking prevalence.

Methods

We consider data from four nationally representative surveys in Mexico, from 2002 to 2016. These surveys ask about current smoking even for adults who do not indicate having smoked 100 cigarettes in their lifetime. We compare estimates of daily and nondaily smoking prevalence by age and gender with and without the 100-cigarette screen.

Results

The relative difference in prevalence estimates with and without the screen was greater for nondaily than daily smoking and for females than males. The difference was especially pronounced for nondaily smokers aged 15-24, where there was a 50%-75% relative difference in estimates, albeit smaller discrepancies (20-49% relative difference) were also found among older smokers. In recent years, the relative difference was greatest at lower levels of educational attainment.

Conclusions

With the growth in nondaily smoking, using the 100-cigarettes screen to define smoking status can have important implications regarding size of smoking population. Further research is warranted in other countries.

[Current and emerging issues in tobacco prevention and control]

OBJECTIVE

To review the implementation of the WHO Framework Convention onTobacco Control in theAmericas, describe two national case studies and analyze the evidence on electronic cigarettes from a public health perspective.

MATERIALS AND METHODS

Revision of the tobacco control legislation and the scientific evidence regarding electronic cigarettes.

RESULTS

Implementation of tobacco control policies is not homogeneous, with important advances in smoke-free environments, pictorial health warnings, and epidemiological surveillance, but challenges that remain for the implementation of a total ban of tobacco advertising, increases in tobacco taxes, and tobacco cessation programs. Tobacco industry interference is one of the main obstacles for advancing and novel products create uncertainty about their regulation.

CONCLUSIONS

There is a need for political will for a comprehensive implementation of the Convention, with evidence-based decisions to confront challenges and to defend the achievements from tobacco industry interference.

Enhancing smoking cessation in Mexico using an e-Health tool in primary healthcare

OBJECTIVE

To evaluate an e-Health tool designed to enhance smoking cessation in Mexico in primary healthcare.

MATERIALS AND METHODS

Smokers 18 years of age and older were recruited in the waiting room of two primary healthcare clinics in Mexico City. Participants used an eHealth smoking cessation tool that included smoking-related assessments, education on pharmacotherapy, and motivational videos. A follow-up assessment was conducted at 12 weeks week on smoking status. Logistic regression models were performed to identify factors associated with smoking cessation or consumption reduction.

RESULTS

A total of 132 smokers were enrolled in the study. At follow-up, 23.5% of participants self-reported smoking cessation. Among those who did not quit smoking, 65.0% decreased the number of cigarettes. Factors associated significantly with smoking cessation were: being a non-daily smoker, being interested in quitting smoking, having low level of physical dependence, and participating in cessation treatment.

CONCLUSIONS

The e-Health tool produced a high rate of smoking cessation. Better outcomes are obtained when this tool is used with conventional cessation programs.

A Mobile Smoking Cessation Intervention for Mexico (Vive sin Tabaco... ¡Decídete!): Single-Arm Pilot Study

Background

Of the 14.3 million Mexicans who smoke, only a minority take advantage of evidence-based approaches to smoking cessation. Mobile health interventions have the potential to increase the reach of effective cessation interventions in Mexico.

Objective

This study aimed to assess the feasibility and acceptability of an innovative, personalized, and interactive smoking cessation mobile intervention developed for Mexican smokers.

Methods

We recruited 40 Mexican smokers to participate in Vive sin Tabaco... ¡Decídete!, a smoking cessation program that uses a tablet-based decision support software to drive a 12-week text messaging smoking cessation program and pharmacotherapy support. Outcome measures included participant text messaging interactivity with the program, participant satisfaction, and 12-week verified abstinence using urinary cotinine testing or exhaled carbon monoxide.

Results

Average age of the participants was 36 years (SD 10.7), and they were primarily male (65%, 26/40) with at least an undergraduate degree (62%, 25/40). Most participants (95%, 38/40) smoked daily and were interested in quitting in the next 7 days. As an indicator of participant interactivity, participants sent an average of 21 text messages during the 12-week intervention (SD 17.62). Of the 843 messages that participants sent to the program, only 96 messages (11.3%, 96/843) used keywords. At 12 weeks, 40% (16/40) of participants were biochemically verified (87%, 35/40, follow-up rate). The majority of participants (85%, 30/35) reported being very satisfied or extremely satisfied with the program.

Conclusions

The Vive sin Tabaco... ¡Decídete! smoking cessation mobile intervention was accepted by participants, generated high satisfaction and high text messaging interactivity, and resulted in a noteworthy cessation rate at the end of treatment. This intervention is a promising strategy for smoking cessation in Mexico. Additional testing as a formal randomized clinical trial appears warranted.