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Introduction
When Mexico, a country of 123 million people, first ratified the World Health Organization’s Framework Convention on Tobacco Control (WHO FCTC) in 2004, there was international and national concern that the tobacco companies operating within the country would subvert progress towards reducing tobacco use.1,2,3,4,5,6Only a month after ratification, Mexico signed an agreement with three major tobacco companies that brought earmarked funds to cover specialized medical care provided through a new insurance program, but the agreement limited Mexico’s ability to fully implement all FCTC requirements. In December 2006, the agreement was canceled, and Mexico has since implemented a broad range of tobacco control measures along with supporting legal infrastructure to fulfill its FCTC commitments.
Here we address tobacco control in Mexico over the 14 years since FCTC ratification. We highlight progress that has been made, while noting the particular challenges faced by Mexico as it struggles to enforce new regulations, grapples with evolving tobacco industry strategies, and confronts its epidemic of non-communicable diseases (NCDs) in a population with rates of obesity and diabetes that are among the world’s highest.7
Background
Mexico has a smoking pattern that is common among Hispanic populations in the United States, Central America, and some countries in northern South America. Data from the 2015 Global Adult Tobacco Survey (GATS)8 indicate that the overall national prevalence, 16.3 % percent in adults, is comparatively low in relation to many other countries. However, this prevalence translates to 14.3 million smokers and the at-risk population for smoking comprised of adolescents and young adults is nearly 30 million.9 Overall prevalence has remained fairly stable in spite of tobacco control initiatives, dropping from 23.5% in 2002 to 20.8% in 2016 as assessed by the National Survey of Tobacco, Alcohol and Drugs Consumption (Encodat 2016 - 2017) (responding to the question: “Did you ever smoke during the last year?”).10 The two GATS surveys for Mexico showed a small, non-significant increase in the prevalence of current smoking from 15.9% in 2009 to 16.3% in 2015 (“Do you currently smoke tobacco on a daily basis, less than daily, or not at all?”).8 In 2015, daily smokers reported smoking only 8.0 and 6.8 cigarettes per day among men and women, respectively. Smoking rates are greater among the higher compared with the lower socioeconomic status group.8
With regard to other major risk factors for NCDs, Mexico’s profile is highly unfavorable (figure 1).11,12Over 70% of adults are overweight or obese;13the prevalence of diabetes diagnosed by a physician is currently at 9.7%.14 Excessive alcohol consumption is also problematic, rising quickly to the most recent figure of 19.8% of adults reporting excessive alcohol consumption in the last month.15
Reflecting the smoking profile observed in Mexico and that of other risk factors for NCDs, the burden of disease pattern in Mexico differs greatly from the United States and other high-income countries with high tobacco use prevalence and more intense smoking patterns.16 At present, obesity, unhealthy diets, low levels of physical activity and binge alcohol drinking, all make greater contributions to disease burden in Mexico than does smoking at 3%, a pattern contrasting with most high-income countries (for example, 11.8% for UK).17 As in the United States, ischemic heart disease is the leading cause of premature mortality; however, lung cancer, which is second in the United States,18 is 19th in Mexico.
Source: Institute for Health Metrics and Evaluation12
Figure 1 Burden of disease attributable to leading risk factors. Mexico, 2017
Progress on tobacco control
Substantial progress with tobacco control legislation has been made in Mexico since 2004 at the national and state levels (table I). Figure 2 shows the evolution of tobacco control policies since 2000. Significant events include the 2008 passage of the General Law for Tobacco Control (GLTC) and its complementary rules in 2009, including the placement of graphic health warnings on tobacco packaging; the progressive rise in taxes over this period and the creation of the Office for Tobacco Control (OTC) in the Ministry of Health (MoH). Beyond these Federal actions, key events have taken place at the subnational level, including the passage of a complete ban on smoking in public places in Mexico City in 2008 with a number of other states passing similar bans thereafter.
Table I Legislation on tobacco control in Mexico before and after FCTC ratification
| MPOWER | FCTC | Before FCTC ratification (2004) The Health General Law establishes the tobacco control legislations (HGL)19 | After FCTC ratification (2004) The General Law for Tobacco Control (GLTC) entered in force in August 200920 | |||
| M | Art. 20 | • The HGL encourages implementing a national surveillance system. The tobacco epidemic is monitored by national and school-based sub national surveys. | • The GLTC establishes in articles 7-13 the National program for tobacco and creates the National and subnational tobacco surveillance system using global indicators to track the epidemic and the tobacco control policies.8,10 | |||
| • The HGL prohibits sales to under age consumers and of single cigarettes. | • The GLTC in articles 14 – 17 prohibits the sale to under age people and by singles. | |||||
| P | Art. 8 | • The HGL establishes smoke-free buildings: Government buildings, hospitals and school campuses (primary, secondary and high schools, universities were not mentioned). | • The GLTC in articles 26 – 29 allows designated smoking areas in indoor places according to specific regulation requirements. | |||
| • Between 2008 – 2014, 100% smoke-free subnational legislations have been approved: Mexico City and Tabasco (2008), Morelos (2011), Veracruz, Zacatecas and Estado de Mexico (2012), Nuevo Leon and Baja California (2013), Baja California Sur and Sinaloa (2014), Oaxaca (2015). | ||||||
| • Allows designated smoking areas at indoor places. | • At municipality level: Tecate, and Cozumel (the first tobacco free Mexican beach, 2013).21 | |||||
| O | Art. 14 | • Mexican Official Standard (NOM-028-SSA2) 1999. This Mexican Official Standard defines the implementation and evaluation of prevention compaigns against addictions. No specific focus on tobacco control. | • The Mexican Official Standard NOM-028-SSA2-2009.1 for the prevention, treatment and control of addictions22 was updated and modified in 2009 and provides new guidelines for the diagnosis and treatment of nicotine addiction. | |||
| • Mexico has made progress establishing a network of over 350 specialized – care units for addictions treatment (tobacco, alcohol and illegal drugs)23 | ||||||
| • Establish a call center: Ceciadic to orient the smoker on how to quit smoking and provide brief advice.24 | ||||||
| W | Art. 11 | • The GHL establishes only text health warnings covering the 30% of the back and one lateral side. | The GLTC establishes in articles 18 – 22: | |||
| - The pictogram must be placed covering 30% of the top of front side. | ||||||
| - The text health warnings must cover 100% of the back side and 100% of one lateral side. | ||||||
| • Every year eight different pictograms by wave are released and are rotated every three months approximately. | ||||||
| • This legislation prohibits the use of terms as light, mild, smooth or others that suggest reduced damage caused by tobacco products | ||||||
| • The inside inserts or in the exterior packing are prohibited by law. | ||||||
| E | Art. 13 | • Since 2004, tobacco advertising is forbidden on radio and TV, but: | • The GLTC in the articles 23-25 | |||
| • It is allowed in billboards, points of sale, and have clearly regulatory restrictions for tobacco advertising (prohibits the appearance of young or underage smoking people, prohibits lit tobacco products, people cannot appear smoking, so the smoking scene shouldn’t appear). | - Prohibts all forms of sponsorship (i.e sponsoring music concerts) and promotional distribution (i.e free samples) | |||||
| - Promotion is allowed in magazines for adults | ||||||
| - Promotion is allowed through personal communication via postal service | ||||||
| R | Art. 6 | • A major tax increase for tobacco products, unfiltered cigarettes increased from 20.9 to 110%. | • The GLTC in articles 30- 34 establishes the previous sanitary permits and the basis for the importation of tobacco products as well as the authority of MoH to combat the illegal production and trade of illicit tobacco products. | |||
| • The IEPS Law. The tobacco taxes have been increased to 68.8% of the final price of package, which corresponds to an increase in the final price of a pack of cigarettes of 7 MXN without automatic inflation adjustment. | ||||||
Data were reviewed according to the HGL and GLTC laws
Source: Ley General de Salud and Congreso General de los Estados Unidos Mexicanos19,20
Figure 2 Timeline of tobacco control policies in Mexico, before and after Framework Convention on Tobacco Control (FCTC ratification). 2000-2017
General Law for Tobacco Control
The GLTC20 established a mandate to the MoH to coordinate government actions and to implement tobacco control policy. Among other provisions, the GLTC established the MoH’s responsibilities for the organization of mass-public education campaigns; the provision of cessation and medical services for smokers; and the descriptions of the national anti-tobacco program’s goals, objectives, and evaluation criteria. This law also gives the MoH broad authority to regulate the manufacture, distribution, advertisement, promotion and marketing of tobacco products and to combat illicit trade, counterfeit and smuggled tobacco products. The GLTC also enabled public participation by requiring that a toll-free phone number be established for reporting violations of the law. Responsibility for enforcing the GLTC resides in the federal, state and local authorities. The GLTC includes sanctions, fines, partial or total closures, or jail for non-compliers.
In relation to advertising restrictions, the GLTC remained well below the global gold standard of a comprehensive ban.21,25 The legislation permits publicity and promotion that is aimed at adults through adult magazines, personal communication by mail, or within establishments exclusively for adults.26 Regrettably, advertising and promotion at the point of sale were included but these restrictions are not enforced.27
Another major loophole in the GLTC was the failure to establish 100%-smoke-free areas, allowing designated smoking areas at work and in public places and not explicitly addressing smoking on public land and in transportation vehicles. In regulations derived from the law, the MoH amended this loophole by specifying strict protection criteria for the designated smoking areas.28 However, enforcement of these provisions by federal and state regulatory agencies proved difficult. For example, the GLTC conflicted with the existing law in Mexico City, which banned smoking in all public places.29 While Mexico’s Supreme Court ruled in favor of Mexico City’s Law, commercial venues frequently claim regulatory ambiguity as a basis for not complying with the city’s smoke-free legislation.
The Office for Tobacco Control
The Office for Tobacco Control (OTC) was created in 2008 to strengthen and coordinate government efforts in tobacco control. This Office was designated as the focal point to oversee the implementation of the WHO FCTC in Mexico, and as the secretariat for the national coordinating mechanism for tobacco control. The OTC also has the mandate to support the implementation of the GLTC and to develop the normative rules for labeling and packaging of tobacco products. The OTC has supported the implementation of mass media information campaigns for smoking prevention, helped strengthen cessation services, and monitors tobacco industry activities. This office is also responsible for evaluating national and local efforts for tobacco control.
The creation of the OTC signaled the MoH’s intention to prioritize tobacco control in the national government and establish clear lines of authority and accountability for tobacco control in the country. While the OCT represents progress, it has a relatively low budget and operates with a small staff, limiting its influence within the MoH and nationally.
Fiscal policy
In 2009, tobacco products were subject to an ad valorem rate of 160%. There was no specific tax. Total taxes, including 15% value added tax (VAT), amounted to 61.4% of retail price. After an intense lobbying effort by the MoH, some legislators, and NGO’s, in 2009 the Congress passed a specific tax that mandated a continuous tax increase for cigarettes so as to increase the price by two pesos per pack by 2013.30
Tax law was reformed in 2010 and a one-time measure to increase the specific tax by seven pesos per pack on top of the average increase of 80 cents was imposed in 2010. This new tax-legislation raised total excise taxes to 69%. The Marlboro pack price increased 36% with this change, from 28 MXN (2.30 USD) to 38 MXN (3.12 USD).31
Associated with this tax increase, reported sales of tobacco dropped by 30% and government revenue from tobacco taxes increased by 38%.30 Since 2011 taxes have not changed and, as they were not indexed to rise with inflation, the affordability of tobacco products has increased over time. We estimate that from 2011 through 2014, federal revenues from tobacco taxes were 113 796 MP (9 350 MUSD) and of these, 45 071 MP (3 549 MUSD) were generated with tax increases introduced since 2011. Unfortunately, none of these additional fiscal revenues were earmarked for tobacco control, or for prevention or treatment of tobacco-related diseases.
Challenges
Mexico has improved its regulatory framework for tobacco control and successfully increased tobacco taxes. Nonetheless, smoking prevalence has remained unchanged over the last decade and the overall goal of decreasing smoking remains elusive.
Tobacco industry
The tobacco industry remains a major barrier to achieving better tobacco control in the country. Table II provides a summary of how the tobacco industry has attempted to thwart legislative changes and tobacco-tax increases in Mexico. Tobacco companies have lobbied extensively against new tax increases and succeeded in blocking one in 2013 and in lowering taxes for hand-rolled tobacco products. Immediately following the 2011 tax increases, the industry initiated a campaign claiming that a related rise in illicit trade had lowered government tax-revenue.37 The media campaign continues to the present, with periodic and well-planned press releases from the industry that exaggerate illegal sales figures. The tobacco industry has repeatedly reported in the mass media, for example, that the magnitude of the illegal cigarette market in Mexico is around 340 million packs per year,38 representing 17% of cigarettes consumed in the country.39 Conflicting with these industry estimates, Saenz de Miera and colleagues40 analyzed national survey data (GATS, Mexico 2009 and the Encuesta Nacional de Adicciones-ENA 2011), and estimated illegal tobacco consumption in Mexico as around 0.5 and 1.4%, respectively, from the two surveys. Considering smoking patterns in Mexico, consumption of smuggled cigarettes would therefore be (in accordance with the GATS Mexico 2009) around 195 million cigarettes (9.8 million packs of cigarettes) and according to the ENA 2011 around 586 million cigarettes (29.3 million packs). Consequently, between 2009 and 2011, the increase in the illegal consumption of cigarettes represents an annual loss of revenue of about 500 million pesos (39.4 MUSD), considerably lower than the six billion pesos (472 MUSD) estimated by industry.
Table II Reaction of tobacco industry after the implementation of tobacco legislation in Mexico
| Reaction of tobacco industry | ||
| Smoke-free legislation | • E-cigarettes have been popularized among youth and smokers to be used in closed places 100% free of tobacco smoke or as strategy to quit smoking. Sales are prohibited by law, however they are available at malls. Internet and retailers promote use even by pregnant women. | |
| • There is a new strategy to administrate nicotine and promote the initiation among youth and dual use among the adults.10,32 | ||
| Health warnings | • The tobacco market was overstocked the months before legislation entered in force.30 | |
| • The package presentation was modified (forms, dimension), some packages have double cover or hard cover.33 | ||
| • Use new cigarette pack colors that create a visual effect and there is no contrast with the pictogram. | ||
| A recent tracking using TPackSS33 confirms: | ||
| Advertising, promotion and sponsorship | • There are 14’s presentations in all legal brands available in the Mexican market. | |
| • Price promotions are increasingly common in tobacco presentation of 14 units. | ||
| • Increasing advertising, promotion at point of sale. | ||
| TPackSS33 reveals: | ||
| Contents and flavors of tobacco products | • An increased menthol product in the Mexican tobacco market. | |
| • Most of the brands have a flavor capsules with “click on” presentation, including Marlboro. | ||
| • The brands' characteristics were modified, all tobacco products were renamed (i.e. light = gold).34 | ||
| Taxes | • Previous to entering in force the 2011 tobacco tax increase, the tobacco market was overstocked.30 | |
| • Immediately following the 2011 tax increases the tobacco industry claimed that government revenue was lower than expected due to the increase of illicit trade and created a mass media campaign promoting this argument.35 | ||
| • Price promotion | ||
| - Most of the brands have presentation of 14 cigarettes. Decreasing prices from 35 MXN to 30 MXN (package of 14’s). | ||
| • Strong legislative lobbying to avoid a new increase of tobacco products taxes after 2013.36 |
In addition, companies have taken advantage of the light daily consumption pattern in Mexico to successfully market 14-cigarette packs, reducing the immediate price, and undercutting the impact of the taxes on consumers. Furthermore, the concurrent commercialization of 20- and 14-cigarette packs increased the difficulty of tracking production sales and tax revenues.
GLTC implementation
Significant challenges remain in implementing the GLTC and its derived rules and regulations in order to protect employees and customers from secondhand smoke (SHS).41 Inadequate enforcement and compliance with regulations result from a lack of resources and insufficient response capacity of state agencies responsible for enforcement. The GLTC failed to require designation of financial resources for its implementation. The manager/owner of an area has the responsibility to ensure that the area remains smoke-free and the expectation was that the majority would adhere to the GLTC dispositions without needing intensive enforcement. However, currently most of the designated smoking areas do not comply with regulations and public exposure to SHS persists in Mexico. Comparing Mexico’s 2009 and 2015 GATS data, self-reported exposure to SHS showed small decrements for government buildings (17.0 to 14.1%), restaurants (29.6 to 24.6%) and bars and nightclubs (81.2 to 72.7%), while the self-reported exposure in workplace, public transportation or health care facilities remained unchanged. Other studies conducted two years after the implementation of the GLTC, that used direct observation as well as measurement of environmental nicotine levels documented low degrees of compliance with smoke-free rules and regulations.42,43,44
As in some other low- and middle-income countries, Mexico’s extensive and unregulated informal market presents a challenge to enforcement. Despite a ban on the sale of single cigarettes in the national legislation, for example, single cigarettes remain widely available throughout commercial districts, undercutting the impact of tax increases and increasing accessibility of cigarettes for adolescents. GATS 2015 showed that single cigarette sales were prevalent; 50% of participants who smoked reported purchasing single cigarettes. Reports of single cigarette purchases were more frequent from younger people and smokers in rural areas.8
Over the last 14 years, anti-smoking mass media campaigns have been conducted sporadically and their content has not been state-of-art, nor has their impact been evaluated.45 Campaigns have been challenged by tobacco control nongovernmental organizations because of their confusing messages and by feminist groups because they were perceived as sexist.46 These failed campaigns point to the need for well-designed, culturally appropriate, frequent, and intensive campaigns based on appropriate formative research. Such campaigns, considered as foundational for comprehensive tobacco control, have largely been absent in Mexico.
In addition, counseling and cessation services continue to be out of reach for most smokers who need them. The barriers are clear. Cessation services are infrequently offered by the Social Security system and cessation is not covered by the government insurance for low-income Mexicans. GATS 2015 reported a significant increase in quit attempts among adult past-year smokers compared with GATS 2009. However, use of pharmacotherapy for cessation remained low among adults who smoked in the past-year, at only 3.5%.8 A nationwide study measuring sales of nicotine patches and varenicline tablets for smoking cessation in private pharmacies47 found total sales were 8.9 million units in 2012, 6.9 million in 2013, and 7.3 million in 2014, or 24 577, 18 814 and 19 883 units sold per day, respectively. These figures contrast sharply with the national estimate of two million addicted smokers.
Cigarette sales to youth also continue. The 2011 GYTS data for Mexico show that among 13-15-year-old students, 39.3% reported buying cigarettes in stores and 65.1% of underage children who bought cigarettes in the past month before the survey were not turned away when purchasing cigarettes, even though 73.4% of students reported having observed a sign prohibiting sales to minors. Half (50.1%) of the students reported having observed the sale of single cigarettes and 19.1% reported buying single cigarettes.48,49,50
Emerging products
As elsewhere, electronic cigarettes (e-cigarettes) are an emerging problem in Mexico. GATS 2015 shows that even though they are prohibited in Mexico, use is increasing. Cross-sectional data collected in 2015 from a representative sample of junior high school students (n=10 067) found that 51% of students had heard about e-cigarettes, 20% believed e-cigarettes were less harmful than conventional cigarettes, and 10% had tried them.32This study suggests that awareness of e-cigarettes is high in a key target market and their use could increase in Mexico, in spite of the ban. The current legal situation for the commercialization of e-cigarettes in Mexico is highly ambiguous, because a recent ruling by the Mexican Supreme Court of Justice granted a suspension of the prohibition to commercialize electronic cigarettes that derived from the GLTC to one importer that complained that this law was violating its rights.51
Towards solutions
Mexico faces diverse domestic challenges that continually stress its progress in tobacco control. Although it has ratified the FCTC, which provides an invaluable framework for comprehensive action, Mexico is not moving forward to sustain national tobacco control, even as the population becomes at ever greater risk for NCDs from epidemic obesity and diabetes.
While tobacco control needs to be maintained as a goal, priorities historically have shifted with changes in government administrations. To ensure continuity, tobacco control needs to be better institutionalized within the relevant government entities at both federal and state levels. Currently, tobacco control is regarded as a MoH responsibility and there is little intersectoral commitment. For example, the MoH was successful in lobbying for tax increases; however, it failed to convince the Ministry of Treasury to earmark funds to support smoking prevention and cessation programs. Similarly, the Mexican Ministry of Economy (MMoE) has not engaged in tobacco control activities included in the FCTC. Furthermore, the MMoE lobbied in the Australian House of Representatives Parliament against Australia’s Tobacco Plain Packaging Bill. The Ministry of Agriculture in Mexico (Sagarpa) has provided weak support for programs designed to create incentives for farmers willing to switch from tobacco to alternative crops. These examples are among the many that illustrate the siloed actions of key government agencies and the barrier that the lack of intersectoral coordination poses to effective tobacco control in Mexico. A strengthened OTC, a dedicated Legislative Commission or a well-established intersectoral committee under the leadership of the MoH with cabinet level support will be more likely to succeed in deploying effective tobacco control policies. Progress in other comparable middle-income countries such as Costa Rica, Turkey and Uruguay illustrates how rapidly consumption could be reduced in Mexico with sustained intersectoral policies.52Turkey, for example, has experienced a 13% relative reduction in smoking prevalence between 2008 and 2012.53 This success is largely credited to intersectoral cooperation, led by the Prime Minister.
Future tobacco control approaches in Mexico also need to be framed in relation to the country’s spiraling NCD burden. Protecting people from tobacco smoke and banning smoking in public places, warning about the dangers of tobacco use, enforcing bans on tobacco advertising, promotion and sponsorship, and raising taxes on tobacco are identified among the best buys for NCD prevention.7 Tobacco control needs to be integrated with policies aimed to control alcohol consumption, improving diet and enhancing physical activity, in order to promote wellness and healthy lifestyles.54
Mexico can build on recent global actions to prioritize NCDs, including World Health Assembly resolutions to reduce premature deaths from cardiovascular diseases, diabetes, cancer and chronic respiratory diseases by 25% by 2025 and the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020.55 Lessons learned from other countries highlight the need for sustained, institutionalized funding to retain gains.56 Earmarked taxes represent a key potential source of funding-an option that has not yet been explored in Mexico despite its success in raising taxes and expanding taxation to sugar-sweetened beverages. Clearly there are demonstrated societal benefits when tobacco-tax revenues are directed to tobacco control, as any reduction of smoking will improve health of smokers and non-smokers and should reduce health sector costs overall. Furthermore, non-earmarked taxes may be in contradiction to the values of a government that provides publicly funded health services and is in search of universal coverage, because it fails to articulate policies to adequately protect health and contain the cost burden of public services to tax payers. It is also potentially unethical,57 as the harm that tobacco consumption inflicts to smokers that provide the tax revenue is not appropriately addressed through prevention and cessation programs. However, non-smokers may benefit from the general government spending that comes from this specific tax. There are examples from the Latin American region (Argentina, Colombia, Costa Rica, El Salvador, Guatemala and Panama) of success in earmarking portions of excise taxes.7
Conclusion
Sustaining FCTC actions in Mexico
The tobacco industry has been too successful in undermining public health efforts, probably because only short periods of experimentation are needed for tobacco dependence to develop, and in part because countries have not consistently invested the resources needed to overcome the effects of tobacco industry marketing of a highly addicting product.58
In order to better protect the Mexican population from the known and avoidable harms of tobacco use, Mexico needs to take further legislative steps to amend the GLTC to meet FCTC recommendations and successfully implement evidence-based tobacco control measures. Together, increasing cigarette taxes, enacting and enforcing regulations prohibiting smoking in public places, intense and well-designed mass media campaigns, and providing support for smoking cessation act synergistically to decrease social acceptance of smoking, while reducing smoking initiation and increasing successful quitting.59,60,61
Important actions have been taking place regarding tobacco control in Mexico; however there is clear evidence from GATS 2015 that there is a need to strengthen tobacco control activities in the country.49 Looking back to 2004, the present situation with regard to tobacco control is better than anticipated at the time. The agreement with the industry was in place only briefly and consequently did little to block progress. Mexico has moved forward with new laws and other measures, but progress has stalled. We have the tools to slow the tobacco epidemic, but need to use them forcefully, while watching carefully for the potential emergence of epidemic e-cigarette use.49
