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Tob Control. Author manuscript; available in PMC 2021 Nov 1.
Published in final edited form as:
Tob Control. 2020 Nov; 29(6): 687–691.
Published online 2020 Feb 4. doi:10.1136/tobaccocontrol-2019-055153
PMCID: PMC7398822
NIHMSID: NIHMS1063623
PMID: 32019893
Luis Zavala-Arciniega, MD, MSc,1 Luz Myriam Reynales-Shigematsu, MD, MSc, PhD,1 David Levy, PhD,2 Yan Kwan Lau, MPH, PhD,3 Rafael Meza, PhD,3 Daniela Sarahí Gutierrez Torres, PhD,1 Edna Arillo-Santillan, MSC,1 Nancy L. Fleischer, PhD,3 and James F. Thrasher, PhD1,4
Author information Copyright and License information PMC Disclaimer
The publisher's final edited version of this article is available at Tob Control
Abstract
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, ad bans). This study assessed trends in the prevalence of current, daily, and nondaily smoking in Mexico before and after the implementation of key FCTC policies.
Methods
Data were analyzed from two comparable, nationally representative surveys (i.e., The National Survey of Addictions 2002, 2011, and 2016 and the Global Adult Tobacco Survey 2009 and 2015). The pooled sample comprised 100,302 persons aged 15 to 65 years old. Changes in the prevalence of current, daily, and nondaily smoking were assessed.
Results
From 2002 to 2016, the prevalence of current smoking fell 11% (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% to 2009 to 19% in 2016). The prevalence of daily smoking decreased by about 50% between 2002 to 2016 (from 13.5% to 7.0%) with most of the decrease occurring by 2009. Conversely, the prevalence of nondaily smoking increased by 35% between 2009 to 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 nondaily smokers, who now comprise more than half of current smokers in Mexico.
Keywords: Low/Middle-income country, public policy, surveillance and monitoring
INTRODUCTION
In 2004, Mexico became the first country in Latin America to ratify the World Health Organization’s Framework Convention on Tobacco Control (FCTC).1 After signing the FCTC in 2004, the tobacco excise tax increased from 58.9% of the final price in 2007 to 68.8% in 2011,2–5 leading to an increase in the real price per pack of 20 cigarettes of 44% ($MX29.9 in 2007 to $MX 42.7 in 2011), after which taxes and prices have remained stable.4,6,7 The 2008 General Law on Tobacco Control (GLTC) included other key FCTC-recommended policies.8,9 Cigarette advertising was banned through all channels except point of sale, adult-only venues (e.g., bars) and adult-oriented magazines.8 Since 2010, pictorial health warnings were required on at least 30% of the front of cigarette packages, with textual warnings on 100% of the back and one side of the pack.10 The GLTC only allows smoking in restrictive designated smoking areas (e.g., with extensive exhaust systems and physically separated from paths traversed by nonsmokers).8,11 However, the GLTC was passed the same day as the comprehensive smoke-free law in Mexico City,12 which caused some confusion around implementation in Mexico City and the rest of the country. Concerns about pre-emption remained until the Supreme Court ruled in favor of the Mexico City legislation in September 2009.12 This likely contributed to the slow, incomplete adoption and implementation of smokefree regulations in other states.13–16 Since 2011, no other national-level policies have been adopted.
Meanwhile, the tobacco industry has continued to lobby the legislature, primarily to avoid further tobacco tax increases.16 At the same time, the industry introduced innovative cigarettes with flavor capsules in the filter, whose market share has rapidly increased, as in many other Latin American countries.17–20 Furthermore, e-cigarette marketing and sales in Mexico are banned, similar to Uruguay and Brazil,21 although consumption is relatively high among adult smokers (4.7%) and youth (i.e., 12% of 8th graders).22–24 Mexico is a key country in Latin American because of its size and economic importance in the region. Therefore, the case study of Mexico’s FCTC experience in the context of the rapidly changing landscape of nicotine products may help inform policy development in other settings, particularly other low- and middle-income countries.
Longitudinal studies of Mexican smokers indicate the effectiveness of FCTC policies,7,25–28 yet the population-level effects of these policies on smoking prevalence remain understudied. This study assesses changes in the prevalence of current, daily, and nondaily smoking in Mexico from 2002 to 2016 using nationally representative surveys over the implementation period for key FCTC policies.
METHODS
Sample
Data come from two comparable nationally representative cross-sectional surveys: 2002, 2011, and 2016 administrations of the National Survey on Addictions (NSA); and the 2009 and 2015 administrations of the Global Adult Tobacco Survey (GATS). These household surveys used multi-stage sampling schemes to provide national-level estimates of tobacco use. Methodological details of each survey have been published previously.29–33 Pooling data across surveys resulted in a sample of 100,302 15 to 65 year olds (NSA 2002 n=10,418; GATS 2009 n=12,294; NSA 2011=14,298; GATS 2015=12,777; NSA 2016 n=50,515).
Measures
Current, Daily and Nondaily Smoking prevalence definition:
Current smokers reported smoking daily (daily smokers) or less often (nondaily smokers). Questions were slightly different across the surveys: Do you currently smoke tobacco on a daily basis, less than daily, or not at all? (GATS 2009, GATS 2015, NSA 2016); How often do you currently smoke? (NSA 2011); and In the past 30 days, have you smoked tobacco? (NSA 2002), with those who indicated yes being asked Approximately, how many cigarettes were smoked daily in the past 30 days? (I don’t smoke daily; 1–5; 6–10; 11–20; 20+ cigarettes). Responses to each question were recoded to indicate daily or nondaily smoking frequency. GATS did not ask whether participants had smoked 100-lifetime cigarettes, so this criterion was not used to define smoking status.
Sociodemographic Variables:
Sex (female/male), age (15–17, 18–24, 25–34, 35–44, 45–54, 55–65), highest educational attainment (primary or less, secondary, high school, university or more), and place of residence (urban/rural) were all assessed.
Analysis
Prevalence and 95% confidence intervals were estimated for current, daily, and nondaily smoking, adjusting for the sampling designs. Two-sample independent t-tests were used to determine differences in these estimates across years for key pre/post milestones in policy implementation (2002 vs. 2009; 2009 vs. 2016; 2002 vs. 2016) both overall and within sociodemographic strata Trends in prevalence are measured relative to the initial level. Statistical analyses were conducted using Stata 15.
RESULTS
Overall, the prevalence of current smoking decreased in relative terms by 11% (from 21.4% to 19.0%) between 2002 from 2016, about 13% in men (from 33.9% to 29.5% men) and about 19% in women (from 11.5% to 9.3%). Over this period, reductions were statistically significant for higher education groups (i.e., university or more=29.6% to 20.7%; high school=26.6% to 21.2% ) and among those aged 35–44 (25.4% to 18.8%) and 45–54 (23.1% to 18.1%). Overall, the relative decrease was limited to the period from 2002 to 2009 (−22.9%), after which prevalence increased by 11.5% (2009=16.5%; 2016=19%). From 2002 to 2016, daily smoking decreased by approximately 50% (2002=13.5%; 2016=6.6%). The relative change in the percentage of daily smokers was generally consistent across sex, age, level of education, and residence. By contrast, from 2009 to 2016, the prevalence of non-daily smoking increased by about a third in both men (2009=13.8%; 2016=18.4%) and women (2002=4.4%; 2016=6.0%). Increases were generally consistent across sociodemographic groups.
DISCUSSION
Our results indicate that the prevalence of current smoking and daily smoking in Mexico decreased from 2002 to 2016, which covers the period from before to after FCTC ratification and policy implementation. However, most of the declines in the prevalence of smoking (2002=21.4%; 2009=16.5%; 2016=19.0%) and daily smoking (2002=13.5%; 2009=7.7%; 2016=7.0%) had occurred by 2009. This decrease was associated with a series of tobacco tax increases between 2000 and 2009 (i.e., the ad-valorem excise tax increased from 100% of the final retail price in 2000 to 160% in 2009).4 There was one further increase in 2011 due to the application of the specific tax of $MX 0.35 per cigarette, but our results indicate no meaningful change in daily smoking after 2009 and only a slight decrease in the average of cigarettes smoked per day (CPD) among daily smokers (9.4 CPD in 2009 to 7.7 CPD in 2015).32 By contrast, the prevalence of non-daily smoking increased from 2002 to 2016 (2002=7.9%; 2009=8.8%; 2016=11.9%). Historically, Mexican smokers have a relatively light smoking pattern, with a high proportion of nondaily smokers.34,35 Our results indicate that this pattern has increased over time, offsetting the declines in daily smoking that were found before 2009. It is important to highlight that nondaily smoking is still dangerous: low cigarette consumption is associated with higher all-cause and cause-specific mortality compared to not smoking.36–37
Tobacco control policy implementation in other jurisdictions has been accompanied by downshifts in smoking frequency,38–42 and policies likely account for the similar downshift found in Mexico. In other jurisdictions, however, these shifts have been accompanied by an overall decline in smoking prevalence, which, in Mexico, appears relatively stable since 2009.
Several reasons may explain the stability in the prevalence of current smoking in Mexico, despite the downshift in smoking frequency in recent years. Tobacco industry interference has disrupted implementation of smoke-free policies,16. In particular, the GLTC allows smoking in designated areas, which may reduce compliance even in the 11 states that have adopted comprehensive smoke-free laws.12 Furthermore, the industry’s 2011 introduction and subsequent rapid growth of cigarettes with flavor capsules17,19 appear to appeal to and add perceived value (e.g., smoother, more stylish, lesser perceived harm) to smoking for smokers of all ages.17–19 While this innovation may have added value to smoking that helped offset the cost of the last tax increase in 2011, further periodic increases in taxes may be necessary, especially given the evidence for the effectiveness of earlier tax increases. Also, the relatively small health warning on the front of the pack (30%) should be increased to align with FCTC guidelines.28,43,44
E-cigarettes could also explain partly the flattening of the trends. Although e-cigarettes are banned, the prevalence of e-cigarette use is not-negligible among some subgroups of current smokers (adolescents (9%), young adults (9%), female smokers (6%), and smokers with higher socioeconomic status (7%).22–24 As in other countries, the strongest correlate of e-cigarette use is being a current smoker (4.7% current smokers vs. 0.4% nonsmokers).22 Nevertheless, it is not clear whether e-cigarette use has kept some people from quitting cigarettes,45 since e-cigarette use is relatively recent, use is relatively low among current smokers (4.7%) and former smokers (1.1%). Indeed, the introduction of e-cigarettes has been associated with a decline in youth and young adult smoking prevalence in other countries where e-cigarette use is more prevalent.46 To evaluate how e-cigarettes influence smoking patterns in Mexico, further research is needed, particularly on how lighter smokers use e-cigarettes. Indeed, psychological dependence47 and potential genetic factors may help explain low levels of consumption among populations of Mexican heritage,48 whose ancestors used tobacco for centuries before European colonization of the Americas. Our study has several limitations. The surveys we analyzed had different focus, with GATS being an international survey that only asks about tobacco, whereas the NSA gathers information not only about tobacco, but also about drug and alcohol use, and violence. Nevertheless, the NSA survey asks about tobacco before other topics. Furthermore, both surveys are nationally representative and used similar sampling designs, helping to minimize issues around their comparability. Similar conclusions are reached if we had just compared estimates from the NSA alone (i.e., 2002, 2011, 2016). Another potential limitation was our inability to analyze results by income level because income was not available in all surveys. Instead, we used education as a proxy for socioeconomic status, which is likely to be correlated with income. The differential changes we found in daily smoking over time by education (i.e., greater decreases with higher educational attainment, although the equivalent prevalence in recent years) are thus likely to also occur across income groups; however, further confirmation is waranted.32,49
Conclusions
To accelerate tobacco control, it is necessary to expand current policies and enhance compliance with existing tobacco control policies and laws in Mexico. Full implementation of FCTC policies should give priority to continued tax increases, comprehensive smoke-free laws, increasing the size of health warnings, enhancing access to cessation therapies for nondaily and daily smokers, and banning all tobacco advertising and promotion. Further strategies are also needed to address the complexity of the rapidly changing landscape of nicotine products, including prohibition of flavors, especially flavor capsules.
Table 1.
Prevalence and changes in daily smoking and non-daily smoking among Mexicans, 2002 −2016
| 2002 | 2009 | Difference (% change), 2002–2009 | 2011 | 2015 | 2016 | Difference (% change), 2009–2016 | Difference (% change), 2002–2016 | |
|---|---|---|---|---|---|---|---|---|
| CURRENT SMOKING | 21.4 | 16.5 | −4.9*** (−22.9%) | 18.3 | 17.2 | 19.0 | 2.4** (11.5%) | −2.5* (−11.2%) |
| Sex | ||||||||
| Female | 11.5 | 8.2 | −3.3** (−28.7%) | 10.0 | 8.8 | 9.3 | 1.1 (13.4%) | −2.1*−(19.2%) |
| Male | 33.9 | 25.8 | −8.1*** (−23.9%) | 27.2 | 26.2 | 29.4 | 3.6** (13.9%) | −4.5**(−13.0%) |
| DAILY SMOKING | 13.5 | 7.7 | −5.9***(−41.0%) | 7.6 | 7.8 | 7.0 | −0.7 (−9.1%) | −6.6***(48.1%) |
| Sex | ||||||||
| Female | 7.1 | 3.8 | −3.3*** (−46.4%) | 3.8 | 3.9 | 3.3 | −0.5 (−13.2%) | −3.8*** (−53.5%) |
| Male | 21.6 | 12.0 | −9.6*** (−44.4%) | 11.6 | 12.1 | 11.0 | −1.0 (−8.3%) | −10.6***(−49.1%) |
| Age | ||||||||
| 15–17 years | 5.1 | 3.5 | −1.6 (−31.4%) | 2.0 | 1.5 | 0.9 | −2.5** (−57.1%) | −4.2** (−70.6%) |
| 18–24 years | 13.6 | 8.0 | −5.6** (−41.2%) | 5.6 | 8.3 | 6.1 | −1.8 (−23.8%) | −7.5*** (−55.1%) |
| 25–34 years | 14.4 | 7.4 | −7.0*** (−48.6%) | 8.3 | 9.5 | 7.4 | 0.0 (0.0%) | −7.0*** (−48.6%) |
| 34–44 years | 16.9 | 7.3 | −9.6*** (−56.8%) | 8.5 | 6.8 | 7.6 | 0.3 (4.1%) | −9.3*** (−45.0) |
| 45–54 years | 14.9 | 10.7 | −4.2* (−28.2%) | 10.1 | 9.1 | 8.5 | −2.1 (−20.6%) | −6.4*** (−43.0%) |
| 55–65 years | 11.7 | 8.5 | −3.2 (−27.4%) | 9.5 | 8.3 | 9.1 | 0.6 (7.1%) | −2.6 (−22.2%) |
| Education | ||||||||
| Primary or less | 10.0 | 7.4 | −2.6** (−26.0%) | 8.4 | 8.1 | 7.7 | 0.3 (4.1%) | −2.3** (−2.3%) |
| Secondary | 14.2 | 8.1 | −6.1**** (−43.0%) | 7.4 | 7.7 | 6.9 | −1.2 (−14.8%) | −7.3***(−51.4%) |
| High School | 16.4 | 7.8 | −8.6*** (−52.4%) | 6.1 | 7.1 | 6.2 | −1.5 (−20.5%) | −10.2***(−62.2%) |
| University or more | 19.7 | 7.5 | −12.2*** (−62.0%) | 9.3 | 9.0 | 7.4 | −0.1 (−1.4%) | −12.3*** (−62.4%) |
| Place of residence1 | ||||||||
| Rural | 7.5 | 4.3 | −3.2*** (−42.6%) | 4.3 | 3.6 | 3.9 | −0.4 (−9.4%) | −3.6*** (−48.0%) |
| Urban | 15.5 | 8.6 | −6.9*** (−44.5%) | 8.5 | 9.0 | 7.9 | −0.7 (−8.1%) | −7.6*** (49.0%) |
| NONDAILY SMOKING | 7.9 | 8.8 | 0.9 (14.2%) | 10.6 | 9.3 | 11.9 | 3.1*** (35.2%) | 4.1*** (50.6%) |
| Sex | ||||||||
| Female | 4.3 | 4.4 | 0.1 (2.3%) | 6.1 | 4.9 | 6.0 | 1.6** (36.3%) | 1.7** (39.5%) |
| Male | 12.3 | 13.8 | 1.5 (12.2%) | 15.6 | 14.1 | 18.4 | 4.6*** (33.3%) | 6.1***(49.6%) |
| Age | ||||||||
| 15–17 years | 5.0 | 6.3 | 1.3 (26.0%) | 8.4 | 4.5 | 7.2 | 0.9 (14.2%) | 2.2* (44.0%) |
| 18–24 years | 10.1 | 12.2 | 2.1 (20.8%) | 16.3 | 13.6 | 17.1 | 4.9*** (40.1%) | 7.0*** (69.3%) |
| 25–34 years | 7.7 | 10.4 | 2.7* (35.1%) | 12.0 | 11.3 | 14.7 | 4.3*** (41.3%) | 7.0*** (91.0%) |
| 34–44 years | 8.5 | 8.6 | 0.1 (1.1%) | 10.2 | 9.9 | 11.1 | 2.5* (27.9%) | 2.6* (29.4%) |
| 45–54 years | 8.2 | 6.9 | −1.3 (−15.9%) | 7.4 | 6.5 | 9.6 | 2.7** (39.1%) | 1.4 (17.1%) |
| 54–65 years | 5.2 | 4.0 | −1.2 (−23.1%) | 5.6 | 4.7 | 6.8 | 2.8*** (31.0%) | 1.6 (30.8%) |
| Education | ||||||||
| Primary or less | 6.2 | 7.3 | 1.1 (17.7%) | 8.5 | 8.1 | 9.4 | 2.1** (28.8%) | 3.2***(51.6%) |
| Secondary | 7.8 | 9.2 | 1.4 (17.9%) | 11.5 | 10.0 | 12.0 | 2.7** (30.4%) | 4.2** (53.8%) |
| High School | 10.2 | 10.5 | 0.3 (2.9%) | 12.6 | 10.6 | 14.8 | 4.3** (41.0%) | 4.6** (45.1%) |
| University or more | 9.9 | 10.8 | 0.9 (9.1%) | 11.5 | 8.4 | 12.9 | 2.0 (19.4%) | 3.0 (30.3%) |
| Place of residence1 | ||||||||
| Rural | 5.0 | 7.0 | 2.0** (40%) | 9.2 | 6.2 | 8.9 | 1.9** (27.1%) | 3.9* (78%) |
| Urban | 8.8 | 9.4 | 0.6 (6.8%) | 11.1 | 10.1 | 12.8 | 3.4*** (36.2%) | 4.0*** (45.5%) |
Open in a separate window
*p value<0.05
**p value<0.01
***p value<0.001
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