Promoting the effective translation of the Framework Convention on Tobacco Control: A case study of challenges and opportunities for strategic communications in Mexico

Abstract

The World Health Organization Framework Convention on Tobacco Control (WHO-FCTC) aims to coordinate the implementation of best-practices tobacco control policies at a global scale. We describe features of the sociocultural and political-economic context of Mexico that pose challenges and opportunities to the effective translation of WHO-FCTC policies there. We also consider how strategic communication efforts may advance these policies by framing their arguments in ways that resonate with prevalent values, understandings, and concerns. A focus on smoke-free policy illustrates barriers to policy compliance, including how similar issues have been overcome among Latino populations in California. Overall, we aim to lay the foundation for comparative research from policy uptake to impact, so that the scientific evidence base on tobacco control policies includes examination of how context moderates this process.

Introduction

The WHO-FCTC is a multilateral treaty that came into force in 2005 and promotes a coordinated, international policy response to the global epidemic of tobacco use (WHO, 2003). Countries that have ratified the treaty signal their intention to enact a range of best-practices tobacco control policies (see Table 1), the evidence for which came primarily from high-income countries. Distinct sociocultural and political-economic histories in low- and middle-income countries may augment tobacco policy impacts or, perhaps, render them less effective (Fong, Cummings, Borland, & Hastings, 2006; Thrasher et al., 2006). Moreover, the WHO-FCTC does not provide enforcement mechanisms to ensure adherence to the policies that it promotes, even among countries that have ratified this treaty. In recognition of these issues, the present article aims to identify the sociocultural and political-economic factors that are likely to moderate the translation of WHO-FCTC policies, from uptake to impact, in the context of Mexico.

Table 1.

Some key Tobacco policies, current Mexican Law and strategies to increase policy support and compliance

FCTC Provisions:	Current Law	Strategies to increase support
Tax policies and, where appropriate, price policies, on tobacco products should be increased to reduce tobacco consumption.	2007, increase tax from 58.6% to 63.8% of price to consumer 2008, increase tax to 65.2% of price 2009, increase tax to 66.6% of price	Earmark revenue for tobacco prevention and treatment Youth are particularly price sensitive
Regulate the packaging and labeling of tobacco products to ensure appropriate product warnings are communicated to consumers, e.g., rotating health warnings on tobacco packaging that cover at least 30 percent (but ideally 50 percent or more) of the principal display areas and can include pictures or pictograms. Misleading and deceptive terms such as “light” and “mild” should be banned.	Warning labels occupy 50% of the back of cigarette packages and have three rotating messages: Smoking is a cause of cancer and emphysema Quitting smoking reduces important health risks Smoking during pregnancy increases risk of premature birth and low birthweight babies “Light” and “mild” descriptors are allowed.	Tobacco products are different from other products that people freely consume (i.e., addictive) and demand additional measures that don’t apply to other products; Build on the belief that education is a key to combating tobacco use, one which demands governmental intervention; Warning labels are a low-cost educational medium; Scientific evidence favors graphic imagery over text only, including Mexico-specific data. Graphic imagery will be particularly important when communicating with youth and illiterate populations Focus on particular components of tobacco and tobacco smoke People falsely believe that “Light” means less addictive and less harmful.
Enact comprehensive bans on tobacco advertising, promotion and sponsorship	Tobacco advertising outlawed on television and radio. Billboards not allowed within 200 meters of schools Billboards maximum of 352 meters.	Tobacco advertising, promotions and sponsorship influence vulnerable youth population Increasingly, young women smoke at the same rate as young men.
Protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places, and, where appropriate, other public places.	Smoking prohibited in hospitals and public buildings	Exposure to tobacco smoke is dangerous in any amount A high percentage of non-smokers, including children, are involuntarily exposed to tobacco smoke Non-smokers have the right to breathe clean air, particularly vulnerable people Raise awareness of policy options, to provide alibi for efforts to tell smokers not to smoke around non-smokers

Our approach is broadly organized by the heuristic of “framing,” which many social movement theorists use to understand how social and political change occurs (Benford & Snow, 2000; Keck & Sikkink, 1998). This concept draws attention to how various social actors engage in struggles over the production and maintenance of meaning around a particular issue. Framing strategies include identifying the source(s) of blame for a problem (e.g., smokers, constituents of tobacco products, the tobacco industry) and proposing a solution to resolve this problem (e.g., educational interventions, voluntary industry policies, governmental regulation of industry practices). The primary social actors who engage in public processes of framing tobacco issues through the Mexican mass media and legal domains come from the government, the medical / public health sector, the tobacco industry, and its allies (e.g., hospitality and advertising industries). Both within and across these groups, social actors may emphasize different understandings of tobacco in order to promote their interests.

To account for the success of any particular framing strategy, social movement researchers have developed the concept of “frame resonance”(Benford & Snow, 2000). This concept suggests that framing strategies are most likely to motivate social and political change if they “resonate” with dominant cultural values, symbols and ideologies. For example, tobacco industry arguments against tobacco control policies in Western countries often capitalize on ideologies of individual autonomy and the right to decide. Reframing the meanings of smoking to include its addictive nature has been critical in changing popular conceptions of tobacco use from an individual decision to a social problem worthy of stronger governmental intervention. The success of this framing strategy depended on the emergence of a scientific discourse on addiction that provided a convincing depiction of why smoking is beyond one’s control.

Efforts to change policy must often reckon with powerful entities whose political and economic interests are threatened by the proposed change. The tobacco industry is the primary antagonist to tobacco control efforts in many countries, and Mexico is no exception. We briefly describe the industry in Mexico, as well as the policies and institutional supports that have so far aimed to address the issue of tobacco use. The contextual features that we describe are brought to bear on our understanding of two separate, but related, efforts: 1) strategic communication efforts to promote the adoption of key WHO-FCTC policies (i.e., taxes, warning labels, advertising bans, smoke-free areas); and, 2) potential strategies to address challenges to compliance with smoke-free policies. Overall, this discussion aims to lay the foundation for comparative research on policy uptake, implementation and impact in the era of the WHO-FCTC.

Our description of tobacco in Mexico is based on both published and unpublished research. The unpublished data mainly come from the following sources: 1) a representative sample of 1,079 adult smokers in four major Mexican cities (ITC-Mexico) [For a description of the design and methods see (Thrasher, Hammond, Fong, & Arillo-Santillan, 2007)], who were surveyed in 2006 as part of the International Tobacco Control Policy Evaluation Project (ITC-Project)(Fong, Cummings et al., 2006); 2) 10 focus groups with adult smokers from different age groups and socioeconomic strata in Mexico City and Cuernavaca, Morelos in 2006 (FG-MexiVaca); and 3) in-depth interviews with 46 public university students in 2003 [For a description of methods see (Thrasher & Bentley, 2006)].

Mexico, the Tobacco Industry, and Tobacco Control Policy

Profile of Mexico

Mexico is the most populous Spanish-speaking country in the world, with a population of 103 million (INEGI, 2006) and approximately 10.6 million additional Mexican nationals living in the US (Passel, 2005). Mexico is an upper-middle income country ($7,310 USD per capita income in 2005); however, income inequality is high (WorldBank, 2004). The informal sector of the economy accounts for 20% to 57% of all jobs (Dalsgaard, 2000), including jobs that involve the illegal sale of contraband and single cigarettes, as well as unregulated, small-scale restaurants, bars, and other public venues that would likely elude smoke-free legislation.

The political-economic system of Mexico is in transition after over 70 years of rule by the Institutional Revolutionary Party (PRI). In 2000, democratic political representation was celebrated when the PRI lost its first presidential election to Vicente Fox, the candidate from the right-of-center National Action Party (PAN). The PAN has maintained the presidency since Fox’s term expired in 2006, and no political party holds the majority in the Mexican Congress. The historically strong concentration of power in the presidency appears to have been replaced by coalition politics.

TheTobacco Industry in Mexico

In the 1980s, the PRI began to open markets to competition from foreign-owned companies, a process which was consolidated under the 1994 North American Free Trade Agreement (NAFTA)(Camp, 2007). When the tobacco market was liberalized in 1997, Phillip Morris (PM) and British American Tobacco (BAT) entered Mexico and now control 97% of its market (R. Hammond, 1998). Until 2007, Carlos Slim—currently the richest man in the world—held a controlling stake in Cigatam, the tobacco subsidiary that PM had purchased. Slim’s wealth equals more than 5% of Mexico’s gross domestic product, and the companies he controls make up 1/3 of the Mexican stock exchange (Mehta, 2007). His political influence is clear; however, his specific influence over tobacco policy is less well-documented. He did, however, divest some of his Cigatam stock in late 2007, around the time when he announced his plans to finance philanthropic endeavors to combat poverty in Mexico and Latin America.

Tobacco companies have clearly impacted tobacco policy making in Mexico. Weeks after the Mexican Congress ratified the WHO’s Framework Convention on Tobacco Control (WHO-FCTC), BAT and PMI signed an agreement with the Mexican Ministry of Health, effectively violating the WHO-FCTC guiding principle of protecting tobacco control policies “against commercial and other vested interests of the tobacco industry” (Madrazo-Lajous & Zambrano-Porras, 2007; Samet, Wipfli, Perez-Padilla, & Yach, 2006). Partly in response to the ensuing controversy (R Tapia-Conyer, Ruíz-Gaytán, & Caso-González, 2006), the Minister of Health who took office at the end of 2006, voided the agreement instead of renewing it (Hernández-Ávila, Rodríguez-Ajenjo, García-Nadal, Ibañez-Hernández, & Martínez-Ruíz, 2007).

Over the last few years, the tobacco industry has been conducting corporate social responsibility campaigns, including those that draw attention to its efforts to develop a “safer cigarette.” The BAT and PM websites contain information on addiction and other aspects of smoking that may help them avoid the costly lawsuits that they have faced in the US and other countries. BAT and PM logos appear on the Ministry of Health’s materials and publicity for its program to keep cigarette vendors from selling to youth, a strategy that has been found to be relatively ineffective but which makes the industry look good (Glantz, 2002). Meanwhile it appears that industry promotional strategies are successfully reaching the next generation of smokers given the Global Youth Tobacco Survey (GYTS) estimate that the percentage of youth who own an object with a tobacco brand on it has increased from 16% to 21% from 2003 to 2006. In each of these years, 12% of youth reported that industry representatives had offered them free cigarettes (Valdes-Salgado, Reynales, Lazcano-Ponce, & Hernández-Avila, 2007).

Tobacco Control Policy in Mexico

A critical issue for effective translation of programs and policies concerns generating the political will to intervene. Over the past 10 years, medical and public health professionals in Mexico have made the scientific case for tobacco use as a public health problem worthy of government intervention and the Mexican government has begun to develop plans for addressing tobacco issues. Studies of the disease burden in Mexican society began to emerge in the mid 1990s, with initial reports using algorithms developed from US studies of the disease-specific attributable fraction due to smoking (Roberto Tapia-Conyer, Kuri-Morales, & Meneses-Gonzalez, 1995). However, Mexican smokers’ lower intensity of smoking raised questions about the validity of these estimates. Subsequent studies focused just on lung cancer trends (Lazcano-Ponce, Tovar-Guzman, Meneses-Gonzalez, Rascon-Pacheco, & Hernández-Ávila, 1997; Tovar-Guzmán, López-Antuñano, & Rodríguez-Salgado, 2005) and developing Mexico-specific attributable fractions to provide better estimates of the cost of tobacco use (Reynales-Shigematsu, Campuzano-Rincón et al., 2006; Reynales-Shigematsu, Rodríguez-Bolaños et al., 2006). Such economic data are now a key element of efforts to lobby for stronger tobacco policy (Sáenz de Miera-Juárez, Jiménez-Ruíz, & Reynales Shigematsu, 2007), and they have provided the rationale for further evolution of the national plan to combat tobacco use (Hernández-Ávila et al., 2007).

Tobacco legislation in Mexico is contained in either the General Health Law or the Tax Law. At the end of 2006—when the agreement between the tobacco industry and the Ministry of Health expired—the Tax Law was amended, gradually increasing the tax from 58.6% of the final price at the end of 2006 to 66.6% of the final price in 2009 (Sáenz de Miera-Juárez et al., 2007). This measure should reduce per capita consumption since previous analyses of cigarette consumption data show that Mexican smokers are sensitive to price increases (Jiménez, Sáenz de Miera, Reynales-Shigematsu, Waters, & Hernández-Avila, 2007; Vásquez-Segovia, Valdés-Salgado, & Hernández-Avila, 2005). The General Health Law establishes regulations for printed and audiovisual advertising, promotion, packaging and labeling of tobacco products, and smoke-free regulations. Policies in these domains will need to be strengthened to meet WHO-FCTC goals (see Table 1).

Since its founding in 1986, the Mexican Ministry of Health’s National Council against Addictions (CONADIC) has been the federal entity that addresses issues related to tobacco, alcohol and other drugs. CONADIC’s National Tobacco Action Plan (CONADIC, 2002) aims to lay the foundation for preventing tobacco use through educational efforts and treating tobacco-related diseases. Prevention activities include the promotion and certification of smoke-free places and educational mass media campaigns. Treatment activities include the expansion and improvement of existing stop-smoking clinics (Hernández-Ávila et al., 2007). Although a regulatory focus on tobacco products and the tobacco industry has been given less emphasis than prevention and treatment, efforts are underway to promote the range of FCTC policies.

Patterns and Meanings of Tobacco Use and Tobacco Smoke Exposure

Patterns of Smoking

Tobacco is a New World plant that in pre-Columbian times was used ritually throughout the Mesoamerican culture area (Robicsek, 1978), most of which is located within contemporary Mexico’s borders. Traces of pre-Columbian practices and beliefs still turn up in Mexico today, with tobacco oils, perfumes, teas, and hand-rolled cigars used to cure various ailments. Nevertheless, the vast majority of tobacco consumption in Mexico today is of factory-made cigarettes.

Smoking prevalence has been relatively stable from 1988 to 2002, at approximately 26% in urban areas (Campuzano, 2003; Campuzano et al., 2004). More adult males than females smoke (38% vs. 17%); however, prevalence and intensity appears to be declining in males while increasing in females (Franco-Marina, 2007; Valdés-Salgado, Micher, Hernández, Hernández, & Hernández-Avila, 2002). GYTS data indicate that smoking prevalence is equivalent among male and female 12- to 15-year-old secondary school students, increasing in both groups from 2003 to 2006, both for the prevalence of having ever smoked (51% to 57%) and having smoked in the previous 30 days (20% to 25%) (Valdes-Salgado et al., 2007).

The intensity of cigarette consumption in Mexico is relatively low. Nationally representative data from 2002 indicate that daily smokers consumed an average of 6.4 cigarettes per day and only 5.5% of daily smokers consumed 20 cigarettes or more a day (Franco-Marina, 2007). This pattern gives some reason for optimism, because less-addicted Mexican smokers could be more responsive to tobacco control policies and programs. Because light smokers still suffer higher rates of disease than non-smokers (Bjartveit & Tverdal, 2005), even small effects on cessation due to enactment and enforcement of tobacco control policies will still impact overall morbidity and mortality.

Meanings of Tobacco Use

Smokers and non-smokers alike associate smoking with health risks, particularly lung cancer (Thrasher, Hammond et al., 2007; Valdes-Salgado et al., 2007). However, the association between smoking and other health outcomes, such as cardiovascular disease, appears less widely known. Youth who believe most strongly in health risks are less likely to be smokers (Arillo-Santillán et al., 2007; Valdés-Salgado et al., 2006) and smokers who believe in health risks are more likely to intend to quit (Thrasher, Hammond et al., 2007). The perceived positive benefits of smoking, especially its tranquilizing effects, are shared with smokers in many countries (Thrasher & Bentley, 2006).

Mexicans widely associate smoking with addiction. In the ITC-Mexico survey, 83% of adult smokers agreed that tobacco was addictive and 80% saw themselves as at least somewhat addicted to smoking. Qualitative research indicates that many smokers view daily consumption of as little as one cigarette a day as an addictive behavior (Thrasher & Bentley, 2006). The meanings that Mexicans associate with the term “addiction” are somewhat ambiguous, however, as has been found for both lay (Quintero & Nichter, 1996) and professional groups in other countries (Schaffer, 1997). In focus groups, smokers found it difficult to articulate what “addiction” meant, although a few participants with higher educational background referred to a biologically anchored compulsion to consume.

The term “vicio,” or vice, is the more common Mexican idiom for describing tobacco’s hold over behavior. The religious, quasi-moralistic roots of this term tie its connotations to negative social evaluations and dangerous consequences. At the same time, vicio emphasizes the pleasurable element that promotes and accompanies the behavior, even if the behavior is ultimately destructive. The focus on pleasure and destruction comes up in a common saying on vice: El que por sus gustos muere, hasta la muerte le sabe, which literally translates as “He who dies because of pleasures (gustos), knows/tastes it until death.” The key to this saying is the double-meaning of saber, as the word for both “to taste” and “to know”. In other words, those who die because of pursuing pleasures do so knowing that death will result, savoring the pleasure along the way. Aside from this connotation of “informed choice,” the meanings of vice include control over and personal accountability for the behavior, according to other research in Mexico (Nuño-Gutierrez, Álvarez-Memegyel, González-Forteza, & Madrigal de León, 2006). Nuño-Gutierrez and colleagues found that the meanings of addiction, on the other hand, are more readily linked to “disease” and perceptions of compulsive behavior that is beyond individual control. Addiction potentially provides a stronger rationale than vice for the exculpation from responsibility, recasting the smoker as a helpless victim of biology instead of a willful pleasure seeker who knowingly chooses the manner of his demise.

Our focus group and ITC-Mexico survey data provide some support for the association between personal responsibility and smoking. Fully 85% of adult smokers agreed with the statement “Any negative health impact that smoking causes is the smokers’ fault”. This sentiment was shared across smokers who participated in focus groups (FG-MexiVaca), who almost unanimously emphasized that smoking was their decision (decisión), choice (elección), or responsibility (responsibilidad), and that nobody forced them (obligar) to smoke. This emphasis on individual accountability is somewhat surprising in the context of what many have characterized as a “collectivistic” culture that emphasizes sacrifice of personal gain for the family or the group (L Baezconde-Garbanati, 2004; Marín & VanOss Marín, 1991). However, collectivist orientations may be more apparent in other domains of behavior, and they have provided a focus for educational efforts to prevent smoking and promote cessation among Latinos by focusing on family-related impacts of smoking (L Baezconde-Garbanati, Beebe, & Perez-Stable, 2007).

Secondhand Smoke Exposure and Beliefs

Existing data indicate that secondhand smoke (SHS) exposure is widespread in Mexico. In 2006, 44% of adolescents self-reported SHS exposure in their homes and 57% reported exposure in public places (Valdes-Salgado et al., 2007). Most adult smokers who participated in the ITC-Mexico study reported that they smoke in their homes and restaurants (69% and 78%, respectively), while 41% smoke in their workplace. However, studies that monitor airborne nicotine in public places indicate that smoke-free policies, where they exist, are often violated (Barrientos-Gutiérrez, Valdés-Salgado, Reynales-Shigematsu, Navas-Acien, & Lazcano-Ponce, 2007; Navas-Acien & Valdés-Salgado, 2005). In sum, there appears to be widespread SHS exposure and faulty compliance with existing smoke-free policies.

In spite of widespread SHS exposure, the dangers posed by SHS exposure appear widely recognized. For example, GYTS data indicate that 76% of Mexican adolescents believe that SHS exposure is “definitely” dangerous, while 15% said that it was “probably” dangerous. ITC-Mexico data show a similar awareness, with 91% of adult smokers agreeing that exposure to SHS causes lung cancer in non-smokers. Focus group (FG-MexiVaca) and interview data (Thrasher & Bentley, 2006) indicated similarly high levels of awareness about SHS dangers. At the same time, however, smokers’ emphasize a countervailing emphasis on their rights to smoke. For example, ITC-Mexico surveyed adult smokers on their agreement with the following statement: If someone does not want to breathe smoke from your cigarette, they should go somewhere else. The results were mixed, with 36% agreeing, 39% disagreeing, and 23% neither agreeing nor disagreeing. Hence, although knowledge of SHS dangers appears widespread, this belief does not currently seem to constrain public smoking behavior.

Challenges and Opportunities for Promoting the Uptake of FCTC Policies

The increasing importance of coalition building across political parties and the fragmented nature of political ideologies in Mexico suggests that successful policy advocacy efforts will be ones that have cross-cutting appeal (Camp, 2007). At the same time, policy arguments should anticipate, to the extent possible, tobacco industry arguments against such policies. In this regard, efforts to quantify the economic costs of tobacco use in Mexico and the declining importance of tobacco production in the Mexican economy (Sáenz de Miera-Juárez et al., 2007) aims to appeal to “bottom line” logic of policy making in the neoliberal era. Moreover, efforts to highlight the incongruence between having ratified an international treaty and not taken steps to implement its provisions could “shame” legislators into taking action. Some have even proposed legal intervention to hold Mexico accountable to its international obligations (Madrazo-Lajous & Zambrano-Porras, 2007). In the end, the FCTC generally lacks any mechanism to hold countries accountable and leaves countries on their own to sort out issues with compliance. Civil society is charged with monitoring FCTC implementation and holding countries accountable, which is potentially problematic in countries that either do not have a strong civil society sector or whose civil society organizations are not focused on tobacco issues or policy (Sussman et al., 2007).

Data indicating that the majority of the general population supports stronger tobacco control measures could be convincing for legislators who view their role as representing the will of their constituents. ITC-Mexico indicates that 68% of adult smokers agreed that the government should do more to combat smoking. Agreement with the need for governmental intervention was also widely held across focus groups with adult smokers; however, when asked what the government should do, focus group participants had difficulty articulating anything aside from “educate people.” The tobacco industry has exploited this orientation toward education as “the answer” by promoting ineffective youth tobacco prevention programs throughout Latin America (Sebrié & Glantz, 2007). To be maximally effective, school-based educational approaches need to be implemented in the context of other tobacco control policies and programs that reinforce curriculum content (Skara & Sussman, 2003).

Tobacco control advocates can exploit the Mexican population’s apparent emphasis on educational solutions for tobacco problems, by turning it toward discussions of warning labels as an educational medium. Warning labels can be a cost-effective educational policy, particularly when the tobacco industry is obligated to bear printing costs. The scientific evidence base around warning labels increasingly supports the integration of graphic imagery into warning labels, such as imagery illustrating the health consequences of smoking (D. Hammond et al., 2007). Probably because of this emerging consensus, the 2004 tobacco industry agreement with the Ministry of Health explicitly prohibited the integration of graphic imagery into cigarette package warning labels (Samet et al., 2006). Anticipating industry arguments about the “unfairness” of such policies when applied to legal products, it will be critical tobacco policy advocates to argue for how tobacco products are addictive and deadly, unlike other products that people can freely consume. Furthermore, advocates may capitalize on Mexican data that indicates the potential impact of graphic warnings among Mexican smokers (Thrasher, Hammond et al., 2007; Thrasher, Rousu et al., 2007). Such arguments can be bolstered by recognizing that most Mexican adult smokers want more information on their cigarette packs (Thrasher, Hammond et al., 2007) and that graphic imagery is likely to overcome issues around communicating warnings to illiterate and youth populations.

Emerging concerns for democratic governance in Mexico (Camp, 2007; Middlebrook, 2004) suggest that gauging and broadcasting popular support for tobacco policies may be an important advocacy tool. Mexicans also generally favor stronger tobacco control policies, when they are asked about their level of support for specific policies. For example, the 2006 GYTS administration found that 85% of the youth surveyed supported smoking bans in public places. Another survey conducted in Tijuana found that most adults supported smoking bans in public places such as workplaces (85%), restaurants (79%), schools (93%), health centers (95%), and public transportation (90%) (Martínez-Donate et al., 2005). ITC-Mexico data among adult smokers suggest similarly high support for complete smoking bans in hospitals (89%) and public transportation (87%). Support was weaker for complete bans in workplaces in general (45%) and for the particular workplaces of restaurants (30%) and bars (12%). Furthermore, 76% of smokers said they were in favor of a complete advertising ban, although only 36% were strongly in favor of such a ban. Overall, these results suggest that the Mexican population would support many of the key policies that the WHO-FCTC promotes. In the end, however, popular support for policies may be less likely to promote legislation in nascent democratic societies such as Mexico, hence more top-down focused advocacy efforts may be critical.

Efforts to expand and/or energize public and political support for tobacco control policies will likely need to include the message that most smokers cannot control their smoking behavior—80% of adult smokers admit as much when they say that they are addicted to smoking. In so doing, smoking may be dislodged from the domain of individual responsibility to the social domain where government intervention is required to protect its citizens. This framing of tobacco use as a biological addiction has been critical in legal and regulatory successes against the tobacco industry in other countries (Brandt, 2007; Chapman & Lieberman, 2005). Internal documents from the tobacco industry show its concern regarding the discourse on addiction: “the entire matter of addiction is the most potent weapon a prosecuting attorney can have in a lung cancer/cigarette case. We can’t defend continued smoking as ‘free choice’ if the person was addicted’”(Knopick, 1980). However, such efforts would need to be undertaken carefully, since any resulting stigma borne by smokers may mobilize them against tobacco control efforts.

Mexicans’ perceptions of the chemicals that comprise cigarettes and cigarette smoke may also need to be addressed in order to promote tobacco control policy. Focus group data among adult smokers indicate very low awareness of these chemicals beyond tar and nicotine, which are the two chemicals that are listed on cigarette packages. Formative message testing among young adults in Mexico suggests that revealing surprising toxic cigarette constituents could be a useful messaging strategy for promoting policy (Thrasher, 2005). For example, once told that cigarettes contained ammonia, one 22-year-old female experimental smoker exhibited a common reaction of imagining other dangerous substances hidden in cigarettes:

There are many cigarette ingredients that aren’t specified, so we don’t really know what they put in cigarettes. And when we know what they really contain, it could be a way of taking a stand, and then trying to not consume [cigarettes].

Mass media educational and counter advertising campaigns could aim to promote such awareness. As described earlier, an inexpensive complement could involve taking advantage of warning labels as a medium for message transmission.

In other countries, tobacco prevention efforts that conjure an image of the industry as deceitful and exploitative have been used to advance tobacco control policy agendas (DHS, 1998) including those designed to prevent youth smoking (Farrelly, Davis, Haviland, Messeri, & Healton, 2005; Thrasher & Jackson, 2006). However, such efforts may be most effective in socio-political milieus where the tobacco industry is the target of other efforts that keep it in the popular imagination, such as was the case with litigation against the industry and relatively strong media advocacy efforts in the US. In Mexico, litigation against the industry is nonexistent and media advocacy efforts have been concentrated around the WHO’s annual World No Tobacco Day. Other media coverage of industry practices mainly focuses on rare, scandalous events such as the tobacco industry agreement with the Ministry of Health and the industry’s luxury trips for Mexican senators. As the Mexican media appears increasingly focused on scandal (Lawson, 2004), media advocacy efforts that highlight the controversial actions of the tobacco industry may be more likely to be reported (Chapman & Lupton, 1994). Such efforts to make the tobacco industry visible in the public imagination may be important in gaining popular support for regulating industry practices and products.

Highlighting the exploitative practices of the tobacco industry may channel other dominant orientations and sentiments among Mexicans, as well, including the relatively universal desire to protect vulnerable populations. In the context of a family-oriented society (Marín & VanOss Marín, 1991), this strategy is most obvious in the case of children. Hence, data showing industry influence over children—particularly a focus on their having promotional items and received free cigarettes from industry representatives—should be prioritized in advocacy efforts. Illustrating this influence will likely only confirm what Mexicans already believe—ITC-Mexico data indicate that 80% of adult smokers believe that advertising influences youth to smoke and 76% of these smokers support a total ban on advertising. Nevertheless, such efforts should anticipate, and be ready to counter, industry arguments regarding educational efforts in schools and their campaigns to prevent the sale of cigarettes to youth (currently conducted with the Ministry of Health), which appear relatively ineffective when implemented in weak policy environments (Glantz, 2002).

Civil society has played a critical role in tobacco policy advocacy in other countries, yet its role in tobacco policy advocacy in Mexico is unclear. The Post-Revolutionary corporatist model of governance in Mexico generally did not allow civil society engagement in policy making processes, hence top-down policy making may still dominate in some areas. Nevertheless, NGO’s have advocated for change in some policy areas, such as family planning policy, which led to dramatic declines in family size and increased educational parity among younger women. The civil society infrastructure involved in these efforts includes professionals from a variety of backgrounds; however, civil society involvement in tobacco control is almost entirely comprised of medical professionals. Medical groups are critical because they can speak with authority and garner attention for the health impacts of smoking. However, links with other sectors of civil society would expand the network of influence at both the grassroots level and among legislators. Data regarding increasing rates of smoking among young women could capture the attention of some women’s groups in Mexico. Indeed, the tobacco control movement in Mexico and other parts of Latin America could exploit the existing infrastructure of activists in the area of reproductive health and women’s rights at a time when funding for many of these groups is on the decline.

Promotion of Smoke-free Policy Compliance

Once tobacco policies are passed, additional steps will be necessary to ensure compliance, although this issue is more pertinent for some tobacco policies than others. For example, compliance with tax policy and warning label legislation is likely to depend on existing governmental-level regulatory mechanisms. The success of smoke-free legislation is of a different character, as its success appears best ensured through self-enforcement. Existing studies already indicate problems with compliance in smoke-free workplaces (Barrientos-Gutiérrez et al., 2007; Navas-Acien & Valdés-Salgado, 2005). Furthermore, as with business taxes and food preparation laws, regulatory controls associated with smoke-free legislation would not easily extend to the many eateries and other public gathering places that operate within the large informal economy in Mexico. Hence, citizens will likely have an important role to play in enforcing smoke-free policies.

Studies from other countries indicate that smoke-free policies are more likely to be successful when they are preceded by consciousness-raising efforts that not only sensitize the general population to the dangers of cigarette smoke but also provide them with arguments in favor of the law (Fong, Hyland et al., 2006). Such campaigns will likely be necessary in Mexico. Decisions about the content of campaign messages can be informed by California’s successful second hand smoke (SHS) media campaign, which includes messages targeted toward Latinos—most of whom are of Mexican origin. Messages to raise awareness about SHS harms have capitalized on concerns about children, focusing explicitly on the Mexican cultural orientation of “familismo.” Familismo captures the focus on the family—both nuclear and extended—as the central unit of social organization (Marín & VanOss Marín, 1991), whose interest and well being takes precedent over individual decisions (Chong & Baez, 2005; Unger et al., 2003). Increasesin calls to the California Smokers Helpline among Latino parents suggest the success of campaign messages that highlight parental obligations to protect children from harm and to serve as role models for their children (L. Baezconde-Garbanati & Stevens, 2005).

Another key cultural value to consider in efforts to promote compliance with smoke-free legislation involves the emphasis on harmonious social interactions, or what has been called simpatía (L Baezconde-Garbanati, 2004; Chong & Baez, 2005; Marín & VanOss Marín, 1991). Simpatía emphasizes avoidance of disagreement with others, particularly in public, and focus groups and surveys among people of Mexican heritage in California confirm their reluctance to ask people to not smoke (L Baezconde-Garbanati, Portugal, Barahona, & Carrasco, 2007). This orientation helps explain why Latinos have the highest exposure to SHS in California, even though they have the highest prevalence of home smoking bans and of smoker fathers who smoke outside the home to protect their children (L Baezconde-Garbanati, Beebe et al., 2007; L Baezconde-Garbanati, Portugal et al., 2007). However, individuals of Mexican origin also indicate that having a clear, widely understood smoke-free policy allows them to defer to the policy as beyond their control. By referring to this policy, their requests that others not smoke do not risk being seen as “antipatético” or lacking “simpatía.”

Conclusions

This article has described some key issues involved in translating to the Mexican context the effective implementation of WHO-FCTC supported tobacco control policies. In so doing, we described dominant elements of the sociocultural and political economic context which might facilitate or hinder this process. Many arguments advanced to support policies in other countries appear likely to help promote the WHO-FCTC in Mexico, including: emphasis on tobacco use as an addictive behavior that is beyond the control of smokers; the need to protect vulnerable populations, particularly children, from predatory tobacco industry practices such as advertising and promotions; the need to protect citizens from cigarette smoke dangers; the need to educate citizens about the dangers of tobacco use and exposure to tobacco smoke including the use of cigarette packs as a low-cost educational medium. Research currently under way will test specific arguments in each of these domains to determine how they can be crafted to best resonate with the values, expectations, and identity concerns of different population segments in Mexico. Similar efforts in other countries would help to determine the viability of translating communication strategies and materials across borders and sociocultural contexts. Furthermore, the present case study of Mexico should be useful in efforts to clarify which contextual features account for cross-country differences along the pathway from policy uptake to impact (Sussman et al., 2007).