Special articles, II: Advances in the diagnosis and treatment of cancer • Salud pública Méx 58 (2) Mar-Apr 2016 •

Tobacco and cancer: epidemiology and new perspectives of prevention and monitoring in Mexico

Tabaquismo: epidemiología y nuevas perspectivas de prevención y vigilancia en México

Luz Myriam Reynales-Shigematsu About the author

Abstract

Tobacco smoking is causal risk factor of at least 16 different types of cancer. In Mexico, smoking causes 6 035 premature deaths annually of lung cancer and 5 154 from other types. Additionally, 16 408 new smoking- attributable cases are diagnosed, causing high costs in the Mexican health sector.

The WHO Framework Convention on Tobacco Control is the global strategy to reduce morbidity and mortality caused by this risk factor. Four more cost-effective strategies to ensure the population benefit are: i) increase tobacco taxes, ii) create 100% smoke-free environments, iii) warn damage through health warnings with pictograms and iv) total ban of advertising and promotion. Mexico is call upon to implement with determination this comprehensive strategy to reduce cancer mortality and assuring the health population.

Keywords:
tobacco use; cancer / prevention & control; public health policy

Resumen

El tabaquismo es factor de riesgo causal de por lo menos 16 diferentes tipos de cáncer. En México, el tabaquismo causa anualmente 6 035 muertes prematuras por cáncer de pulmón y 5 154 por otros tipos de cáncer. Adicionalmente, se diagnostican 16 408 casos nuevos atribuibles a tabaco, provocando altos costos en el sector salud mexicano. El Convenio Marco de la Organización Mundial de la Salud para el Control del Tabaco (CMCT-OMS) es la estrategia global para reducir la morbimortalidad causada por este factor de riesgo. Son cuatro las estrategias más costoefectivas para garantizar el beneficio poblacional: i) incrementar los impuestos al tabaco, ii) crear ambientes 100% libres de humo de tabaco, iii) advertir los daños a través de advertencias sanitarias con pictogramas y iv) prohibición total de la publicidad. México está llamado a implementar, de manera decidida, esta estrategia integral para reducir la mortalidad por cáncer.

Palabras clave:
uso de tabaco; cáncer / prevención y control; políticas públicas de salud

Tobacco consumption and exposure to tobacco smoke continue to be the primary preventable risk factors for cancer worldwide

Tobacco consumption and the burden of disease from cancer

In 2012, there were a total of 56 million deaths worldwide, 38 million of which were caused by noncommunicable diseases (NCDs). These deaths were primarily caused by cardiovascular diseases (17.5 million, 46.2%), cancer (8.2 million, 21.7%), respiratory diseases (4.0 million, 10.7%), and diabetes (1.5 million, 4%). Altogether, these four diseases were responsible for 82% of all NCD-related deaths.11. WHO. Global status report on noncommunicable diseases 2014. [internet document] [accessed on 2015 April]. Available at: http://www.who.int/nmh/publications/ncd-status-report-2014/en/.
http://www.who.int/nmh/publications/ncd-...

Cancers are among the leading causes of morbidity and mortality worldwide. The global incidence of cancer for 2012 was 14 million new cases, and a substantial increase to 22 million is estimated for 2030. Lung, breast, stomach, and colorectal cancer, as a whole, were responsible for half of all cancer deaths worldwide. Unfortunately, two-thirds of these deaths occurred in low- and middle-income countries.11. WHO. Global status report on noncommunicable diseases 2014. [internet document] [accessed on 2015 April]. Available at: http://www.who.int/nmh/publications/ncd-status-report-2014/en/.
http://www.who.int/nmh/publications/ncd-...

2. Cancer Incidence and Mortality Worlwide: Lyon, International Agency for Research on Cancer, 2011(IARC CancerBase No 10).-33. Jemal A, Vineis P, Bray F, Torre L, Forman D (Eds). The cancer Atlas. 2nd edition. Atlanta GA: American Cancer Society; 2014. [Internet Document] [Accesed on 2015 April] Available at: http://canceratlas.cancer.org/?_ga=1.94994329.465927236.1429465038.
http://canceratlas.cancer.org/?_ga=1.949...

The principal risk factors that cause cancer are environmental contaminants, tobacco consumption, poor diet, obesity, occupational carcinogens, infections, and reproductive habits, the majority of which are preventable.33. Jemal A, Vineis P, Bray F, Torre L, Forman D (Eds). The cancer Atlas. 2nd edition. Atlanta GA: American Cancer Society; 2014. [Internet Document] [Accesed on 2015 April] Available at: http://canceratlas.cancer.org/?_ga=1.94994329.465927236.1429465038.
http://canceratlas.cancer.org/?_ga=1.949... There is sufficient scientific evidence that all forms of tobacco are carcinogenic.44. WHO - IARC. IARC monographs on the evaluation of carcinogenic risks to humans; 83. Tobacco smoke and involuntary smoking [online monograph]. Lyon, France, 2004 [accessed on 2015 April]. Available at: http://monographs.iarc.fr/ENG/Monographs/vol83/mono83.pdf.
http://monographs.iarc.fr/ENG/Monographs... Tobacco use is a causal risk factor of at least 16 different types of cancer. Compared with nonsmokers, smokers are at 15 to 30 times greater risk of developing lung cancer,55. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General [online monograph]. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010 [accessed on 2015 April]. Available at: http://www.ncbi.nlm.nih.gov/books/NBK53017/.
http://www.ncbi.nlm.nih.gov/books/NBK530... ,66. U.S. Department of Health and Human Services. The Health Consequences of Smoking -50 Years of Progress: A Report of the Surgeon General [online monograph]. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. [accessed on 2015 April]. Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/index.html#fullreport.
http://www.surgeongeneral.gov/library/re... and tobacco use is responsible for 70% of all deaths from lung cancer and 20% of all cancer deaths that occur annually at the population level.33. Jemal A, Vineis P, Bray F, Torre L, Forman D (Eds). The cancer Atlas. 2nd edition. Atlanta GA: American Cancer Society; 2014. [Internet Document] [Accesed on 2015 April] Available at: http://canceratlas.cancer.org/?_ga=1.94994329.465927236.1429465038.
http://canceratlas.cancer.org/?_ga=1.949...

Nonsmokers exposed to second-hand tobacco smoke have a higher risk of developing lung cancer and other types of cancer.44. WHO - IARC. IARC monographs on the evaluation of carcinogenic risks to humans; 83. Tobacco smoke and involuntary smoking [online monograph]. Lyon, France, 2004 [accessed on 2015 April]. Available at: http://monographs.iarc.fr/ENG/Monographs/vol83/mono83.pdf.
http://monographs.iarc.fr/ENG/Monographs...

5. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General [online monograph]. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010 [accessed on 2015 April]. Available at: http://www.ncbi.nlm.nih.gov/books/NBK53017/.
http://www.ncbi.nlm.nih.gov/books/NBK530... -66. U.S. Department of Health and Human Services. The Health Consequences of Smoking -50 Years of Progress: A Report of the Surgeon General [online monograph]. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. [accessed on 2015 April]. Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/index.html#fullreport.
http://www.surgeongeneral.gov/library/re... It is estimated that this exposure is responsible for at least 21400 deaths from lung cancer annually worldwide.33. Jemal A, Vineis P, Bray F, Torre L, Forman D (Eds). The cancer Atlas. 2nd edition. Atlanta GA: American Cancer Society; 2014. [Internet Document] [Accesed on 2015 April] Available at: http://canceratlas.cancer.org/?_ga=1.94994329.465927236.1429465038.
http://canceratlas.cancer.org/?_ga=1.949...

In the region of Latin America and the Caribbean, 1.1 million new cancer cases and approximately 600000 deaths occur annually. Prostate, lung, and stomach cancers are the primary causes of death among men, and breast, cervical-uterine, and lung cancers are the leading causes of death among women. Death rates for lung cancer have begun to stabilize and decrease among men in some countries, such as Brazil and Argentina, due to declines in the prevalence of tobacco use. However, one should not disregard the fact that the mortality from lung cancer in women is increasing in most countries of the region.33. Jemal A, Vineis P, Bray F, Torre L, Forman D (Eds). The cancer Atlas. 2nd edition. Atlanta GA: American Cancer Society; 2014. [Internet Document] [Accesed on 2015 April] Available at: http://canceratlas.cancer.org/?_ga=1.94994329.465927236.1429465038.
http://canceratlas.cancer.org/?_ga=1.949...

Lung cancer is highly fatal; therefore, the best way to prevent the occurrence of these deaths is to motivate smokers to completely quit smoking and to prevent smoking initiation among young people. Tobacco consumption and exposure to its smoke continue to be the most significant preventable risk factors for cancer worldwide.33. Jemal A, Vineis P, Bray F, Torre L, Forman D (Eds). The cancer Atlas. 2nd edition. Atlanta GA: American Cancer Society; 2014. [Internet Document] [Accesed on 2015 April] Available at: http://canceratlas.cancer.org/?_ga=1.94994329.465927236.1429465038.
http://canceratlas.cancer.org/?_ga=1.949...

Mexico

According to the GLOBOCAN report for 2014, in Mexico, 71 900 cancer deaths occur annually; 33 900 occurred in men, and 38 000 occurred in women. The leading causes of cancer death in men were prostate cancer (17%), lung cancer (11.7%), stomach cancer (9%), liver cancer (7.4%), and colorectal cancers (7.1%). In women, the primary causes of cancer mortality were breast cancer (15.8%), cervical-uterine cancer (12%), liver cancer (7.9%), stomach cancer (7.5%), and lung cancer (6.4%).77. IARC. Globocan 2014. Cancer country profile [internet document]. Mexico 2014 [accessed on 2015 April]. Available at: http://www.who.int/cancer/country-profiles/mex_en.pdf?ua=1.
http://www.who.int/cancer/country-profil...

In Mexico each year, tobacco use causes 43 246 premature deaths, 6 035 of which are from lung cancer and another 5 154 of which are from other types of cancer. Annually, at least 16 408 new cases of cancer attributable to tobacco are diagnosed, leading to high costs in the Mexican health sector and amounting to 10.5 billion Mexican pesos.88. Pichon-Riviere A, Reynales-Shigematsu LM, Bardach A, Caporale J, Augustovski F, Alcaraz A, et al. Carga de Enfermedad Atribuible al Tabaquismo en México.Documento Técnico IECS Nº 10. Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina. Agosto de 2013. [accessed on 2015 April]. Available at: http://media.controltabaco.mx/content/2013/Tabaquismo_en_M%C3%A9xico.pdf.
http://media.controltabaco.mx/content/20... ,99. Quintana-Carrillo R, Reynales-Shigematsu LM. Costos de atención médica atribuibles al consumo de tabaco en México: estimaciones 2010 In: Salud pública y tabaquismo, volumen I. Políticas para el control del tabaco en México. Cuernavaca, México: Instituto Nacional de Salud Pública, 2013 [accessed on 2015 April]. Available at: http://www.controltabaco.mx/publicaciones/salud-publica-y-tabaquismo-volumen-i.
http://www.controltabaco.mx/publicacione...

The national health surveys (Encuesta Nacional de Salud y Nutrición [National Health and Nutrition Survey], Ensanut 2012)1010. Gutiérrez JP, Rivera-Dommarco J, Shamah-Levy T, Villalpando-Hernández S, Franco A, Cuevas-Nasu L, et al. Encuesta Nacional de Salud y Nutrición. Ensanut 2012 Resultados Nacionales. Cuernavaca, México: Instituto Nacional de Salud Pública (MX), 2012 [accessed on 2015 April]. Available at: http://ensanut.insp.mx/informes/ENSANUT2012Resultados-Nacionales.pdf.
http://ensanut.insp.mx/informes/ENSANUT2... and epidemiological systems for the surveillance of tobacco (Encuesta Global de Tabaquismo en Adultos [Global Adult Tobacco Survey], GATS 2009,1111. OPS - INSP. Organización Panamericana de la Salud; Instituto Nacional de Salud Pública (MX). Encuesta Global de Tabaquismo en Adultos. México 2009. Cuernavaca (México): Instituto Nacional de Salud Pública, 2010. Coeditado con la Organización Panamericana de la Salud, 2010 [accessed on 2015 April]. Available at: http://www.controltabaco.mx/publicaciones/encuesta-global-de-tabaquismo-en-adultos.-gats-mexico-2009.
http://www.controltabaco.mx/publicacione... Encuesta Nacional de Adicciones [National Survey of Addictions], ENA 2011,1212. SSA. Encuesta Nacional de Adicciones 2011 [accessed on 2015 April]. Available at: http://www.controltabaco.mx/publicaciones/encuesta-nacional-de-adicciones-2011-tabaco.
http://www.controltabaco.mx/publicacione... and Encuesta de Tabaquismo en Jóvenes [Survey of Tobacco Use by Young People], ETJ 2011)1313. Encuesta de Tabaquismo en Jóvenes. México 2011 [accessed on 2015 April]. Available at: http://www.controltabaco.mx/publicaciones/encuesta-de-tabaquismo-en-jovenes-mexico-2011.
http://www.controltabaco.mx/publicacione... confirm that the tobacco use epidemic in Mexico continues to be a serious public health problem, demonstrating an increasing trend among adolescents, young adults (18-25 years), and women, in both urban and rural areas. Although the prevalence of tobacco consumption has decreased among Mexican men in the last decade and despite a consumption pattern of a few cigarettes daily or occasionally, we must not disregard the fact that all tobacco products are carcinogenic; therefore, there are no safe levels of consumption or exposure to its smoke.22. Cancer Incidence and Mortality Worlwide: Lyon, International Agency for Research on Cancer, 2011(IARC CancerBase No 10).

3. Jemal A, Vineis P, Bray F, Torre L, Forman D (Eds). The cancer Atlas. 2nd edition. Atlanta GA: American Cancer Society; 2014. [Internet Document] [Accesed on 2015 April] Available at: http://canceratlas.cancer.org/?_ga=1.94994329.465927236.1429465038.
http://canceratlas.cancer.org/?_ga=1.949...

4. WHO - IARC. IARC monographs on the evaluation of carcinogenic risks to humans; 83. Tobacco smoke and involuntary smoking [online monograph]. Lyon, France, 2004 [accessed on 2015 April]. Available at: http://monographs.iarc.fr/ENG/Monographs/vol83/mono83.pdf.
http://monographs.iarc.fr/ENG/Monographs...

5. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General [online monograph]. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010 [accessed on 2015 April]. Available at: http://www.ncbi.nlm.nih.gov/books/NBK53017/.
http://www.ncbi.nlm.nih.gov/books/NBK530... -66. U.S. Department of Health and Human Services. The Health Consequences of Smoking -50 Years of Progress: A Report of the Surgeon General [online monograph]. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. [accessed on 2015 April]. Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/index.html#fullreport.
http://www.surgeongeneral.gov/library/re... Thus, the most cost-effective strategy is prevention.

Tobacco control within the framework of the Global Action Plan for the Prevention and Control of Noncommunicable Diseases

Globally, the consumption of tobacco is the most significant preventable cause of cancer, and tobacco consumption is a globalized risk factor for which there is already a comprehensive control strategy led by the World Health Organization (WHO). The cornerstone for the control of tobacco is the WHO Framework Convention for Tobacco Control (WHO FCTC),1414. Asamblea Mundial de la Salud. Convenio Marco de la OMS para el Control del Tabaco. Resolución adoptada en la 56ª Asamblea Mundial de la Salud (WHA56.1). Punto 13 del orden del día 21 de mayo de 2003. [accessed on 2015 April]. Available in: http://www.who.int/tobacco/framework/en/.
http://www.who.int/tobacco/framework/en/... which was adopted by the 56th World Health Assembly on May 21, 2003, becoming a historical event in global public health by promoting, for the first time, a legal instrument that provides guidelines and best practices1515. WHO Framework Convention on Tobacco Control: guidelines for implementation Article 5.3; Article 8; Articles 9 and 10; Article 11; Article 12; Article 13; Article 14 - 2013 edition [accessed on 2015 April]. Available at: http://apps.who.int/iris/bitstream/10665/80510/1/9789241505185_eng.pdf?ua=1.
http://apps.who.int/iris/bitstream/10665... to prevent tobacco consumption and exposure to tobacco smoke. Currently, 10 years after its entry into force, 180 parties1616. FCTC Convention Secretariat. Parties to the WHO Framework Convention on Tobacco Control [accessed on 2015 April]. Available at: http://www.who.int/fctc/signatories_parties/en/.
http://www.who.int/fctc/signatories_part... have ratified the WHO FCTC, demonstrating a strong commitment and the political will to make rapid progress on its implementation, with the highest standards of performance.

To help countries with the implementation and fulfillment of the obligations established in the FCTC, the WHO established the MPOWER measures1717. World Health Organization. WHO report on the global tobacco epidemic, 2008: the MPOWER package. Geneva, World Health Organization [accessed on 2015 April]. Available at: http://www.who.int/tobacco/mpower/gtcr_download/en/index.html.
http://www.who.int/tobacco/mpower/gtcr_d... in 2008, which are an integral part of the WHO action plan for the prevention and control of tobacco. MPOWER measures include the six most cost-effective strategies that should be implemented by member countries to abate the tobacco epidemic globally: Monitor the consumption of tobacco and the prevention policies, Protect people from exposure to second-hand tobacco smoke, Offer help for ceasing tobacco consumption, Warn about the dangers of tobacco, Enforce prohibitions on advertising, promotion, and sponsorship, and Raise the taxes on tobacco.

In September 2011, the United Nations (UN) General Assembly adopted the Political Declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Noncommunicable Diseases1818. Naciones Unidas. Declaración Política de la Reunión de Alto Nivel de la Asamblea General sobre la Prevención y el Control de las Enfermedades No Transmisibles. September 2011. Género: ONV, 2011. worldwide, primarily focusing on the global development agenda and the social and economic repercussions on low- and middle-income countries. Similarly, the declaration reaffirmed all relevant resolutions and decisions adopted by the World Health Assembly in relation to the prevention and control of NCDs, particularly recognizing the conflict of interest between the tobacco industry (TI) and public health. Likewise, the declaration underscored the importance of the issue that the Member States continue to face major preventable risk factors (control of tobacco, reduction of salt intake, improved diet, increased physical activity, and reducing the harmful use of alcohol) through priority interventions that consider the health effects, cost-effectiveness, low cost of implementation, and financial and political feasibility.1919. The Global Economic Burden of Non-communicable Diseases - prepared by the World Economic Forum and the Harvard School of Public Health (2011) [accessed on 2015 April]. Available at: http://www.weforum.org/EconomicsOfNCD.
http://www.weforum.org/EconomicsOfNCD...

The Global Action Plan for the Prevention and Control of NCDs 2013-20202020. WHO. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva. World Health Organization [accessed on 2015 April]. Available at: http://www.who.int/global-coordination-mechanism/publications/global-action-plan-ncds-eng.pdf.
http://www.who.int/global-coordination-m... incorporates the guidelines of the Political Declaration and the guidelines of the WHO FCTC, recommending that Member States should implement the most cost-effective interventions ("best buys") for the control of tobacco during the period 2013-2020. The proposed interventions are grouped into three basic pillars: 1. measures to reduce tobacco demand; 2. measures to reduce the supply of tobacco products, and 3. interministerial and intersectorial coordination (figure 1).

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Figure I
Strategy for the control of tobacco within the framework of the Global Action Plan for the Prevention and Control of Noncommunicable Diseases, 2013-20201919. The Global Economic Burden of Non-communicable Diseases - prepared by the World Economic Forum and the Harvard School of Public Health (2011) [accessed on 2015 April]. Available at: http://www.weforum.org/EconomicsOfNCD.
http://www.weforum.org/EconomicsOfNCD... ,2020. WHO. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva. World Health Organization [accessed on 2015 April]. Available at: http://www.who.int/global-coordination-mechanism/publications/global-action-plan-ncds-eng.pdf.
http://www.who.int/global-coordination-m...

The evidence has demonstrated that there are four highly cost-effective interventions for reducing the demand for tobacco and achieving the greatest benefits in population health when they are comprehensively and simultaneously implemented with the highest standards of execution. The increase of specific taxes on tobacco products2121. WHO. Guideline for implementation of Article 6 of WHO FCTC [accessed on 2015 April]. Available at: http://www.who.int/fctc/guidelines/adopted/Guidelines_article_6.pdf?ua=1.
http://www.who.int/fctc/guidelines/adopt... is the most cost-effective strategy to reduce the consumption of tobacco because it discourages the consumption of tobacco among smokers and prevents the initiation of smoking among young non-smokers. Additionally, the tax collection levels are increased and earmarked so they can be invested in strategies for the prevention of risk factors or in the treatment of nicotine addiction and NCDs. This approach could also represent an innovative financing mechanism within the health sector, which would permit sustainability of the policy for the control of tobacco in the long term.1919. The Global Economic Burden of Non-communicable Diseases - prepared by the World Economic Forum and the Harvard School of Public Health (2011) [accessed on 2015 April]. Available at: http://www.weforum.org/EconomicsOfNCD.
http://www.weforum.org/EconomicsOfNCD...

Complete implementation implies adopting additional measures to reduce the demand and to help smokers quit, a measure beneficial to all ages but most cost-effective for the prevention of cancer and NCDs when consumption is abandoned before 40 years of age.2222. FCTC/COP4(8) Guidelines for implementation of Article 14 of the WHO Framework Convention on Tobacco Control (Demand reduction measures concerning tobacco dependence and cessation) [accessed on 2015 April]. Available at: http://www.who.int/fctc/Guidelines.pdf?ua=1.
http://www.who.int/fctc/Guidelines.pdf?u... The economic analysis of the global impact of the fiscal policy for the control of tobacco estimates that a 70% increase in the price of tobacco products could reduce consumption in the population by 10%, avoiding approximately 25 million cancer deaths by 2050.33. Jemal A, Vineis P, Bray F, Torre L, Forman D (Eds). The cancer Atlas. 2nd edition. Atlanta GA: American Cancer Society; 2014. [Internet Document] [Accesed on 2015 April] Available at: http://canceratlas.cancer.org/?_ga=1.94994329.465927236.1429465038.
http://canceratlas.cancer.org/?_ga=1.949...

The integral execution of the WHO FCTC also involves implementing measures oriented at reducing the supply, such as combating illicit trade, implementation of alternative crops, and total prohibition of sale to and by minors (sale of single cigarettes).2020. WHO. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva. World Health Organization [accessed on 2015 April]. Available at: http://www.who.int/global-coordination-mechanism/publications/global-action-plan-ncds-eng.pdf.
http://www.who.int/global-coordination-m...

Additionally, there are two measures that cannot be ignored; the first measure is oriented at counter tobacco industry (TI) interference and protect the established laws, and the second measure is oriented at establishing and/or strengthening mechanisms for interministerial and multispectral coordination for full WHO FCTC implementation in each country.2020. WHO. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva. World Health Organization [accessed on 2015 April]. Available at: http://www.who.int/global-coordination-mechanism/publications/global-action-plan-ncds-eng.pdf.
http://www.who.int/global-coordination-m...

Governments should safeguard the achievements made in the control measures already implemented and should not retreat before interference from the tobacco industry. Furthermore, governments should accelerate the full and comprehensive implementation of all measures to reduce the supply and demand for tobacco products, promoting multi-sectoral policies and plans with a broader perspective of the Global Action Plan for the Prevention and Control of NCDs 2013-2020.2020. WHO. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva. World Health Organization [accessed on 2015 April]. Available at: http://www.who.int/global-coordination-mechanism/publications/global-action-plan-ncds-eng.pdf.
http://www.who.int/global-coordination-m...

The WHO FCTC and its guidelines constitute a global instrument that permits the Member States to achieve a 30% relative reduction in the prevalence of tobacco consumption by 2025 and consequently achieve a 25% relative reduction in mortality from NCDs, including cancer mortality.

Strategy for the control of tobacco within the framework of the National Plan for Cancer Control2323. Organización Mundial de la Salud. Programas Nacionales de Control del Cáncer. Políticas y pautas para la gestión. Washington D.C.: OPS, 2004. in Mexico, 2013-2020

Considering the high healthcare costs generated for the Mexican health sector by cancer treatments and an adverse global economic environment that requires making good use of resources, it is necessary to invest in health promotion and the prevention of risk factors. Health promotion circumscribes not only health education for modifying individual lifestyles but also a set of multidisciplinary and intersectorial societal actions that includes communities as well as governments (figure 2).33. Jemal A, Vineis P, Bray F, Torre L, Forman D (Eds). The cancer Atlas. 2nd edition. Atlanta GA: American Cancer Society; 2014. [Internet Document] [Accesed on 2015 April] Available at: http://canceratlas.cancer.org/?_ga=1.94994329.465927236.1429465038.
http://canceratlas.cancer.org/?_ga=1.949...

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Figure 2
Strategies for health promotion within the framework of the National Plan for Cancer Control 2013-202033. Jemal A, Vineis P, Bray F, Torre L, Forman D (Eds). The cancer Atlas. 2nd edition. Atlanta GA: American Cancer Society; 2014. [Internet Document] [Accesed on 2015 April] Available at: http://canceratlas.cancer.org/?_ga=1.94994329.465927236.1429465038.
http://canceratlas.cancer.org/?_ga=1.949...

Mexico requires the consideration and positioning of health objectives as a priority in all public policies and levels of government (federal, state, and local), with guiding interministerial approaches that involve, as required, secretariats of education, energy, agriculture, sports, transportation, communications, planning, environment, labor, industry and commerce, finance, and social and economic development to prevent all risk factors (consumption of tobacco) of NCDs (cancer) and modify the basic determinants of health comprehensively and decisively.

To achieve the goals set for 2020, Mexico should implement the Global Action Plan for the Prevention and Control of NCDs decisively, synergistically, and sustainably, and in the particular case of tobacco control, Mexico should consider implementing the WHO FCTC completely within a short period.

Measures oriented at reducing tobacco demand:

  1. Substantially increase specific taxes on all tobacco products in such a way that the affordability of tobacco is reduced (Article 6 of the WHO FCTC):

    1. Promoting an amendment to the Law of Special Tax on Production and Services (Ley del Impuesto Especial sobre Producción y Servicios - IEPS) D.O.F. (Diario Oficial de la Federación [Official Gazette of the Federation]) December 30, 1980,2424. Ley del impuesto especial sobre producción y servicios Nueva Ley publicada en el Diario Oficial de la Federación el 30 de diciembre de 1980 Última reforma publicada DOF 11-12-2013 [accessed on 2015 April]. Available at: http://www.google.com.mx/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5&ved=0CDYQFjAE&url=http%3A%2F%2Fwww.sat.gob.mx%2Fcomext%2Fcertificacion_exportadoras%2FDocuments%2FLIEPS.doc&ei=-9Y1VdCUBYbjsAWm_oHoCg&usg=AFQjCNHn6fCSOG4lYZXh2a28TdcVsPql3A&bvm=bv.91071109,d.b2w.
      http://www.google.com.mx/url?sa=t&rct=j&...       including the latest reform of November 19, 2010, according to the guidelines of Article 6 of the WHO FCTC.2121. WHO. Guideline for implementation of Article 6 of WHO FCTC [accessed on 2015 April]. Available at: http://www.who.int/fctc/guidelines/adopted/Guidelines_article_6.pdf?ua=1.
      http://www.who.int/fctc/guidelines/adopt...

  2. Create and implement national legislation for 100% tobacco smoke-free environments that include all indoor workplaces and public places, as well as public transportation (Art. 8 WHO FCTC):

    1. Promoting a reform of the General Law for the Control of Tobacco (Ley General para el Control del Tabaco - LGCT)2525. Ley General para el Control del Tabaco. Diario Oficial de la Federación (30 de mayo de 2008) [accessed on 2015 April]. Available at: http://www.diputados.gob.mx/LeyesBiblio/doc/LGCT.doc.
      http://www.diputados.gob.mx/LeyesBiblio/...       that establishes 100% tobacco smoke-free public spaces and indoor workplaces in accordance with Article 8 of the WHO FCTC and its guidelines.2626. WHO. Guidelines on protection from exposure to tobacco smoke [accessed on 2015 April]. Available at: http://www.who.int/fctc/cop/art%208%20guidelines_english.pdf?ua=1.
      http://www.who.int/fctc/cop/art%208%20gu...       This approach is the second most cost-effective strategy for protecting the entire population, especially women and children, from health harm, significantly avoiding the initiation of tobacco use among the young.

  3. Advertise the tobacco-initiation damage to health through the implementation of health warnings and effective media communication campaigns. (Art. 11 and 12 WHO FCTC):

    1. Promoting a reform of the General Law for the Control of Tobacco (LGCT),2525. Ley General para el Control del Tabaco. Diario Oficial de la Federación (30 de mayo de 2008) [accessed on 2015 April]. Available at: http://www.diputados.gob.mx/LeyesBiblio/doc/LGCT.doc.
      http://www.diputados.gob.mx/LeyesBiblio/...       which increases the size of the pictograms to at least 75% of the surface of the packaging as established by the guidelines of Article 11 of the WHO FCTC.2727. Guidelines for implementation of Article 11 of the WHO Framework Convention on Tobacco Control (Packaging and labelling of tobacco products) [accessed on 2015 April]. Available at: http://www.who.int/fctc/guidelines/article_11.pdf?ua=1.
      http://www.who.int/fctc/guidelines/artic...       Developing and monitoring compliance with Secretariat agreements for packaging and labeling of all tobacco products in Mexico.2828. DOF. Acuerdo por el que se dan a conocer la serie de leyendas, imágenes, pictogramas, mensajes sanitarios e información que deberá figurar en todos los paquetes de productos del tabaco y en todo empaquetado y etiquetado externo de los mismos a partir del 24 de marzo de 2015 y hasta el 23 de marzo de 2016 [accessed on 2015 April]. Available at: http://www.dof.gob.mx/nota_detalle.php?codigo=5383929&fecha=02/03/2015.
      http://www.dof.gob.mx/nota_detalle.php?c...

    2. Implementing intersectorial programs for the prevention of tobacco consumption and health promotion, accompanied by campaigns in mass communications media aimed at vulnerable populations of adolescents, young adults, and women with the participation of key actors in prevention and control, such as health professionals and educational sector personnel.

    3. Considering the bases and concepts of social marketing in health sector projects that generate a true change of behavior in Mexican society to create a collective of health and wellbeing. These strategies should move beyond an isolated campaign in the mass communication media and should be creative and innovative, including strategies of research, monitoring, and evaluation.

  4. Totally prohibit all forms of advertising, promotion, and sponsorship of tobacco products. (Art. 13 WHO FCTC):

    1. Promoting a reform to the LGCT2525. Ley General para el Control del Tabaco. Diario Oficial de la Federación (30 de mayo de 2008) [accessed on 2015 April]. Available at: http://www.diputados.gob.mx/LeyesBiblio/doc/LGCT.doc.
      http://www.diputados.gob.mx/LeyesBiblio/...       that completely prohibits advertising, promotion, and sponsorship (direct or indirect) of all tobacco products in accordance with Article 13 of the WHO FCTC and its guidelines.2929. WHO. Guidelines for implementation of Article 13 of the WHO Framework Convention on Tobacco Control (Tobacco advertising, promotion and sponsorship) [accessed on 2015 April]. Available at: http://www.who.int/fctc/guidelines/article_13.pdf.
      http://www.who.int/fctc/guidelines/artic...       The prohibition should include points of sale, internet promotion through social media, and personal mail to private addresses.

  5. Help smokers to quit smoking. (Art. 14 WHO FCTC)

    1. Integrating diagnostic algorithms of tobacco consumption and exposure to its smoke into health service medical care routines (primary and specialized care), providing preventive actions (brief medical advice) and the referral and counter-referral of patients to specialized centers, promoted in accordance with the guidelines of Article 14 of the WHO FCTC.2222. FCTC/COP4(8) Guidelines for implementation of Article 14 of the WHO Framework Convention on Tobacco Control (Demand reduction measures concerning tobacco dependence and cessation) [accessed on 2015 April]. Available at: http://www.who.int/fctc/Guidelines.pdf?ua=1.
      http://www.who.int/fctc/Guidelines.pdf?u...

    2. Strengthening the network of support centers for smoking cessation with trained and certified health professionals and psychotherapeutic and pharmacological treatments for nicotine addiction in accordance with NOM 028-SSA2 2009.3030. Modificación a la Norma Oficial Mexicana NOM-028-SSA2-1999, Para la prevención, tratamiento y control de las adicciones, para quedar como Norma Oficial Mexicana NOM-028-SSA2-2009, Para la prevención, tratamiento y control de las adicciones. Publicado en el Diario Oficial de la Federación el 21 de agosto de 2009 [accessed on 2015 April]. Available at: http://www.conadic.salud.gob.mx/pdfs/norma_oficial_nom.pdf.
      http://www.conadic.salud.gob.mx/pdfs/nor...

    3. Ensuring access to health services and universal coverage of patients with tobacco addiction through the incorporation of pharmacological treatment for tobacco cessation into the universal catalog of health services (catálogo universal de servicios de salud - CAUSES).3131. SSa. Catálogo universal de servicios de salud 2014. CAUSES [accessed on 2015 April]. Available at: http://www.seguro-popular.salud.gob.mx/images/Contenidos/CAUSES%202014.pdf.
      http://www.seguro-popular.salud.gob.mx/i...

Measures oriented toward reducing the tobacco supply:

  1. Implement the illicit trade protocol (Art. 15 WHO FCTC)

    1. Adhering to the illicit trade protocol3232. WHO. Protocol to eliminate illicit trade in tobacco products. 2013 [accessed on 2015 April]. Available at: http://apps.who.int/iris/bitstream/10665/80873/1/9789241505246_eng.pdf?ua=1.
      http://apps.who.int/iris/bitstream/10665...       that aims to eliminate all forms of illicit trade in tobacco products, which would force Mexico to take measures to achieve effective control of the supply chain of tobacco products (including tracking and tracing labels) and cooperate internationally in a wide range of related issues.

  2. Implement alternative crop programs. (Art. 17 and 18 WHO FCTC)

    1. Supporting small tobacco farmers with crop replacement programs for sustainable alternatives beneficial to health and the environment in accordance with Articles 17 and 18 of the WHO FCTC.3333. WHO. Economically sustainable alternatives to tobacco growing (in relation to Articles 17 and 18 of the WHO Framework Convention on Tobacco Control) [accessed on 2015 April]. Available at: http://apps.who.int/gb/fctc/PDF/cop5/FCTC_COP5%288%29-en.pdf?ua=1.
      http://apps.who.int/gb/fctc/PDF/cop5/FCT...

  3. Totally prohibit sales to and by minors. (Art. 16 WHO FCTC)

    1. Severely sanction noncompliance with the articles of the LGCT that prohibit sale to minors and the sale of loose cigarettes in addition to prohibiting free access to the products at points of sale in vending machines, by free distribution, or in the form of sweets or toys in accordance with Articles 15 and 16 of the WHO FCTC.

Coordination mechanisms

  1. Implement mechanisms to counteract TI interference (Art. 5.3 WHO FCTC)

    1. Implementing measures for the protection of public health policies regarding the control of tobacco against commercial and other vested interests of the tobacco industry in accordance with the provisions of Article 5.3 of the WHO FCTC.3434. WHO. Guidelines for implementation of Article 5.3 of the WHO Framework Convention on Tobacco Control on the protection of public health policies with respect to tobacco control from commercial and other vested interests of the tobacco industry [accessed on 2015 April]. Available at: http://www.who.int/fctc/guidelines/article_5_3.pdf.
      http://www.who.int/fctc/guidelines/artic...

  2. Implement mechanisms for interministerial and intersectorial coordination (Art. 22 WHO FCTC)

    1. Strengthen the national capacity for the prevention and control of cancer risk factors:

      1. Promoting academic programs (undergraduate and postgraduate) for the training of multidisciplinary human resources with the possibility of joining in the prevention, health promotion, and medical care programs at the local, regional, or national level.

      2. Supporting research at the basic, clinical, and public health levels and promoting relationships and the mobility of teachers-researchers and students within the groups already consolidated nationally and internationally.

      3. Strengthening the national programs for the prevention and control of tobacco and cancer and incorporating actions directed at vulnerable groups with active participation of communities and civil society both in the execution as well as the evaluation of programs.

      4. Actively involving the civilian population in confidential and anonymous citizen complaints about violations of tobacco legislation and regulations. A timely and effective response of institutions is essential to guarantee the correct application of the federal and local regulations.

    2. Ensure financial resources for the sustainable execution of preventive programs and control strategies

      1. Reassigning and optimizing the existing resources into the implementation of new strategies, which should be based on scientific evidence, be highly cost-effective, and attempt equitable benefit for the entire population.

      2. Achieving a better negotiation in the budget allocation for all sectors involved in reaching the health objectives.

      3. Managing new sources of funding, economic resources, and infrastructure through international or national cooperation that permits the operation of the preventive programs and the action strategies without departing from parameters of ethics, transparency, and accountability.

      4. Advocating for the earmarking of economic resources from the tobacco taxes revenues for the treatment of nicotine addiction and diseases attributable to tobacco that currently are not covered by social security nor the System of Social Protection in Health (Sistema de Protección Social en Salud - SPSS).

Strategies for surveillance, monitoring, and evaluation

Surveillance, monitoring, and evaluation of the risk factors, results of interventions, and population impact measures must be analyzed and assessed in an interministerial, intersectorial academic, and research working group that enables the following:

  1. Monitoring and surveillance of the tobacco and cancer epidemic and evaluating the impact of control strategies:

    1. Implementing screening strategies for cancers caused by tobacco consumption and exposure to its smoke, particularly lung cancer.

    2. Improving the health system information of tobacco legislation and quality of vital statistics registries, particularly the death certificate, to quantify the burden of disease from cancer attributable to each risk factor.

    3. Implementing a national population-based cancer registry (state and national) that permits the accumulation of reliable data on the incidence and mortality by cancer type, considering the Global Initiative for Cancer Registry Development (GICR).3535. WHO. IARC. iniciativa mundial para el desarrollo de registros del cáncer (GICR) [accessed on 2015 April]. Available at: http://gicr.iarc.fr/es/.
      http://gicr.iarc.fr/es/...       These data orient the planning of medical care services and the evaluation of the impact of population control measures.

    4. Implementing an observatory (state and national) that considers the epidemiological indicators of the risk factors, especially in vulnerable populations, such as youth, women, and low-income populations without access to social security.

    5. Monitoring the behavior of the TI to identify about new products in the market, such as cigarettes with flavored capsules,3636. German Cancer Research Center (Ed.) Menthol Capsules in Cigarette Filters - Increasing the Attractiveness of a Harmful Product Heidelberg, Germany, 2012 [accessed on 2015 April]. Available at: https://www.dkfz.de/de/tabakkontrolle/download/Publikationen/RoteReihe/Band_17_Menthol_Capsules_in_Cigarette_Filters_en.pdf.
      https://www.dkfz.de/de/tabakkontrolle/do...       or new technologies, such as electronic cigarettes or nicotine delivery devices,3737. WHO. Electronic nicotine delivery systems [accessed 2015 april]. Available at: http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10Rev1-en.pdf?ua=1.
      http://apps.who.int/gb/fctc/PDF/cop6/FCT...       so the contents and the damages to health can be determined to establish mechanisms of regulation and citizen complaint.

    6. Take advantage of New Information and Communications Technology (NICT) so that the data and information are available for patients (support websites for smoking cessation),3838. INSP. Diseño de una herramienta interactiva para dejar de fumar [accessed on 2015 April]. Available at: http://www.controltabaco.mx/diseno-y-evaluacion-de-una-herramienta-interactiva-para-la-cesacion-del-tabaquismo-en-mexico.
      http://www.controltabaco.mx/diseno-y-eva...       for decision makers (support software),3939. WHO. OneHealth Tool [accessed on 2015 April]. Available at: http://www.who.int/choice/onehealthtool/en/.
      http://www.who.int/choice/onehealthtool/...       and for the general public in a timely and transparent manner.

Impact indicators

The indicators for the prevention and control of smoking and NCDs in accordance with the WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020 are summarized in table I.

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Table I
Goals and population impact indicators in accordance with the WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020

Conclusions

Tobacco control can reduce the consumption of tobacco, which is currently the most significant preventable cause of cancer. Tobacco control measures at the population level can prevent cancer at a low cost when compared with the high costs that would be needed for cancer treatment.

Mexico is called upon to strengthen its governmental and social capacities to adopt lifestyles that promote the good health of all individuals and the welfare of the population. It is necessary to choose cost-effective alternatives aimed at reducing inequities in cancer prevention and treatment.

References

Publication Dates

  • Publication in this collection
    Mar-Apr 2016

History

  • Received
    03 July 2015
  • Accepted
    29 Oct 2015
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This is an open-access article distributed under the terms of the Creative Commons Attribution License
Instituto Nacional de Salud Pública Cuernavaca - Morelos - Mexico
E-mail: spm@insp3.insp.mx
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