Mexico and the tobacco industry: doing the wrong thing for the right reason?BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7537.353 (Published 09 February 2006) Cite this as: BMJ 2006;332:353
All rapid responses
We read the article: Mexico and the tobacco industry: doing the wrong
thing for the right reason? by Samet J et al. (1). The analysis has strong
basis in their conclusions. However, with a different perspective, before
the year 2004, 35% of Mexican children with cancer didn’t receive any
orthodox treatment. Furthermore, that the mortality rate in childhood
cancer is on the rise (2).
What are the benefits of the National Program? It has permitted uniformity
of treatment regimens under international standards. All medical expenses
in every child are being covered. Also it has developed Hospital
Accreditation requirements for all the participant institutions. This
program sponsors and produced new residency programs in pediatric oncology
-currently there are only 95 Pediatric Oncology Mexican Board certified
physicians- which will eventually permit 8 states without medical coverage
to have a specialist.
This program started in January 2005; by December of that year 879
children with acute lymphoblastic leukemia have been registered
nationwide. These children have had evaluation and treatment according to
risk categories. Less than 1% of this population has abandon treatment.
Next June 2006 the program will incorporate children with acute non-
lymphoblastic leukemia’s, lymphomas and solid tumors.
When we look at a mirror, we visualize two sides, on the back side it will
not permit us to see the spectrum of light, on the other side it will give
us the full imagine of the object that is being reflected. We think that
with this controversial program, on one side the dramatic outcome is
becoming promising for those children with limited resources. On an
optimistic approach, it will probably offer an eventual decline of smoking
behavior of the Mexican population through the awareness that their
tobacco habits will finance such a magnificent program for the benefit of
children with cancer.
1. Samet J, Wipfli H, Perez-Padilla R, Yach D. Mexico and the tobacco
industry: doing the wrong think for the right reason? BMJ 2006;332:353-
2. Abdullaev FI. Rivera-Luna R, Roitenburd-Belacortu V, Espinoza J.
Pattern of Childhood Cancer Mortality in Mexico. Archives of Medical
+Roberto Rivera-Luna, MD*
+Rocio Cárdenas-Cardos, MD
+Alberto Olaya-Vargas, MD
+Armando Martínez-Avalos, MD
+National Institute of Pediatrics
Division of Hem/Oncology
Mexico City 04530
*Head of the Division of Hem/Oncology, National Institute of Pediatrics
and National Technical Coordinator for the National Council for the
Prevention & Treatment of Childhood Cancer of Mexico.
Correspondence: Roberto Rivera-Luna, MD
Competing interests: No competing interests
The article published by Samet, et al, in the BMJ (2006; 332:353-4),
raises important issues regarding tobacco control in our country.
Unfortunately, it has also touched sensible fibres within our national
health authorities who have gone to the trouble of replying the above
mentioned article by diminishing the authors credibility and enhancing the
actions which, undoubtedly, have been established by the current
As part of the medical professional community in my country, I can be no
more sure of the fact that it is during this administration that actions
against tobacco consumption have been established in a more determined
manner than never before in our history. However, this can not be taken as
a great feat if one considers that the historical delay in actions of this
type was putting our country years behind that which was happening in
The World Health Organization´s Framework Convention on Tobacco Control
has the purpose of levelling out historical differentials between
countries. This is one of the moral pillars of the Framework Convention.
I believe no one in my country can argue against the positive actions
taken at all levels by our health authorities against tobacco consumption.
However, taking administrative actions to the altar is not enough if the
moral support of the situation is left unattended. It is at the least
unfair to promote the agreement established with the tobacco industry in
Mexico as an intelligent strategy to obtain greatly needed financial
resources to be put to work in our health system. It is unfair because
similar strategies have been rendered non-operational in other parts of
the world (i.e.: the California experience); and also because these
strategies, as implemented in our country, present an extremely flimsy
ethical support. This is not the proper forum to discuss the ethics of
this agreement, however, a moral equivalent can be extrapolated somewhere
between the view one could have of receiving financial support for the
treatment of diseases related to drug abuse by some important mexican drug
cartel, and the ongoing discussion regarding the industrial funding of
research. The moral question comes down to the discussion of the influence
(positive or negative), that the financial “agent” could end up exerting:
the discussion on incentives versus coercions, and the secondary benefits
such agencies obtain.
But aside from this, common knowledge has it that agreements of this sort
come down to nothing more than the age-old fact of “sleeping with the
enemy”, and this has never been a good idea.
The medical profession in Mexico considers tobacco consumption to be a
dangerous foe which must be defeated. Designing strategies that establish
agreements with the tobacco industry end up implying the acceptance of a
healthy coexistence with such industry. This, to say the least, results
in a terrible oxymoron we must avoid.
A final, personal worry relates to the fact that there has been a
suspiciously utter silence on part of mexican academic and professional
organizations that undoubtedly make the treatment of chronic lung disease,
ischaemic cardiopathy and cancer their reason to be. In spite of the
possible explanations to this (avoidance of political conflict, lack of
interest), I risk my participation in this debate in order to present an
alternate view which, as limited as it is, could be taken or not as the
view from the common man.
Competing interests: No competing interests
We do not disagree with the statements that the Mexican government,
led by Minister of Health Julio Frenk, implemented policies to reduce
tobacco use in the past. The Ministry won tax increases and developed
smoking cessation programs, which are among the best in the region.
These accomplishments do not, however, change the fact that the agreement
with the tobacco industry arrest future progress. In making its agreement
with the tobacco industry, the Ministry ignored the evidence, from both
developed and developing countries around the world, that voluntary
agreements with the tobacco industry have never served the public’s
Mexico was an early ratifier of the Framework Convention for Tobacco
Control (FCTC). The FCTC is clear that such voluntary agreements are to
be avoided: Article 5, section 3 states “In setting and implementing their
public health policies with respect to tobacco control, Parties shall act
to protect these policies from commercial and other vested interests of
the tobacco industry in accordance with national law.” A strong
motivation for both the paper by Samet et al  and our accompanying
commentary  was to alert other ratifying nations that Mexico’s
agreement was not an appropriate model for implementing the FCTC.
The Mexican “legal and fiscal realities” offered by the Ministry as
justification for the agreement are not unique to Mexico; they apply in
one form or another in most democracies. Many governments prohibit
dedicated taxes and virtually all democracies allow parties affected by
government regulations to sue if they believe that these regulations are
unfair or illegal. As Sebrié and Glantz  pointed out, the prohibition
on dedicated taxes does not, in any way, prevent the government from
increasing cigarette taxes and then, in separate legislation,
appropriating the same amount of money to health programs.
The tobacco industry could – and probably would – sue to stop
effective restrictions on cigarette advertising or effective graphical
warning labels on the front of cigarette packages. Despite this threat,
many countries have successfully implemented image-based warnings on
packages, including Brazil, Venezuela, and Uruguay in Latin America, as
well as Canada, Australia, Thailand, Singapore and a number of EU
countries. Being sued by the tobacco industry has become a cost of
implementing effective tobacco control strategies [3, 4]. If the Mexican
government is not willing to consider policies that the tobacco industry
might fight, then it has effectively left the scope of tobacco control
policy to the multinational tobacco companies.
More to the point, at least one tobacco control measure has already
been successfully defended against a legal challenge in Mexico. The weak
local legislation on “Health Protection of Nonsmokers” in Mexico City
(establishing 30% of the total area for nonsmokers and allowing for
ventilation systems) that passed at the end of 2003, was challenged in
court in 2004 by the Vips restaurant chain under the Mexican “Ley de
Amparos” . The court dismissed the case in 2005 .
The statement that Mexico’s agreement with the transnational tobacco
companies (Philip Morris and British American Tobacco) is temporary and
that it will end in December 2006 is not correct. Clause 19 states “This
Agreement will take effect between the parts [the Ministry of Health and
the transnational tobacco companies] the day of its signature… It will
have an indefinite effect or until the moment in which all of its
provisions are incorporated into new legislation or regulation, and it
will only be modified by written agreement between the parties. [emphasis
While it is true that the cigarette taxes have increased under the
current government, the claim that the current tax level is
“unprecedented” is not accurate. In 1981, the year that the tobacco tax
was established, the tax was 139.3% of the price, more thant the present
110%. The tax was also much higher than now during 1986-1987, reaching
180%. Most important, the agreement with the tobacco companies to make
their “donation” to the health fund would be terminated if new taxes are
imposed on cigarettes. Therefore, as long as the agreement is in place it
creates a de facto restriction on taxing cigarettes, effectively blocking
implementation of the FCTC provision (article 6) calling for tax
The agreement with the tobacco industry will also prevent Mexico from
completely ending tobacco industry advertising, promotion, and sponsorship
as required by the FCTC (article 13). The partial restrictions such as
the removal of advertisements on radio and television in the agreement
simply reflect the tobacco industry’s September 2001 voluntarily self-
regulating advertising code “International Marketing Standards. In its
agreement with the companies, the Ministry simply received a pledge from
the tobacco companies to comply with their own voluntary code.
Indeed, the only effect of the agreement on advertising appears to
have been the proliferation of advertising at eye level throughout the
cities of Mexico (see photo taken in Mexico City in January 2006).
The increase of the health warning labels up to 50% on the back face
of the cigarette packages was also a voluntary measure conceded by the
tobacco industry to prevent large warnings on the front of packages as
recommended by the FCTC (article 11). The agreement explicitly precludes
“images or pictures,” which are more effective than text alone in
communicating important information to smokers and their families.
In addition, the industry voluntarily included one warning label
printed on the lateral side of the pack that reads “Currently there is no
cigarette that reduces health risks” and an insert (written in complex
language in small type) with information for smokers warning that “tobacco
consumption causes different types of cancer, heart and cerebrovascular
disease, embolism, chronic bronchitis, and emphysema.” These last two
measures might be used by the industry to defend itself from future
lawsuits brought by injured smokers or their families, and in any case are
too obscure to be expected to have an impact. It also allows the industry
to continue using misleading and deceptive descriptors such as “mild” and
“light” on the packages, which the FCTC requires (article 11) to be
eliminated within 3 years of entry into force (for Mexico, this would be
27 February 2008).
Claims that federal government buildings are smokefree are also
exaggerated. Consistent with the tobacco industry’s goals, the
government’s regulations require smoking areas for smokers.
The Ministry of Health has ignored the fact that, by agreeing to
accept a “contribution” from the tobacco industry, it gives the
multinational tobacco companies (based in New York and London) a tax break
that, through December 2006 alone, will cost the Mexican people 1000
million pesos (US$96 million).
The agreement with the tobacco companies has also another major
effect, documented in other parts of the world [6, 7]: it creates a
corrupting influence on government. The money the tobacco industry
“donates” can buy a new building for the National Cancer Institute of
Mexico, or funding for treating children with leukemia , but these
“gifts” come at the cost of premature deaths of smokers and secondhand
smokers when the government agrees to abandon the effective tobacco
control strategies required and recommended by the FCTC.
Ernesto Sebrie, MD MPH
Stanton A. Glantz, PhD
Professor of Medicine
University of California San Francisco
1. Samet, J., et al., Mexico and the tobacco industry: doing the
wrong thing for the right reason? BMJ, 2006. 332(7537): 353-4.
2. Sebrie, E. and S.A. Glantz, The tobacco industry in developing
countries. BMJ, 2006. 332(7537): 313-4.
3. Nixon, M.L., L. Mahmoud, and S.A. Glantz, Tobacco industry
litigation to deter local public health ordinances: the industry usually
loses in court. Tob Control, 2004. 13(1): 65-73.
4. Ibrahim, J.K. and S.A. Glantz, Tobacco industry litigation
strategies to oppose tobacco control media campaigns. Tob Control, 2006.
5. Aviles, C., Defienden derechos de no fumadores, in El Universal.
2005: Mexico. p. 2.
6. Glantz, S.A. and E.D. Balbach, Tobacco War: Inside the California
Battles. 2000, Berkeley: University of California Press.
7. Gilmore, A., J. Colin, and M. McKee, British American Tobacco's
erosion of health legislation in Uzbekistan. BMJ, 2006. 332(7537): 355-8.
8. Godlee, F., A time for courage. BMJ, 2006. 332(7537):
Competing interests: No competing interests
Glantz and Sebrie have separately addressed the response from the
Ministry of Health. We both recognize the past accomplishments of the
Ministry of Health but have a shared concern with regard to the potential
implications of the agreement made by Mexico for tobacco control in the
country. We assume that the Ministry of Health will be closely
considering the consequences of the agreement. We look forward to
learning about whether the agreement continues to figure in Mexico’s
future approach to tobacco control.
Competing interests: No competing interests
Brief report of the National Institute of Respiratory Diseases (INER)
in Mexico against smoking
The analysis and comment section of the BMJ, Volume 332 February
11th, 2006, published an article signed, among others, by a Mexican
researcher that might give a misleading idea of the general opinion of the
medical community on the subject March 09, 2006. Nowadays, we have to use
many different ways so we can inform the public about what INER is doing.
• Special care has been given to the preparation of leaflets that
clearly explain in a very direct manner, the problem with smoking and its
fatal consequences. Those leaflets are freely available and are
distributed to many schools, health facilities, within factories and
other places where people gather.
• We also sponsor an annual poster´ and photo contest that is later
exhibited at the institute. Afterwards, they are edited and widely
• There is also an extensive educational program aimed at teachers
and students at the primary school level, as we have tried to forestall
early stage smoking. That initiative is supported by educational material
and manuals, together with leaflets, posters and “Power point”
presentations. DVD’s and a feature film that illustrates, -in a very
direct way- the grievous dangers inherent in smoking, such as pulmonary
insufficiency and cancer. There are other sequels such as impotence,
cardiovascular diseases, dental problems and possible premature
deliveries or infertility.
• We have also furnished a WEB site (http:www.iner.gob.mx) with much
information about INER’s activities which are mainly those related to the
tobacco problem and are directed towards the public and general
• We have also opened specialized courses that support “quit
smoking” programs and a postgraduate course that is preparing
INER has given paramount importance to research in order to generate
applied knowledge that will provide us with new weapons against this
lethal problem. Thus, we have founded a specialized research unit that
will deal with epidemiological, clinical and other basic applications
directed towards finding answers. We have now established a laboratory
and clinical network with other national health institutes dealing with
cancer, medical sciences, nutrition and within the INER itself.
The abovementioned activities have been carried out under the
leadership of Dr. Julio Frenk, Secretary of Health who has given strong
support as Chief Executive of the INER Staff Board in its campaign to
denounce the practice of smoking and to warn both smokers and non-smokers
of the dangers and damage caused by the use of tobacco.
Dr. Fernando Cano Valle, INER General Director
Competing interests: No competing interests
Effective global action requires respect for diversity, sensitivity
to local realities and adherence to ethical norms regarding the use of
complete information. None of these attributes is present in two comments
, published in the February 11, 2006 issue of the BMJ that discuss a
tobacco-control measure recently implemented by the Mexican government.
Both pieces focus on an agreement between the Ministry of Health of Mexico
(MoH) and the tobacco industry, signed in June 2004 and valid until
December 2006 which, among other measures, imposes an additional
contribution per cigarette package that is earmarked for health actions.
The two comments are flawed because they provide incomplete information
and disregard the context in which this specific measure was implemented.
They also demonstrate a lack of background research on the legal and
fiscal realities of Mexico that explain the reasons why such a temporary
agreement was adopted.
Since 2001 Mexico has carried out a comprehensive tobacco-control policy
and has been an active supporter of the WHO Framework Convention on
Tobacco Control (FCTC), as demonstrated by the fact that it was the first
country in the Americas to ratify it.
Actions adopted in Mexico have included major FCTC provisions related both
to demand and to supply reduction. Salient among these measures are the
• unprecedented increases in the taxation rates of tobacco products,
amounting to a fivefold hike for unfiltered cigarettes (from an excise-tax
rate of 20.9% in 2000 to 110% in 2005) and a one-third increase for
filtered cigarettes (from 85% in 1999 to 110% in 2004);
• a total ban on tobacco publicity in radio, television and Internet, as
well as major restrictions on printed media;
• a substantial increase in the size of the warning label, from small
texts on the side face of cigarette packs to 50% of one of the frontal
• a seven-fold growth in the number of smoking-cessation clinics from 36
in 2000 to 250 in 2005;
• total restriction on smoking in all federal buildings;
• the implementation of a programme on tobacco-free schools, including
limits on sales of cigarettes near educational institutions;
• the prohibition to sell cigarettes in drugstores and to persons under
• several mass-media campaigns against tobacco.
The two comments published in the BMJ suggest that little has been done in
the tobacco-control arena in Mexico and that, due to the agreement, no
additional measures will be taken. This mistaken assessment stems from two
major sources of misunderstanding by the authors. First, the agreement was
negotiated and signed after the most severe anti-tobacco measures outlined
above had already been implemented. None of these measures was reverted by
the agreement. Second, the agreement imposed additional obligations on
tobacco companies to the ones already contained in the law. By taking the
agreement out of its context, the authors give the false impression that
its provisions were limitative, whereas in fact they expanded on
previously adopted legislation. To state that the agreement serves “to
prevent meaningful tobacco control”ii in Mexico is at best a reflection of
ignorance and at worst an attempt to misinform the readers of the BMJ.
The authors of these comments also disregard certain characteristics of
Mexican legal and fiscal reality that explain the manner in which tobacco-
control policies have unfolded. In Mexico, the Ley de Amparo allows
citizens and corporations to legally contest any action by government
authorities. The implementation of new deterrents to the consumption of
tobacco through an agreement, prior to passing them as a law, prevents the
use of this legal procedure. In fact, the MoH applied this strategy
successfully in order to secure the banning of publicity in electronic
media, which was first imposed on the tobacco companies through an
agreement in 2002 and then passed into law the following year. Otherwise,
valuable time and resources could have been lost in litigation that
typically takes several years, during which the control measures would
have been suspended.
In addition, Mexican fiscal policy does not allow the earmarking of taxes.
Had the additional burden imposed in the agreement been in the form of a
tax, the collected resources could not have been directly allocated, as
they are now, to health-related activities, including tobacco prevention
efforts (contrary to what Samet et al.i mistakenly claim). The authors of
one of the papers state that the government “could simply have
appropriated to the insurance fund the money that an increased tax
produced.”ii This claim demonstrates a lack of knowledge about the
intricacies of the process for allocating fiscal revenues, especially now
that, thanks to the ongoing reform, the MoH has received the largest
increase ever in its regular budget.
There is yet another tactical reason for the agreement, which again
reveals the absence of adequate investigation by the authors of both
papers. Because yearly tax increases had been approved by law from 2002
until 2005, any additional hike would have had to wait until after this
period. The agreement made it possible to impose an additional
contribution since 2004, with the added advantages that it could be
earmarked for health and that it was added to the final price, thus
reinforcing the demand-reduction effect of a regular tax.
Both papers neglect to inform the reader of the crucial fact that the
agreement has a limited duration (until December 2006), thus leaving the
door open for legislating further tobacco-control measures, including tax
increases. In this respect, it is important to clarify that the MoH is not
planning its future budgets under the assumption that the funds obtained
through this agreement will continue to flow after 2006. In fact, the main
objective of both the tax increases and the additional contribution
secured by the agreement has not been to raise fiscal revenues, but rather
to limit the consumption of an unhealthy product through price hikes.
Beyond the inaccuracies in their content, both comments exhibit major
flaws in the process by which they were produced, which ought to motivate
a broader debate about the most effective modes of global health action.
Both pieces are highly judgmental and reflect a lack of appreciation for
the complexities of policy making in specific settings. The title of the
article by Samet et al. says it all, since the authors purport to be able
to judge what is “right” and what is “wrong.”i Despite having access to
health authorities in Mexico, they did not bother to make any consultation
on the reasons that explain the strategy of signing an agreement with the
tobacco industry in the context of a comprehensive control policy.
The editorial by Sebrié and Glantz is an even more flagrant example of
what could be called “imperialistic arrogance,” whereby activists based in
rich countries believe that they can impose their beliefs on poorer
countries without the need to understand the specific circumstances that
prevail there. This attitude was reflected during their recent visit to
Mexico, where Sebrié and Glantz accused the Mexican government of
misconduct, without listening to the position of those they were
indicting. It was only
after they carried out an aggressive media campaign that they approached
Shortly after he took office, the Minister of Health demanded from
multinational tobacco companies that they observe the same rules of
behavior in Mexico as they have in their home countries (i.e., the United
States and Great Britain). This was the fundamental principle through
which he stood up to very powerful interests in order to achieve a huge
increase in tobacco taxes and a total ban on publicity in electronic
The same principle ought to be applied to interventionist activists. Mexico believes in transparency and international collective action. However, we cannot yield to self-appointed judges who, lacking the most
fundamental information, question the decisions of a group of respected
public health policy makers that have demonstrated the courage and
imagination to successfully confront one of the most powerful industries
worldwide in search of better health for the Mexican population.
Roberto Tapia-Conyer, MD, DrSc, Undersecretary for Disease Prevention
and Health Promotion, Ministry of Health of Mexico
Cristóbal Ruíz-Gaytán, MD, MPH, Technical Secretary, National
Council against Addictions, Ministry of Health of Mexico
Luis Alfonso Caso-González, BA, Commissioner, National Commission for
Protection against Health Risks, Ministry of Health of Mexico
(i) Samet J, Wipfli H, Pérez-Padilla R, Yach R. Mexico and the
tobacco industry: doing the wrong thing for the right reason? BMJ
(ii) Sebrié E, Glantz SA. The tobacco industry in developing countries.
Competing interests: No competing interests
It is sometimes very easy for multinational companies with
their huge financial power to influence government policies
and decisions.In India ,with a population crossing a billion,there is a
huge market for tobacco companies.The
political and administrative machinery is prone to
manipulation by giant corporations in ways similar to
those mentioned in this article.However, the government
over last few years has been gradually coming down heavily on tobacco
companies,which is a very encouraging sign .
I would like to mention a small success in recent times which is
commendable in a developing country.The railway ministry banned smoking
and the sale of cigarettes on railway stations and trains a few years
ago.A system of spot checks and imposition of fines on those breaking this
law was implemented.The rule was firmly implemented and on one occasion I
witnessed the authorities in action while I was travelling by train.Two
people were caught smoking by a
railway team of "spot checkers" and they had to pay a fine
there and then.
The mission has on the whole been very succesful and led to reduction
of smoking on railway stations and trains.I
do not know whether things have reverted back to usual after waning of
initial enthusiasm,as I have not travelled
by railways on my recent visits to my country.
I mention this example to show that with strong political and
administrative will,it is possible to control the
tobacco industry inspite of its might and manipulations
in developing countries.
1.Samet J,Wipfli H et al.Mexico and the tobacco industry:
doing the wrong thing for the right reason?.BMJ2006;332:353-4.(11th
2.Sebrie E,Glantz AS.The tobacco industry in developing
Competing interests: No competing interests