摘要：We examined the association between exposure to the California Tobacco Control Program and tobacco-related behaviors and perceptions among adults of Mexican descent. Three cross-sectional population-based surveys were conducted among adults in cities that represent full, partial, and no exposure to the program: San Diego, Calif, Tijuana, Mexico, and Guadalajara, Mexico, respectively. After we controlled for socioeconomic differences, we found significantly different rates of smoking, exposure to environmental tobacco smoke, and smoking bans in the 3 cities. We also observed a parallel gradient of cross-city differences in theoretical mediators of tobacco control. This suggests a significant association among the California Tobacco Control Program, tobacco-control outcomes, and theoretical mediators of these outcomes. Similar programs should be implemented in other regions; they have widespread effects on social norms and behaviors related to smoking and environmental tobacco smoke and can help achieve tobacco control across nations. Tobacco use is one of the leading preventable causes of death in the United States 1 and the world. 2 In contrast with the improvements observed in high-income countries, smoking rates and related mortality are increasing in poor- and middle-income nations. 3 International research on tobacco control and policies is crucial to expand the progress achieved in high-income countries to less-affluent regions of the world. 4 This research can be strengthened with the use of comprehensive health behavior models. The Behavioral Ecological Model (BEM) 5 provides a strong foundation for the identification of determinants of health behaviors and has been applied to different health research areas. 6 – 10 The BEM represents an extension of the operant learning principles 11 and the theory of social learning, 12 with emphasis on the role of reinforcement and modeling processes. 5 This model posits that behaviors are determined by a hierarchy of determinants, including individual characteristics, the proximal social network, community-level factors, and the broader social and cultural context. Some factors are highly idiosyncratic (e.g., personal history of reinforcement), whereas others apply to large groups of individuals (e.g., policies, social norms, culture). Bidirectional influences operate between factors that belong to different levels of this hierarchy. Because of their consistent and generic influence, 5 social norms and cultural factors are among the most powerful determinants of health behaviors. Laws, regulations, and public policies affect other levels of influence, leading, for instance, to changes in social norms, community sentiments, and individual attitudes and behaviors. The California Tobacco Control Program’s (CTCP’s) comprehensive and policy-oriented tobacco-control efforts are consistent with the BEM. This program encompasses smokefree laws, tobacco taxation, restrictions in tobacco advertising and promotion, community involvement, media campaigns, and cessation services. Since its inception in 1988, this program has resulted in a shift in tobacco use and public attitudes toward tobacco and environmental tobacco smoke among California residents. 13 The scope of the CTCP contrasts with the level of tobacco-control efforts of neighboring Mexico. Measures of economic nature, such as increasing tobacco taxes to reduce smoking, have only been partially used in Mexico. 14 Moreover, advertising of tobacco in public venues is still permitted, sponsorship of events and use of promotional tobacco-related items is legal and widespread, and enforcement of bans on tobacco sales to minors is limited. 15 , 16 Previous research in the United States has examined the association between state- and local-level tobacco-control policies and rates of tobacco use, 17 , 18 exposure to environmental tobacco smoke, 19 and smoking bans. 20 We extend this work by examining the differences in tobacco use, exposure to environmental tobacco smoke, and related behaviors and perceptions among 3 populations of Mexican-descent adults who represented 3 different levels of exposure to tobacco-control policies: those who lived in a California city (i.e., San Diego, Calif), those who lived in a Mexican city located on the California–Mexico border (i.e., Tijuana, Baja California, Mexico), and those who lived in another Mexican city far away from California (i.e., Guadalajara, Jalisco, Mexico). We hypothesized that, because of their exposure to the CTCP, adults of Mexican descent in San Diego would exhibit lower smoking rates, less exposure to environmental tobacco smoke, and a more negative perception of tobacco than their counterparts in Mexico. Moreover, because of exposure to California antitobacco media, social interactions with California residents, and exposure to smokefree public policies when traveling into California, we hypothesized that adults who lived in the Mexican border city of Ti-juana would experience some of the benefits of the CTCP. This would translate into lower rates of smoking, less exposure to environmental tobacco smoke, and more negative views on tobacco use among Tijuana residents compared with those in other Mexican cities located farther from California. By testing this hypothesis, we sought to add to previous literature and further our understanding of how exposure to different tobacco-related policies was associated with differential tobacco use and environmental tobacco smoke. To our knowledge, this was the first study on this topic that involved an international comparison. The results may inform the widespread effects of comprehensive antitobacco programs, such as the CTCP, on social norms and behaviors related to smoking and environmental tobacco smoke and contribute to the expansion of this type of tobacco-control intervention to other regions of the world.
