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Resumen Objetivo Evaluar las practicas clinicas, barreras y facilitadores para dejar de fumar en clinicas de primer nivel de atencion en la Ciudad de Mexico. Material y metodos Diseno de metodos mixtos. Se realizaron encuestas (n = 70) y entrevistas semiestructuradas (n = 9) a personal de salud involucrado en el servicio de las clinicas para dejar de fumar. Resultados Datos cuantitativos muestran que el personal medico realizo mas que el de enfermeria las siguientes practicas: preguntar a pacientes si fumaban (57,9% vs. 34,5%, p = 0,057), si tenian interes en dejar de fumar (65,7% vs. 26,9%, p = 0,003), brindar asesoria (54,3% vs. 29,2%, p = 0,056) y necesidad de farmacoterapia (21,9% vs. 10%, p = 0,285). El personal de enfermeria informo mas que el personal medico la falta de recursos, farmacoterapia y necesidad de capacitacion para asesoria. Los resultados cualitativos muestran como barreras: percepcion de falta de motivacion para dejar de fumar entre pacientes, falta de tiempo en consulta, largos tiempos de espera para citas y falta de capacitacion; y como facilitadores: contar con servicio para dejar de fumar, farmacoterapia sin costo, y equipo multidisciplinario. Conclusiones Las intervenciones para dejar de fumar se implementan parcialmente. Es necesaria una reestructuracion de los servicios, donde el personal de enfermeria tenga un mayor rol.

AIMS To measure the effects of changing attributes of pictorial health warning labels (HWLs) on cigarette packs in a country that has already implemented pictorial HWLs. MEASURES For each choice set, participants were presented with two cigarette packs and asked the following three questions: (1) 'If only these two cigarette packs were available, which would you buy?'; (2) 'Each of these two packs has warnings on the front and back about the health effects of smoking. Which of these warnings best informs you about the dangers from smoking?'; and (3) 'Which warning most makes you think about quitting smoking?'. As recommended for best practices in discrete choice experiments, each of these questions was followed by an 'opt-out' question for participants to indicate whether they really believed there was a difference between the options presented (i.e. 'Would you really choose one of them?'; 'Do you really think that either of these warnings informs you about dangers from smoking?'; or 'Do you really think that either of these warnings would make you think about quitting smoking?', respectively). Each choice set could be viewed for as long as the participant wished. For each choice question (i.e. willingness to buy, informative, motivating to quit), the pack chosen was coded as 1 and the other pack as 0, with both packs being given a value of 0 if the participant 'opted out'. DESIGN A within-subject discrete choice experiment that involved systematic manipulation of pictorial HWL size [75 versus 30% (current policy)]; inclusion of imagery on the back of the pack [versus none (current policy)]; and color formatting [black on yellow versus yellow on black (current policy)]. SETTING Mexico, on-line panel. PARTICIPANTS Adult smokers (n = 705). MEASUREMENTS For each choice set, participants selected one pack as having the most informative HWL about smoking harms, the one that makes them think the most about quitting and the one they were most willing to buy. We assessed the independent and interactive effects of HWL attributes on choices. FINDINGS Larger HWL size on the pack front (75 versus 30%) and inclusion of a pictorial image on the pack back were both independently associated with lower willingness to buy a pack [b = -0.228, standard error (SE) = 0.023 and -0.089, SE = 0.016, respectively] and greater perception of an HWL as informative (b = 0.214, SE = 0.022, and 0.191, SE = 0.017, respectively) and motivating to quit (b = 0.251, SE = 0.023 and 0.194, SE = 0.017, respectively). HWL with black text and yellow background were perceived as less informative (b = -0.037, SE = 0.016) and less motivating to quit (b = -0.032, SE = 0.015) compared with yellow text on a black background. CONCLUSIONS Among adult Mexican smokers, pictorial health warning labels on cigarette packages that are larger or cover both sides of the pack appear more effective at lowering purchase intentions and increasing risk perceptions and motivation to quit than smaller health warning labels or health warning labels with imagery only on the pack front.

Purpose: This study aimed to characterize the patterns of smoking, e-cigarette use, other substance use (alcohol and marijuana), and depression by sexual orientation in a sample of Mexican adult smokers. Methods: Data came from a 2018–2020 (six waves) online survey of adult smokers, recruited from a commercial research panel (92.5% heterosexual, n = 4786; 3.1% lesbian/gay, n = 160; and 4.4% bisexual, n = 229). After stratifying the data by sex, logistic, multinomial, and linear logistic regression models were estimated (depending on the outcome), including as independent variables sexual orientation (i.e., gay/lesbian, bisexual, heterosexual = Reference), age, education, household income, and wave. Results: Being a gay male was independently associated with greater smoking dependence (β = 0.20; 95% confidence interval [CI]: 0.02 to 0.39), greater likelihood of preference for flavored capsule cigarettes (adjusted odds ratio [AOR] = 2.10, 95% CI: 1.33 to 3.28), and depression diagnosis (AOR = 2.85, 95% CI: 1.64 to 4.95). Bisexual males had higher e-cigarette dependence (β = 0.37; 95% CI: 0.05 to 0.68, among dual users only) and were more likely to have been diagnosed with depression (AOR = 2.34, 95% CI: 1.30 to 4.18). Lesbian females were more likely to prefer menthol cigarettes (AOR = 3.32, 95% CI: 1.60 to 6.86), to have used marijuana more than once (AOR = 3.23, 95% CI: 1.83 to 5.72), and to have depressive symptoms (AOR = 1.85, 95% CI: 1.04 to 3.29). Bisexual females had a greater likelihood of depressive symptoms (AOR = 1.71, 95% CI: 1.14 to 2.56) and depression diagnosis (AOR = 2.22, 95% CI: 1.43 to 3.42). Conclusion: Lesbian, gay, and bisexual adult smokers in Mexico appear more likely than heterosexual adult smokers to report having depression. Substance use and depression among sexual minority populations need to be addressed further.

espanolObjetivo. Describir el perfil de los usuarios duales y fumadores exclusivos, asi como los factores asociados con la frecuencia de uso de cigarro electronico. Material ymetodos. Se realizaron modelos logisticos de una encuesta en linea de fumadores adultos para estimar asociaciones de usuarios duales (fumador exclusivo vs. usuario dual) sobre variables sociodemograficas, tabaquismo y otras sustancias. Adicionalmente, mediante modelos binomiales censurados se evaluaron los factores asociados con la frecuencia de consu-mo de cigarro electronico. Resultados. Los usuarios duales fueron mas jovenes, con mayor educacion (AOR=2.22), tenian mayores niveles de dependencia de tabaquismo (AOR=1.31), preferirian usar cigarros con capsulas de sabor (AOR=1.58) y tuvieron una mayor proporcionde intentos de dejar de fumar (AOR=1.38).El consumo de marihuana y fumar diario se asocio con una mayor frecuencia de consumo de cigarro electronico. Conclusion. Eluso dual se asocio con un perfil de riesgo mas alto; este perfil es mas prominente en usuarios duales que usan cigarros electronicos con mayor frecuencia. EnglishObjective. To describe the profile and patterns of dual uses (n=954) and exclusive cigarette users (n=2 070) and determine the correlates of more frequent e-cigarette use among dual users and their reasons for e-cigarette use. Materials andmethods. An online survey of Mexican adult smokers. Logistic models regressed dual-use (exclusive smoking vs. dual user) on sociodemographic, smoking varia-bles and substance use behaviors. We conducted censorial binomial models to estimate the correlates of frequency of e-cigarette use among dual users. Results. Dual users were younger had higher education (AOR=2.22) and higher levels of smoking dependence (AOR=1.31), preferred cigarettes with flavor capsules (AOR=1.58) and had recently attempted to quit smoking (AOR=1.38). Marijuana use and being daily smokers were correlates of higher frequency of use among dual users. Conclusion. Dual users had a higher risk profile than exclusive smokers, which was even more prominent in dual-users who used e-cigarettes frequently.

Objective: To systematically review published articles reporting the use of smoking cessation mobile health (mHealth) interventions in Latin America. Methods: Five different databases were searched from database inception to 2020. Criteria: (1) the research was a smoking cessation randomized controlled trial (RCT), quasi-experimental research, or single-arm study; (2) the intervention used at least one type of mHealth intervention; (3) the research was conducted in Latin American; and (4) the research reported the cessation rate. Results: Of the seven selected studies, four were conducted in Brazil, two in Mexico, and one in Peru. Only one study was an adequately powered RCT. Interventions relied on text messages ( n = 3), web-based tools ( n = 2), and telephone calls ( n = 3). Some studies ( n = 4) provided pharmacotherapy support. Smoking cessation outcomes included self-reported ( n = 5) and biochemically verified ( n = 2) abstinence. Follow-ups were conducted at Month 6 ( n = 2), Week 12 ( n = 4), and Day 30 ( n = 1). Cessation rates varied from 9.4% at Week 12 to 55.5% at Day 30. Conclusion: Despite the promising cessation rates of mHealth interventions in Brazil, Mexico, and Peru, there is a need to rigorously evaluate these interventions in different Latin American countries with RCTs that are long-term, adequately powered, and use biochemical verification of cessation.

Men who have sex with men (MSM) are more likely to use drugs and other substances compared to their heterosexual peers. No studies have evaluated patterns of substance use among MSM adults in Mexico. We used latent class analysis (LCA) to identify MSM subgroups with specific substance use patterns and their associations with sexual behaviors. Methods: Data from 1850 adult MSM were collected at HIV clinics in Mexico City between September 2018 and December 2019. The structural equation modeling approach was used to estimate a LC model to identify patterns of substance use by self-report of substance use (i.e., cigarette smoking, alcohol, and drugs). To evaluate LC membership, we included HIV status, condomless anal sex (CAS), and serosorting, while controlling for demographic variables. Results: 30.3% were under the age of 22. Alcohol use in last 30 days (76.2%), binge drinking (29.2%), marijuana (29.4%), sex-drugs (23.9%), stimulants (13.7%), and depressants (6.3%). MSM reported engaging in CAS (55.9%) and serosorting (13.5%) behaviors, and 40% reported being HIV positive. LCA indicated three general categories of MSM substance users: Class 1 (49.0%), Class 2 (29.8%), and Class 3 (20.4%). Members of Class 3 were younger: 23–28 age years (aOR = 1.86) and 29–33 age years (aOR = 1.86), more educated: completed graduate studies (aOR = 1.60), had a high probability of polysubstance use and were more likely to engage in CAS and serosorting. Conclusions: Attempts to detect alcohol and problematic use of substances are needed for MSM followed by culturally competent approaches that address alcohol and drug use disorders.

Previous studies have identified variants in genes encoding proteins associated with the degree of addiction, smoking onset, and cessation. We aimed to describe thirty-one single nucleotide polymorphisms (SNPs) in seven candidate genomic regions spanning six genes associated with tobacco-smoking in a cross-sectional study from two different interventions for quitting smoking: (1) thirty-eight smokers were recruited via multimedia to participate in e-Decídete! program (e-Dec) and (2) ninety-four attended an institutional smoking cessation program on-site. SNPs genotyping was done by real-time PCR using TaqMan probes. The analysis of alleles and genotypes was carried out using the EpiInfo v7. on-site subjects had more years smoking and tobacco index than e-Dec smokers (p &lt, 0.05, both), in CYP2A6 we found differences in the rs28399433 (p &lt, 0.01), the e-Dec group had a higher frequency of TT genotype (0.78 vs. 0.35), and TG genotype frequency was higher in the on-site group (0.63 vs. 0.18), same as GG genotype (0.03 vs. 0.02). Moreover, three SNPs in NRXN1, two in CHRNA3, and two in CHRNA5 had differences in genotype frequencies (p &lt, 0.01). Cigarettes per day were different (p &lt, 0.05) in the metabolizer classification by CYP2A6 alleles. In conclusion, subjects attending a mobile smoking cessation intervention smoked fewer cigarettes per day, by fewer years, and by fewer cumulative pack-years. There were differences in the genotype frequencies of SNPs in genes related to nicotine metabolism and nicotine dependence. Slow metabolizers smoked more cigarettes per day than intermediate and normal metabolizers.

Introduction: While smoking remains one of the leading causes of death in Mexico, uptake of evidence-based cessation therapy remains low. Widespread use of mobile devices and internet in Mexico has created new avenues for providing access to cessation treatment. Methods: We assessed the feasibility and acceptability of “Vive Sin Tabaco… ¡Decídete!” (English: Live without Tobacco…. Decide!), a web-based, informed decision-making tool designed to help Mexican smokers develop a quit plan and take advantage of cessation resources. We invited 164 smokers in two primary care clinics. Measures included physical, situational, and psychological nicotine dependence, interest in using pharmacotherapy and counseling, smoking status at 3 months, and satisfaction with the program. Results: Most participants were light smokers and reported low-to-moderate nicotine dependence. Immediately after using ¡Vive Sin Tabaco… ¡Decídete!, the majority were interested in quitting, set a quit date, and reported interest in using pharmacotherapy and cessation counseling. Follow-up rate at 3 months was 81.5%; seven-day point prevalence abstinence was 19.1% using intention-to-treat analysis. Conclusion: Integration of e-Health tools in primary healthcare settings has the potential to improve knowledge about cessation treatments among smokers and integrate smoking cessation into routine of care.

BACKGROUND Of the 14.3 million Mexicans who smoke, only a minority take advantage of evidence-based approaches to smoking cessation. Mobile health interventions have the potential to increase the reach of effective cessation interventions in Mexico. OBJECTIVE This study aimed to assess the feasibility and acceptability of an innovative, personalized, and interactive smoking cessation mobile intervention developed for Mexican smokers. METHODS We recruited 40 Mexican smokers to participate in Vive sin Tabaco... ¡Decídete!, a smoking cessation program that uses a tablet-based decision support software to drive a 12-week text messaging smoking cessation program and pharmacotherapy support. Outcome measures included participant text messaging interactivity with the program, participant satisfaction, and 12-week verified abstinence using urinary cotinine testing or exhaled carbon monoxide. RESULTS Average age of the participants was 36 years (SD 10.7), and they were primarily male (65%, 26/40) with at least an undergraduate degree (62%, 25/40). Most participants (95%, 38/40) smoked daily and were interested in quitting in the next 7 days. As an indicator of participant interactivity, participants sent an average of 21 text messages during the 12-week intervention (SD 17.62). Of the 843 messages that participants sent to the program, only 96 messages (11.3%, 96/843) used keywords. At 12 weeks, 40% (16/40) of participants were biochemically verified (87%, 35/40, follow-up rate). The majority of participants (85%, 30/35) reported being very satisfied or extremely satisfied with the program. CONCLUSIONS The Vive sin Tabaco... ¡Decídete! smoking cessation mobile intervention was accepted by participants, generated high satisfaction and high text messaging interactivity, and resulted in a noteworthy cessation rate at the end of treatment. This intervention is a promising strategy for smoking cessation in Mexico. Additional testing as a formal randomized clinical trial appears warranted.

This study aimed to assess sex differences in predictors for becoming a current exclusive electronic cigarette (e-cigarette) user, current exclusive smoker, or current dual user (concurrent smoking and e-cigarette use). This longitudinal study included 2399 females and 2177 males who had tried neither cigarettes nor e-cigarettes at baseline and attended 57 middle schools in the three largest cities in Mexico. We estimated multinomial logistic models stratified by sex. At follow-up, the prevalence of current exclusive e-cigarette use was 6.4% for males and 5.5% for females, current exclusive smoking was similar among males (3.6%) and females (3.5%), dual use was 2.4% females and 1.8% males. In the adjusted model, current e-cigarette use among females was associated with baseline current drinking (ARR = 1.85, p &lt, 0.05), having a job (ARR = 1.99, 0.05), higher technophilia (ARR = 1.27, 0.05), and higher positive smoking expectancies (ARR = 1.39, 0.05). Among males, only having friends who smoke cigarettes at baseline was a significant predictor of current exclusive e-cigarette use at follow-up (ARR = 1.44, 0.05). For both sexes, current exclusive smoking at follow-up was associated with baseline current drinking (male ARR = 2.56, 0.05, female ARR = 2.31, 0.05) and, among males, only with having a parent who smoked (ARR = 1.64, 0.05). For both sexes, dual use at follow-up was associated with baseline current drinking (male ARR = 3.52, 0.005, female ARR = 2.77, 0.05), among females, with having paid work (ARR = 2.50, 0.001), and among males, with parental smoking (ARR = 3.20, 0.05). Results suggested both common and different risk factors by sex, suggesting that interventions may need to consider targeting sex differences.

Objetivo: Diseñar, implementar y evaluar una intervención educativa que contribuya al manejo adecuado de los residuos sólidos urbanos con participación de una comunidad semiurbana, al norte de Cuernavaca, Morelos, México. Material y métodos: Estudio con medición pre y post-intervención educativa, también llamado diseño pre-experimental, con aproximación cuanti-cualitativa. Cuestionario hecho en 27 hogares, 3 grupos focales, 8 entrevistas y creación de un registro etnográfico, de agosto 2010 a mayo 2011. Resultados: Participaron 23 niños/niñas y 14 mujeres de manera directa, en actividades de la intervención. Se incrementó 4,74% el conocimiento sobre manejo de los residuos ( p = 0,036), 4.5% la susceptibilidad percibida ( p = 0,041) y 3.39% los beneficios percibidos ( p = 0,032). La basura se percibe como problema asociado a daños a la salud y medio ambiente. Se identificó a la mujer como responsable del manejo de residuos sólidos. Se favoreció la relación vecinal e incorporación de acciones de separar residuos y barrer las calles con más frecuencia. Conclusiones: Reconocer a la población como guía de acciones en salud es fundamental para el éxito de intervenciones comunitarias. Se recomienda el uso de una metodología participativa en otras propuestas de intervención.

BackgroundOf the 14.3 million Mexicans who smoke, only a minority take advantage of evidence-based approaches to smoking cessation. Mobile health interventions have the potential to increase the reach of effective cessation interventions in Mexico. ObjectiveThis study aimed to assess the feasibility and acceptability of an innovative, personalized, and interactive smoking cessation mobile intervention developed for Mexican smokers. MethodsWe recruited 40 Mexican smokers to participate in Vive sin Tabaco... ¡Decídete!, a smoking cessation program that uses a tablet-based decision support software to drive a 12-week text messaging smoking cessation program and pharmacotherapy support. Outcome measures included participant text messaging interactivity with the program, participant satisfaction, and 12-week verified abstinence using urinary cotinine testing or exhaled carbon monoxide. ResultsAverage age of the participants was 36 years (SD 10.7), and they were primarily male (65%, 26/40) with at least an undergraduate degree (62%, 25/40). Most participants (95%, 38/40) smoked daily and were interested in quitting in the next 7 days. As an indicator of participant interactivity, participants sent an average of 21 text messages during the 12-week intervention (SD 17.62). Of the 843 messages that participants sent to the program, only 96 messages (11.3%, 96/843) used keywords. At 12 weeks, 40% (16/40) of participants were biochemically verified (87%, 35/40, follow-up rate). The majority of participants (85%, 30/35) reported being very satisfied or extremely satisfied with the program. ConclusionsThe Vive sin Tabaco... ¡Decídete! smoking cessation mobile intervention was accepted by participants, generated high satisfaction and high text messaging interactivity, and resulted in a noteworthy cessation rate at the end of treatment. This intervention is a promising strategy for smoking cessation in Mexico. Additional testing as a formal randomized clinical trial appears warranted.

Objetivo. Describir las estrategias de publicidad, mercadeo, y venta productos del tabaco en 12 ciudades de México. Material y métodos. Los puntos de venta de tabaco, a 500mts alrededor de escuelas participantes de la Encuesta de Tabaquismo en Jóvenes (2005-2006), fueron identificados usando formatos observacionales y un Sistema de Información Geográfica en línea. Resultados. En promedio se encontraron 8 establecimientos y 5 puestos de calle alrededor de las 257 escuelas visitadas. 44.4% de los establecimientos tenía publicidad en interior, 8.3% poseían productos a la altura de los ojos de los niños y 6.5% tenía alguna promoción. El 33.6% tenía letrero de prohibición de venta a menores, en tanto que 44.4% de los establecimientos y 58.8% puestos de calle vendían cigarros sueltos. Conclusiones. Los productos de tabaco son ampliamente publicitados y comercializados alrededor de las escuelas. Existe un alto incumplimiento de las leyes referentes a la venta a menores y por menores. Es urgente implementar un sistema que permita una vigilancia continua de las estrategias de la industria y para el control del tabaco.

Determinar en población fumadora el nivel de exposición a la mercadotecnia de la industria tabacalera (IT), a través de diferentes métodos de promocionar sus productos, antes y durante la publicación de la Ley General para el Control del Tabaco (LGCT) en 2008. Material y métodos. Estudio de cohorte en fumadores adultos (n=941 pre-LGCT y n=1 051 post-LGCT) de cuatro ciudades mexicanas. Se realizaron análisis multivariados mediante modelos de ecuaciones de estimación generalizada (GEE). Resultados. Se incrementó el autorreporte de recepción de muestras gratis de cigarros (3.7 a 8.1%), ropa o artículos con marcas o logos (3.6 a 6.4%), haber visto información sobre eventos especiales (1.9 a 4.7%), y publicidad en bares y discotecas para mayores de edad (21.4 a 28%). Se observaron decrementos de publicidad en exteriores (54.7 a 47.2%). Conclusión. Es necesaria una política integral con prohibiciones totales de la publicidad y promoción de los productos de tabaco que integre mayor vigilancia y sanciones para lograr la disminución y prevención del consumo de tabaco.

To describe strategies used in the publicity, marketing, and sale, of tobacco products in 12 cities in Mexico.Tobacco products points of sale (POS) were identified within a 500 m radius of Global Youth Tobacco Survey (2005-2006) schools. We used observational surveys and an online Geographic Information System (GIS).In the 257 schools visited, we found, on average, 8.3 stores and 5 street vendors around each of them. Forty-four percent of the stores had interior tobacco publicity, 8.3% had tobacco products at children's eye level, 6.5% had some promotion, 33.6% had a no selling to minors sign, and 44.4% of stores and 58.8% of street vendors sold single cigarettes.Tobacco products are largely publicized and marketed around schools. There is no compliance of tobacco control legislation in regards to selling to minors and single cigarettes. It is necessary to implement a surveillance system to monitor strategies for tobacco control and the tobacco industry.

"Objetivo. Identificar la susceptibilidad cognitiva a fumar y los factores asociados en estudiantes de 12 a 15 años. Material y métodos. Se analizó la medición basal de una encuesta autoaplicable en 12 293 estudiantes no fumadores de escuelas secundarias, en el ciclo 2005-2006. Susceptible es aquel que contestó que aceptará un cigarrillo de su mejor amigo y cree que el año próximo fumará. Se obtuvieron modelos de regresión logística de multinivel. Resultados. La prevalencia de susceptibilidad fue de 30%. Los factores asociados fueron autoestima baja (RM = 1.2, IC95% 1.0-1.5), búsqueda de nuevas sensaciones (RM = 1.6, IC95% 1.3-2.0) y actitud favorable a fumar (RM = 2.6, IC95% 2.2-3.2), así como permisividad social reflejada en reglas del hogar (RM = 2.2, IC95% 1.7-2.8). Sólo en mujeres existió interacción entre permisividad de fumar en el hogar y consumo de tabaco en padres (RM = 2.1, IC95% 1.1-3.8). Conclusiones. La prevención debe promover la sensibilización de profesores y padres de familia como modelos antitabaco e incentivar hogares libres de tabaco."

OBJETIVO: Identificar la susceptibilidad cognitiva a fumar y los factores asociados en estudiantes de 12 a 15 anos. MATERIAL Y METODOS: Se analizo la medicion basal de una encuesta autoaplicable en 12 293 estudiantes no fumadores de escuelas secundarias, en el ciclo 2005-2006. Susceptible es aquel que contesto que aceptara un cigarrillo de su mejor amigo y cree que el ano proximo fumara. Se obtuvieron modelos de regresion logistica de multinivel. RESULTADOS: La prevalencia de susceptibilidad fue de 30%. Los factores asociados fueron autoestima baja (RM = 1.2, IC95% 1.0-1.5), busqueda de nuevas sensaciones (RM = 1.6, IC95% 1.3-2.0) y actitud favorable a fumar (RM = 2.6, IC95% 2.2-3.2), asi como permisividad social reflejada en reglas del hogar (RM = 2.2, IC95% 1.7-2.8). Solo en mujeres existio interaccion entre permisividad de fumar en el hogar y consumo de tabaco en padres (RM = 2.1, IC95% 1.1-3.8). CONCLUSIONES: La prevencion debe promover la sensibilizacion de profesores y padres de familia como modelos antitabaco e incentivar hogares libres de tabaco.

Objetivo. Cuantificar el efecto de las enfermedades atribuibles al consumo de tabaco, en términos epidemiológicos (morbilidad) y económicos (costos de atención médica), en el Instituto Mexicano del Seguro Social (IMSS) a escala nacional. Material y métodos. Los costos de la atención médica se estimaron desde la perspectiva del proveedor y se empleó la metodología del costeo de enfermedad. A partir de una muestra de pacientes (n= 1 596) atendidos en las unidades médicas se estableció la frecuencia de utilización de servicios en los tres niveles de atención. Para cada enfermedad se consideraron costos promedio por paciente y costos totales de enfermedad, los cuales se mensuraron en pesos mexicanos de 2004. Se calculó la fracción atribuible al consumo de tabaco para cada enfermedad, misma que se usó para atribuir los costos al tabaco. Resultados. Los costos totales anuales de atención médica nacional corresponden a 7 114 millones para el infarto agudo del miocardio, 3 424 millones para la enfermedad vascular cerebral, 1 469 millones para la enfermedad pulmonar obstructiva crónica y 102 millones para el cáncer pulmonar. El costo total anual para el IMSS por estas cuatro enfermedades asciende a 12 100 millones de pesos. Los costos atribuibles al consumo de tabaco corresponden a 7 100 millones de pesos, lo cual equivale a 4.3% del gasto de operación de la institución en el año 2004. Conclusiones. Estos resultados confirman el elevado costo de la atención médica de las enfermedades atribuibles al consumo de tabaco en el IMSS y generan información de primera mano necesaria para impulsar las medidas de prevención en esa institución y reforzar las políticas de control del tabaquismo ya aplicadas en México.

OBJETIVO: Determinar la actitud del personal de salud en la identificacion y la referencia de las victimas de violencia de genero (VG), asi como los factores relacionados con dicha actitud. Asimismo, conocer las barreras para tal identificacion y referencia, y evaluar el nivel de conocimiento sobre las Normas y Procedimientos para la Atencion de la Violencia Intrafamiliar entre el personal de salud del Ministerio de Salud de Nicaragua (MINSA). MATERIAL Y METODOS: Se realizo un estudio transversal entre el personal de salud de 5 de los 17 Sistemas Locales de Atencion Integral en Salud (SILAIS) de Nicaragua: medicos, enfermeras y auxiliares de enfermeria (n=213) del Programa de Atencion Integral a la Mujer, Ninez y Adolescencia en el primer nivel de atencion del MINSA, durante los meses de abril a junio de 2003. La actitud se midio de acuerdo con una escala tipo Likert y se construyo un indice de conocimiento sobre las normas de atencion. La informacion se obtuvo por medio de un instrumento de autoaplicacion, basado en el cuestionario de un estudio que se realizo entre el personal del Instituto Mexicano de Seguro Social (IMSS) de Morelos, Mexico. Se utilizo un modelo de regresion logistica para evaluar la asociacion de la actitud con diversos factores, asi como con el conocimiento sobre las normas de atencion. RESULTADOS: La actitud de rechazo hacia la VG fue de 76.06%. En el analisis multivariado, los factores asociados con la actitud de rechazo fueron la profesion medica (RM 6.5, IC 95% 2.70-15.82), al igual que los niveles medio (RM 4.3, IC 95% 1.87-10.26) y alto (RM 3.3, IC 95% 1.03-10.75) de conocimiento sobre las normas de atencion y la cercania de familiares o amigos que han sido victimas de violencia (RM 3.2, IC 95% 1.56-6.80). La escasa capacitacion sobre el tema (59.9%), el temor a involucrarse en asuntos legales (52.6%) y el caracter privado de la violencia (50.7%) constituyen las barreras mas importantes para la identificacion y la referencia de las victimas. CONCLUSIONES: En general, el personal de salud presento valores altos en la actitud de rechazo hacia la VG. Sin embargo, se identificaron barreras que indican la persistencia de creencias tradicionales como la de considerar el problema de la violencia un asunto privado. Por esta razon, para que en la practica se observe un cambio significativo, es importante que se consolide la capacitacion sobre el tema con una perspectiva de genero en las escuelas de medicina. Los hallazgos que se obtuvieron en el presente estudio permitiran mejorar el modelo de atencion en los servicios de salud del primer nivel de atencion de Nicaragua.