Progress in adopting bans on tobacco advertising, promotion, and sponsorship in the Americas: lessons from Uruguay and Argentina.

Objective: To assess progress in and barriers to implementing bans on tobacco advertising, promotion and sponsorship (TAPS) in Uruguay, which has a complete ban, and Argentina, with a partial ban.
Methods: Legislation on TAPS bans in Uruguay and Argentina was reviewed and relevant published literature, news stories, civil society reports and tobacco industry reports retrieved to analyze progress in implementing TAPS bans.
Results: In Uruguay, the complete TAPS ban, which includes standardized tobacco packaging, maintains high compliance and severely limits exposure of TAPS, despite a few problems with corporate social responsibility, social media, and transnational advertising. In Argentina, the partial TAPS ban has more problems with compliance and exposure to TAPS. The most important barriers to implementing TAPS bans in both countries are the tobacco companies. In Uruguay, tobacco companies do not comply in a few areas but the complete ban greatly minimizes this. In Argentina, however, tobacco companies can more easily exploit gaps in the partial TAPS ban, such as advertising at the points of sale, promoting contests, and using influencers on social media. Conclusions: The partial TAPS ban in Argentina illustrates the problems with enforcement and the tobacco industry's ability to exploit loopholes and continue to market their products, especially to young people. A complete TAPS ban, including standardized tobacco packaging, as in Uruguay, is easier to implement and enforce and is effective in reducing exposure to tobacco advertising. Nevertheless, governments should prioritize implementing TAPS bans on social media, which remains a difficult sphere to monitor and allows tobacco companies to continue recruiting and targeting young people.

The World Health Organization (WHO) estimates that eight million people die every year from tobacco use and one million of these deaths occur every year in the WHO Region of the Americas (1). In this Region, an estimated 142 million people use tobacco and tobacco use accounts for 16% of deaths from cardiovascular disease, 25% from cancer, and 52% from chronic respiratory diseases (1). Transnational tobacco companies play an important role in contributing to these deaths by aggressively marketing their products in the Americas Region to recruit new smokers, especially young people and women (2, 3).

To combat the global tobacco epidemic, Article 13 of the WHO Framework Convention on Tobacco Control (FCTC) and its guidelines recommend prohibiting all forms of tobacco advertising, promotion, and sponsorship (TAPS) (4). Furthermore, guidelines on Article 11 of the FCTC (tobacco packaging and labeling) recommend that governments “prohibit the use of logos, colors, brand images or promotional information on packaging other than brand names and product names displayed in a standard color and font style (plain packaging)” (5).

Out of the 35 countries of the WHO Region of the Americas, eight countries have adopted complete or comprehensive legislation on TAPS: Antigua and Barbuda, Brazil, Colombia, Guyana, Panama, Suriname, Uruguay, and Venezuela (Bolivarian Republic of) (6). Uruguay has gone further and adopted standardized tobacco packaging as well. Eighteen countries have a partial TAPS ban: Argentina, Bahamas, Barbados, Bolivia (Plurinational State of), Canada, Chile, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Jamaica, Mexico, Nicaragua, Paraguay, Peru, Trinidad and Tobago, and USA (6). Finally, nine countries have not established any TAPS restrictions: Belize, Cuba, Dominica, Dominican Republic, Grenada, Haiti, Saint Kitts and Nevis, Saint Lucia, and Saint Vincent and the Grenadines (6).

While reliable literature exists on tobacco industry marketing (7) and evidence of exposure to tobacco marketing in the Americas Region (8), little research has been done to date on evaluating TAPS policies (9, 10). Within this limited research, most consists of case studies that document TAPS provisions (11–13); only a few multicountry studies have been conducted that discuss TAPS provisions (14–16). This study examines the implementation of TAPS bans in two countries in South America, one with a complete TAPS ban (Uruguay) and the other with a partial TAPS ban (Argentina) to better understand the progress in and barriers to implementing TAPS in the Region of the Americas. Uruguay and Argentina share similar cultural backgrounds, are neighboring countries, are part of Mercosur (the common trade market in South America), and had a similar prevalence of tobacco use among young people (aged 13 to 15 years): current tobacco use in 2007 was 28.0% in Argentina (17) and 23.2% in Uruguay (18) before the implementation of the TAPS measures.

METHODS

Data collection

A comparative case study analysis was conducted to understand the differences between implementing TAPS bans in Uruguay and Argentina. Between August and November 2021, keyword searches in Google, Google Scholar, and PubMed were conducted using standard snowball searches to retrieve and compare published literature, media stories, civil society reports and tobacco industry reports on TAPS implementation in Uruguay and Argentina. Initial search terms both in English and Spanish included “Argentina”, “Uruguay”, “tobacco”, “advertising”, as well as individual tobacco company names. The searches resulted in the retrieval of 32 relevant documents. New snowball search terms included “point-of-sale”, “Santa Fe”, and “mobile delivery apps” and resulted in retrieval of 14 additional relevant documents.

Data analysis

Knill and Tosun’s policy cycle model, which has been used to identify best practices, gaps, patterns, and trends in implementing effective public policies (19), was applied to analyze the implementation of TAPS bans in Uruguay and Argentina. The results of applying the policy cycle model are presented for Uruguay and Argentina with the following information provided: an overview analysis of the TAPS legislative bans, compliance reporting, evaluations of TAPS restrictions, and barriers to implementing TAPS bans. Within the barriers to implementing TAPS bans, the findings were organized and analyzed by: TAPS at the point of sale; digital and direct communications; mobile delivery apps; corporate social responsibility; parties, concerts, other events, contests, and games; packaging and promotional tactics on cigarettes packages; and legal action against TAPS bans (Table 1) based on the publicly available information collected.

TABLE 1.

Features of TAPS bans, Uruguay and Argentina, 2021

Provisions	Uruguay	Argentina
TAPS ban	National Tobacco Control Law 19.244 (2014): complete ban on TAPS, including at points of sale (21) Decree 317/014: implement and enforce TAPS ban (20)	National Tobacco Control Law 26687: banned TAPS, except at points of sale, in trade publications, and direct communication to legal adults (27) Decree 602/2013: implement law 26687 (27)
Standardized tobacco packaging	Law 19.723 (2019) amended Article 8 of law18.256 to adopt standardized tobacco packaging (21)	None
Compliance reporting	Ministry of Health enforces law, and issues sanctions and penalties for violations Reporting: hotlines, website, email or filing complaint Cannot confirm action was taken after violations reported (22)	Ministry of Health enforces law, and issues sanctions and penalties for violations Reporting: hotline, website, email or filing complaint Cannot confirm action was taken after violations reported. Complaints not publicly available (28)
Evaluations	Global adult tobacco survey (2017): 19.5% of adults saw cigarette advertising in stores (3) Global youth tobacco survey (2019): 4.1% of students claimed they were offered a free tobacco product from company representative and 4.9% said it had a tobacco brand logo; 45.1% of students noticed TAP at point of sale (2)	National survey of risk factors (2018): 43% of respondents had seen tobacco advertising at point of sale (30) Argentinean global youth tobacco survey (2018): 38.2% of students noticed antitobacco messages in the media, but 41.8% noticed TAPS at point of sale (31)
Barriers to implementation	Digital and direct communication: advertising to young people through influencers, social networks, online video platforms, telephone series and movies, and new consumer products (23 24). Parties, concerts and other events: prohibited, no complaints Mobile delivery apps: display cigarette brand advertising. (i.e., Rappi, PedidosYa) (22) Corporate social responsibility: promote tobacco plantations with emphasis on family livelihood and local labor, distribution of cigarettes in food baskets to prison inmates during coronavirus disease 2019 (25) Packaging and promotional tactics on cigarette packs: use of additives, flavorings, bright colors, holograms, phrases of enjoyment, and flavor capsules to increase attractiveness and palatability of products, especially to young people (22) Legal action against labeling restrictions and bans on cigarette packages: use of litigation and threat of litigation to block, weaken, and delay tobacco standardized packaging but Uruguayan court upheld the law (26)	Point of sale: offer promotional prices and discounts, promote products through product exhibits (32) Digital and direct communication: advertising on, for example, brand websites, social media, and email-marketing campaigns, with contests, promotions, and event experiences offered (16, 23, 28, 33) Parties, concerts and other events: sponsor summer events, advertise at nightclubs, concerts, and parties, use brand ambassadors to offer promotional products and increase clients (28) Mobile delivery apps: display and advertise tobacco products, offer promotions (i.e., Rappi, PedidosYa) (34) Corporate social responsibility: support tobacco families, helping to eradicate child labor, and promote citizenship as forms of brand sponsorship, while targeting adolescents to increase corporate image and establish community partners (35) Packaging and promotional tactics on cigarette packs: promote contests, insert discounts, QR codes, and gifts, and advertise flavors, capsules, and limited editions (38) Legal action against TAPS ban in Santa Fe: use of litigation and threat of litigation to block TAPS ban but the Argentine court upheld the ban (38)

RESULTS

Uruguay model: a complete TAPS ban and standardized tobacco packaging

Uruguay became a Party to the WHO FCTC on February 27, 2005. In July 2014, Uruguay approved the national Tobacco Control Law 19.244, amending Law 18.256 from 2008 (which had adopted some TAPS restrictions) to establish a complete ban on TAPS (Table 1 and Figure 1). The law was implemented in November 2014 with Decree 317/014 (20) and it broadly bans all forms of TAPS including product display at point of sale, advertising via electronic media, and direct communications. Overall advertising and product display at the point of sale has been eliminated and the only elements allowed are a list of prices along with a pictorial warning label without logos (Figure 2).

FIGURE 1.

TAPS bans and the prevalence of tobacco use, Uruguay and Argentina, 2007–2020

FIGURE 2.

Points of cigarette sale in Uruguay (left) and Argentina (right), November 2021

In December 2018, Uruguay approved Law 19.723 amending Article 8 of Law 18.256 to require standardized tobacco packaging; this was implemented with Decree 120/019 in January 2020 (21). The national Ministry of Public Health is in charge of enforcing both national laws.

Compliance reporting. The national Ministry of Public Health enforces the law by issuing penalties for violations. Anyone can report violations through a hot line, website, email or filing a complaint to the National Tobacco Control Program within the ministry. In practice, it is difficult to determine how the law is being enforced as the ministry’s website for compliance (https://www.gub.uy/tramites/denuncia-incumplimiento-tabaco) has a form to report violations, but it is not clear what happens after the violations have been reported. However, according to reports of civil society groups, compliance with the TAPS ban appears to be high (22).

Impact of the TAPS ban. With regard to exposure to tobacco advertising at point of sale, according to the Global Adult Tobacco Survey in Uruguay, the percentage of adults (15 years and older) who saw cigarette advertising at point of sale decreased from 26.8% in 2009 to 19.5% in 2017 (3). The Global Youth Tobacco Survey in Uruguay reported that the percentage of students (13 to 15 years) who noticed tobacco advertisements or promotions when visiting points of sale decreased from 58.1% in 2014 to 45.1% in 2019 (2). With regard to tobacco use, the prevalence of smoking in adults (15 years and older) declined from 25.0% in 2009 to 21.6% in 2017. In addition, the prevalence of current use of any tobacco products among young people (13 to 15 years) decreased from 23.2% in 2007 to 11.5% in 2019 (17).

Barriers to implementing TAPS bans. The biggest barrier to implementing TAPS bans in Uruguay is the tobacco industry’s ability to aggressively market their products on social media, especially to young people, despite a complete TAPS ban.

As for digital and direct communications, while compliance with the TAPS law is still high, the tobacco industry continues to advertise to young people through influencers, social networks, online video platforms, and television series and movies (e.g., on Netflix), and by offering new consumer products (23). This includes a campaign by Philip Morris called #NightHunters, which uses paid influencers to post about a brand of menthol cigarettes; it was reported to have been seen by almost 10% of Uruguay’s population (24). An influencer hired to promote Philip Morris brands stated that, “the chosen influencers were always the youngest” (24).

Tobacco companies also display tobacco products on mobile delivery apps such as Rappi and PedidosYa, which show cigarette brand advertising, but in Uruguay, no photographs or advertisements appear on these apps (Figure 3) (22). This illustrates that the exposure to TAPS is limited to almost nonexistent.

FIGURE 3.

Tobacco advertising through mobile delivery app Rappi in Uruguay (panel a) and Argentina (panel b), November 2021

With regard to corporate social responsibility, tobacco companies are promoting tobacco plantations in Uruguay highlighting the livelihood of families and local labor efforts. This argument is widely disseminated in local media and official social networks of the local state governors and municipalities. During coronavirus disease 2019 (COVID-19), cigarette boxes were included free of charge in 700 “food” baskets donated to prison inmates in Montevideo, which was promoted by the national Ministry of Public Health on Twitter (25).

Tobacco companies use additives and flavorings to increase the attractiveness and palatability of products (e.g., menthol is refreshing). Furthermore, their packaging designs are attractive with bright colors, holograms, and phrases of enjoyment, thereby building loyalty with consumers, especially young people. Since the implementation of standardized tobacco packaging in January 2020, compliance remains high, but a few businesses are still selling imported cigars without standardized packaging.

In addition to marketing activities, tobacco companies have also used litigation and the threat of litigation to block, weaken, and delay government TAPS bans or restrictions. When Uruguay attempted to introduce standardized tobacco packaging with Decree 235/018 in August 2019, the tobacco companies filed amparos (injunctions) to block and delay the policy on constitutional grounds of violating individual and commercial rights (26). These injunctions could have delayed standardized tobacco packaging for a year but the Uruguayan legislature passed and implemented Law 19.723 in January 2020, which canceled Decree 235/018. In July 2020, the court dismissed the injunctions, stating that the executive branch did not exceed its authority with Decree 235/018 (26).

Argentina model: partial TAPS ban

Despite not being a Party of the FCTC, in June 2011, Argentina approved National Tobacco Control Law 26687 (27). Among other measures, this law banned many forms of TAPS except at the point of sale, trade publications intended exclusively for the tobacco sector (e.g., tobacco magazines with tobacco employees), and direct communications to people over 18 years with prior consent and age verification (Table 1). Decree 602/2013, adopted in May 2013, implemented the TAPS measures in accordance with the law. This decree further clarified that, although advertising at the point of sale was permitted, tobacco companies were only allowed to place two signs, one with the list of brands and prices and the other with an advertisement that required a pictorial health warning covering 20% of the sign. Direct communications to people older than 18 years was restricted to informative content that required prior consent. The decree also specified it was prohibited to: 1) place coupons or items to participate in contests or giveaways inside or next to tobacco products; 2) provide direct or indirect incentives (including at the point of sale) that promote buying or using tobacco products (e.g., discounts, gifts, and contests or competitions); and 3) deliver free samples as a gift or exchange for another product.

According to Law 26687, the national and provincial ministries of health and the National Communications Entity (Ente Nacional de Comunicaciones) are charged with enforcing TAPS regulations (27). The law is applicable to all 24 provinces in the country but Article 39 (as well as the federal constitutional system) allows the provinces to pass laws that exceed the minimum standard of protection under Law 26687. Seven provinces (Córdoba, La Pampa, Neuquén, San Luis, Santa Cruz, Santa Fe and Tierra del Fuego) have passed comprehensive TAPS bans that exceed the national Law 26687 and three (Córdoba, La Pampa, and Tierra del Fuego) explicitly ban product display at the point of sale.

Compliance reporting. The national Ministry of Health enforces the law and issues penalties for violations. Anyone can report violations through a hot line, website, or email or by filing a complaint to the Ministry of Health. The Ministry can also delegate surveillance and sanctions to other bodies (national or provincial). However, in practice, it is difficult to determine compliance as the health ministry’s website for compliance (https://www.argentina.gob.ar/salud/consumo-de-tabaco) has a form to report violations, but it is not clear how to send the form and what happens after the violations have been reported. Furthermore, the complaints, fines, penalties or the name of the company that committed the violation are not publicly available. Despite the lack of transparency of the system, tobacco control groups have submitted numerous complaint letters to the Ministry of Health detailing each violation with photographs as evidence, but the Ministry has yet to act upon these reported violations (28). This includes reporting complaints about the brand ambassadors offering promotional products and gifts at night clubs, and advertising activities at the Lollapalooza festival (see section on barriers to implementing TAPS) (28). These groups have also submitted requests for access to public information, but the fines are not published.

Evaluation of the impact of the TAPS restrictions. As regards exposure to tobacco advertising at point of sale, according to the 2012 Global Adult Tobacco Survey in Argentina, 41.9% of adults (15 years and older) had noticed any cigarette advertisements at point of sale in the previous 30 days (29). This was similar to the 2018 national survey of risk factors which reported that 43.2% of adults (18 years and older) had seen cigarette advertising at point of sale in the previous 30 days (30). However, the Global Youth Tobacco Survey in Argentina reported that the percentage of students (13 to 15 years) who noticed tobacco advertisements or promotions when visiting a point of sale decreased from 70.7% in 2012 to 41.8% in 2018 (31).

The prevalence of cigarette smoking among adults (18 years and older) declined from 27.1% in 2009 to 22.2% in 2018 (30). In addition, the prevalence of current use of any tobacco products among young people (13 to 15 years) decreased from 28.0% in 2007 (17) to 20.2% in 2018 (31).

Barriers to implementing TAPS bans. The biggest barrier to implementing TAPS restrictions in Argentina is the tobacco industry’s ability to take advantage of the law’s loopholes and aggressively market their products through various forms of advertising, especially to young people.

Although advertising at point of sale is prohibited by law, tobacco companies have used the point of sale to offer promotional prices and discounts and used product displays to promote their products (Figure 2), except in some provinces (Córdoba and Tierra del Fuego) where product display is explicitly banned at the point of sale. For example, a September 2019 study monitoring advertising at the point of sale in six cities found that 38% of point-of-sale sites had tobacco advertising signs or promotional objects and 91% displayed tobacco products (32).

As regards digital and direct communications in Argentina, the tobacco companies advertise on brand websites and social media and in email marketing campaigns, among others. Tobacco companies also integrate these digital marketing strategies with contests, promotions and event experiences, which violates Law 26687. For example, in 2015, Philip Morris launched the campaign “hacé tu movida” (make your move) which included email marketing activities, contests, promotions inside cigarette packs and at live events, and advertising in discos, at the point of sale, and on the Marlboro brand website (33). In 2018, the Marlboro website in Argentina promoted tobacco products where people could leave their contact information and participate in a contest, play games, and buy promotional products (28). Under certain promotions, people would have to provide the contact information of a friend in order to participate and win rewards (28). Although direct communications to people older than 18 years is permitted under the law, once individuals leave their contact information on the website, they will be exposed to tobacco advertising and receive promotional emails (23). For example, British American Tobacco promoted a campaign called “LikeUs” using influencers to promote Lucky Strike cigarettes (23).

Tobacco companies continue to sponsor summer events at decorated bars and on the beach, among other places. In these same locations, certain individuals act as “promotores/promotoras” (i.e., brand ambassadors) who offer promotional products (e.g., discounts for buying two packs of cigarettes) and ask individuals for their contact information to potentially increase their client databases for future marketing activities. In 2018, stands were set up with Marlboro and Lucky Strike advertising and promotions at the popular festival Lollapalooza as well as at beaches and nightclubs at popular holiday destination cities such as Mar del Plata and Villa Gesell (28).

Tobacco companies promote contests and games through websites, e-mail marketing and QR codes inserted inside the packages, among other tactics. The winners receive awards, such as trips and economic support to start an enterprise. They also offer games to play, both online on the brands’ websites and at parties and events and different kinds of contests (e.g., asking the contestants to design their own cigarettes pack).

With regard to mobile delivery apps, a 2021 study analyzed four mobile delivery apps (Rappi, PedidosYa, Wabi, and Uber Eats) in seven cities and found that 93% of the content examined displayed tobacco products in the apps, including in Córdoba, where the provincial law bans product displays (34). Despite Law 26687 banning promotions with candies, 73% of the mobile apps studied had combined promotions that sold candies jointly with cigarette packs (35).

In Argentina, tobacco companies portray themselves as supporting tobacco families, helping eradicate child labor, and promoting citizenship. These programs are forms of brand sponsorship which is prohibited by Law 26687. They also target adolescents from vulnerable sectors while promoting their corporate image and establishing important community partners (35).

Tobacco companies in Argentina use packaging and promotional tactics on their cigarette packages. A study in Argentina evaluated the design of cigarette packages and found that tobacco companies promote contests, insert discount coupons, QR codes or gifts, and advertise flavors and capsules (36). They have also launched limited editions and colored flavored cigarettes (37).

As regards legal action against TAPS, Nobleza Piccardo, an affiliate of British American Tobacco, challenged the constitutionality of the TAPS ban in Santa Fe, arguing the ban violated freedom of expression and commercial freedoms and that Santa Fe did not have the authority to implement this ban (38). However, in October 2015, the Argentine Supreme Court ruled in favor of the local ban, stating that it was a reasonable restriction of commercial freedoms because commercial speech is not entitled the same level of protection as political or social speeches and because it protected an individual’s right to life and health (38). Notably, even though Argentina has not ratified the FCTC, the Supreme Court used the treaty as an international standard for tobacco control policies (38).

DISCUSSION

The case of Uruguay is a model for the region both in terms of banning TAPS and advertising on cigarette packages through standardized tobacco packaging. Overall compliance appears to be high and early evaluations indicate success in terms of limiting exposure to TAPS. Tobacco companies continue to use corporate social responsibility programs and social media to advertise their products, especially to young people in Uruguay, although not to a great extent. Uruguay is also exposed to transnational advertising through international movies and television programs, which appear to be difficult to regulate. International and regional solutions should be tailored to enforcing bans that prohibit transborder TAPS and helping governments acquire tools to implement the bans on the Internet.

The case of Argentina illustrates the problems of only partially regulating TAPS. Similar to other countries throughout the region, tobacco companies exploit loopholes to market and advertise their products. In particular, advertising at the point of sale, the promotion of games, contests, parties, and festivals, and using influencers on social media to promote products is a real concern, especially among young people. Lack of enforcement of the law is another issue, which allows tobacco companies to advertise and promote their products, and in some cases, violate parts of the law where TAPS is banned.

Tobacco companies continue both to aggressively advertise products where permitted in Argentina and privately advertise products where they are banned in both countries, thereby creating the illusion that the advertising content is organic (not paid for). Despite effective regulation, tobacco companies continue to advertise their products on social media by paying or incentivizing influencers to share images of tobacco brands or smoking and encourage attendees of sponsored parties to post specific campaign hashtags to their social media accounts. Health advocates can file complaints or take legal action to ensure tobacco companies no longer target young people with Internet advertising on social media, which sometimes goes under the radar of regulators and government monitoring.

The tobacco industry also uses flavors to advertise their products and make them more attractive to young people. The adoption of a complete ban on advertising and standardized tobacco packaging reduces the possibility of using this tactic, which can be observed when comparing Argentina and Uruguay’s regulatory framework and market. A study found 23 types of flavored cigarettes in Argentina and only eight in Uruguay (39).

Tobacco companies have also attempted to threaten and legally sue governments over their TAPS bans, arguing they violate freedom of expression, the right of free enterprise, and intellectual property rights protected by international treaties (38). However, domestic courts have dismissed these arguments and ruled in favor of public health in Argentina, Colombia, Panama, and Uruguay (38). Courts have noted that complete bans do not interfere with the rights of consumers to receive information about the content of tobacco products (Panama, 2010); that free enterprise and economic freedoms are not absolute rights that can be regulated (Colombia, 2010); and that these bans are adequate and proportionate (Argentina, 2015) (38). Thus, governments should reject these threats and challenges and implement TAPS bans without delays to protect public health.

Limitations

This study was conducted and relied on information publicly available in news media, industry websites, and government and intergovernmental reports. While much information was found on the barriers to implementing the partial TAPS ban in Argentina, less information was found in Uruguay. This could be due to the fact that the TAPS ban in Uruguay has been so effective that reported complaints have been minimal. This study also has some important strengths, including providing a deeper understanding of the implementation of TAPS bans in the WHO Region of the Americas. By analyzing the situation on TAPS in two countries in the region, this study provides an important comparison between the implementation of a partial and complete TAPS ban. In doing so, this study illustrates the problems with partial bans, such as the difficulty in enforcing them and the many loopholes that the tobacco industry can exploit.

Conclusions

A partial TAPS ban in Argentina illustrates some of the problems with enforcement and the tobacco industry’s ability to exploit loopholes and further market and advertise their products, especially to young people. A complete TAPS ban, including standardized tobacco packaging, such as in Uruguay, is easier to implement and enforce because of fewer loopholes and is effective in reducing exposure to tobacco advertising. Nevertheless, governments should prioritize implementing TAPS bans on social media, which remains a difficult sphere to monitor and allows the tobacco industry to continue recruiting and targeting young people.

Disclaimer.

The authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública / Pan American Journal of Public Health and/or those of the Pan American Health Organization.