Methods involved are triangulated government legislation, news sources, and interviews with policy-makers and health advocates in Colombia. Colombia, a middle-income country, passed a tobacco control law in that included a prohibition on tobacco advertising, promotion, and sponsorship; and required pictorial health warning labels, ingredients disclosure, and a prohibition on individual cigarette sales. Tobacco companies challenged the implementation through litigation, tested government enforcement of advertising provisions and regulations on ingredients disclosure, and lobbied local governments to deprioritise policy responses to single cigarette sales. This network included vigilant efforts by local health groups, which continuously monitored and alerted the media to noncompliance, engaged government officials and policy-makers on implementation, and raised public awareness. Support from international health NGOs and funders and continuous engagement by local health groups enhanced implementation capacities to counter continued tobacco industry interference and ensure effective tobacco control implementation. This case study of Colombia contributes to the existing literature by demonstrating how a middle-income country succeeded in implementing a multifaceted tobacco control law although many middle-income countries have struggled with implementing more narrowly tailored tobacco control laws.
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Smokefree implementation in Colombia: Monitoring, outside funding, and business support. San Francisco. Santa Cruz, CA. San Francisco, CA. To analyze successful national smokefree policy implementation in Colombia, a middle income country. Key informants at the national and local levels were interviewed and news sources and government ministry resolutions were reviewed. Nongovernmental organizations provided technical assistance and highlighted noncompliance.
Organizations outside Colombia funded some of these efforts. Tobacco interests did not openly challenge implementation. Health organization monitoring, external funding, and hospitality industry support contributed to effective implementation, and could be cultivated in other low and middle income countries. Organizaciones fuera de Colombia financiaron algunos de estos esfuerzos.
Smokefree laws protect nonsmokers from secondhand smoke and reduce tobacco-induced diseases. The experience of high income countries 4 , 5 , 6 , 7 , 8 , 9 , 10 shows that successful implementation requires active education and enforcement, 9 , 11 appropriate enforcement agencies, 5 and support from nongovernmental organizations NGOs.
Smoke-free implementation for low and middle-income countries LMICs is challenging because tobacco companies often have more resources than the health authorities, 14 and tobacco industry activities are less controlled,12 making implementation weak or uneven. Colombia, with an adult smoking prevalence of In July , Ley de , a comprehensive tobacco control law, expanded smokefree coverage to all hospitality venues, 20 making Colombia the country with lowest gross domestic product per capita with such a national smokefree law.
We conducted interviews with 14 in-country tobacco control advocates, national and local health authorities, and policymakers between October and December following protocol IRB approved by the University of California, San Francisco Committee on Human Research table I. Colombia, Ronderos M. Health advocates then argued for legislation to comply with the FCTC. Toro, passed in July to implement FCTC Articles 8 and including smokefree areas, prohibiting tobacco advertising, promotion and sponsorship, and prohibiting individual cigarette sales.
Implementation of the smokefree provisions did not face the concerted tobacco industry opposition common elsewhere, 4 , 6 , 9 , 10 , 11 , 12 , 13 , 16 , 32 likely because the companies seem to have focused on countering the prohibitions on tobacco advertising, promotion and sponsorship. Implementation, with generally good compliance and enforcement, varied regionally.
As in high income countries, 33 , 34 , 35 implementation included guidance from the Health Ministry to local health departments, education by health departments and advocates, and enforcement by local health authorities and police, especially in major cities. The Health Ministry provided guidance, but local agencies had autonomy a in educational efforts, and worked with local police on enforcement.
For the law, the Health Ministry shared surveillance, education, and enforcement practices among local health departments. Local health departments distributed materials to business owners and the public before and after implementation. Implementation was weakest in rural areas and the Atlantic coast, with less interest from agencies in these areas e. Health advocates had focused on large cities, e and the Colombian state had more presence in departmental capitals. Rural and small-city health agencies often knew little of the law e or claimed having limited resources and personnel.
Consistent with FCTC guidelines, 3 the law authorized enforcement by local police and health authorities. The law required signage about smokefree environments, but without a predefined list, allowing for more expansive text figure 1.
Organizations outside Colombia funded Colombian NGOs to create educational materials and train local health department staff. In and Fenalco distributed flyers to business owners and employees claiming smoking in terraces was allowed 44 , 50 because they were not under roofs 51 and claimed that health advocates were maligning Fenalco for its interpretation. Universities developed educational campaigns to implement smokefree educational institutions.
Different from high income countries, in Colombia there were few government resources, weak state capacity, and enforcement agencies focused on public security.
Like many Latin American countries, Colombia lacked a strong national smokefree education campaign, 16 but had many vigorous local campaigns. Three factors in Colombia especially contributed to strong implementation.
First, noncompliance vigilantly exposed by NGOs, including for terraces, as in the case of local implementation in Mexico and the US. Since , Asobares, with the help from the Campaign for Tobacco-Free Kids, visited hospitality associations throughout Latin America to encourage national smokefree laws. Third, international organizations aided implementation, supporting NGOs to provide education and technical assistance.
Smokefree legislation should clearly cover all workplaces and specify national and local agency responsibilities. Health advocates should cultivate hospitality association support in advance of legislation, when possible. International funders should continue strongly funding LMIC implementation, as moderate resources can make substantial impacts. We attempted to contact tobacco control staff in departmental and large-city health agencies throughout Colombia.
Only those highly engaged in implementation agreed to interviews, so our findings hold to the extent that such interviews captured the key issues of local implementation. Colombia serves as an example of successful implementation of smokefree air in a middle income country. Beyond government agency activities, health organization vigilance, outside organization funding, and hospitality industry support contributed to strong implementation.
The funding agencies played no role in the selection of the research question, conduct of the research, or preparation of the manuscript. Department of Health and Human Services. Atlanta, GA. World Health Organization. Framework Convention on Tobacco Control. Geneva, Switzerland: WHO, Guidelines on Protection from Exposure to Tobacco Smoke.
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