Abstract:

Objective:

To analyze successful national smokefree policy implementation in Colombia, a middle income country.

Materials and methods:

Key informants at the national and local levels were interviewed and news sources and government ministry resolutions were reviewed.

Results:

Colombia’s Ministry of Health coordinated local implementation practices, which were strongest in larger cities with supportive leadership. Nongovernmental organizations provided technical assistance and highlighted noncompliance. Organizations outside Colombia funded some of these efforts. The bar owners’ association provided concerted education campaigns. Tobacco interests did not openly challenge implementation.

Conclusions:

Health organization monitoring, external funding, and hospitality industry support contributed to effective implementation, and could be cultivated in other low and middle income countries.

Keywords:
tobacco; tobacco industry; public policy; Latin America; Colombia

Resumen:

Objetivo:

Analizar la implementación exitosa de políticas nacionales de ambientes libres de humo en Colombia, un país de ingresos medios.

Material y métodos:

Entrevistas con informantes claves a nivel nacional y local, y revisión de artículos en las noticias y resoluciones ministeriales nacionales.

Resultados:

El Ministerio de Salud de Colombia coordinó las prácticas locales para la implementación, que fueron más fuertes en las ciudades grandes y en las ciudades con líderes políticos que la apoyaron. Organizaciones no gubernamentales proporcionaron asistencia técnica y destacaron el incumplimiento. Organizaciones fuera de Colombia financiaron algunos de estos esfuerzos. La asociación de propietarios de bares proporcionó campañas de educación concertadas. Intereses tabacaleros no desafiaron abiertamente la implementación.

Conclusiones.

La vigilancia de las organizaciones no gubernamentales, la financiación externa y el apoyo de la industria de la hospitalidad contribuyeron a una implementación eficaz. Tales factores pueden ser cultivados en países de ingresos bajos y medios.

Palabras clave:
tabaco; industria del tabaco; política social; América Latina; Colombia

Introduction

Smokefree laws protect nonsmokers from secondhand smoke and reduce tobacco-induced diseases.¹1. U.S. Department of Health and Human Services. Smokefree and Tobacco-Free Legislation in the Health Consequences of Smoking--50 Years of Progress. Atlanta, GA. [accessed on February 2016]. Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf
http://www.surgeongeneral.gov/library/re... The 2005 World Health Organization Framework Convention on Tobacco Control’s²2. World Health Organization. Framework Convention on Tobacco Control. Geneva, Switzerland: WHO, 2003. [accessed on February 2016]. Available at: http://whqlibdoc.who.int/publications/2003/9241591013.pdf
http://whqlibdoc.who.int/publications/20... (FCTC) Article 8 commits parties to implementing smokefree laws.³3. World Health Organization. Guidelines on Protection from Exposure to Tobacco Smoke. Geneva, Switzerland. [accessed on February 2016]. Available at: http://www.who.int/entity/fctc/cop/art%208%20guidelines_english.pdf
http://www.who.int/entity/fctc/cop/art%2...

The experience of high income countries⁴4. Magzamen S, Glantz SA. The New Battleground: California’s Experience with Smoke-Free Bars. Am J Public Health 2001;91:245-252. https://doi.org/10.2105/AJPH.91.2.245
https://doi.org/10.2105/AJPH.91.2.245... ,⁵5. Mamudu HM, Dadkar S, Veeranki SP, He Y. Tobacco Control in Tennessee: Stakeholder Analysis of the Development of the 2007 Non-Smoker Protection Act. [accessed on February 2016]. Available at: http://www.escholarship.org/uc/item/8z38c04x
http://www.escholarship.org/uc/item/8z38... ,⁶6. Dearlove JV, Bialous SA, Glantz SA. Tobacco Industry Manipulation of the Hospitality Industry to Maintain Smoking in Public Places. Tob Control 2002;11:94-104. https://doi.org/10.1136/tc.11.2.94
https://doi.org/10.1136/tc.11.2.94... ,⁷7. Ibrahim JK, Glantz SA. Tobacco Industry Litigation Strategies to Oppose Tobacco Control Media Campaigns. Tob Control 2006;15:50-58. https://doi.org/10.1136/tc.2005.014142
https://doi.org/10.1136/tc.2005.014142... ,⁸8. Thomson G, Wilson N. Implementation Failures in the Use of Two New Zealand Laws to Control the Tobacco Industry: 1989-2005. Australia and New Zealand Health Policy 2005;2:32. https://doi.org/10.1186/1743-8462-2-32
https://doi.org/10.1186/1743-8462-2-32... ,⁹9. Drope J, Glantz S. British Columbia Capital Regional District 100% Smokefree Bylaw: A Successful Public Health Campaign Despite Industry Opposition. Tob Control 2003;12:264-268. https://doi.org/10.1136/tc.12.3.264
https://doi.org/10.1136/tc.12.3.264... ,¹⁰10. Tsoukalas T, Glantz SA. The Duluth Clean Indoor Air Ordinance: Problems and Success in Fighting the Tobacco Industry at the Local Level in the 21st Century. Am J Public Health 2003;93:1214-1221. https://doi.org/10.2105/AJPH.93.8.1214
https://doi.org/10.2105/AJPH.93.8.1214... shows that successful implementation requires active education and enforcement,⁹9. Drope J, Glantz S. British Columbia Capital Regional District 100% Smokefree Bylaw: A Successful Public Health Campaign Despite Industry Opposition. Tob Control 2003;12:264-268. https://doi.org/10.1136/tc.12.3.264
https://doi.org/10.1136/tc.12.3.264... ,¹¹11. Gonzalez M, Glantz SA. Failure of Policy Regarding Smoke-Free Bars in the Netherlands. Eur J Public Health 2013;23:139-145. https://doi.org/10.1093/eurpub/ckr173
https://doi.org/10.1093/eurpub/ckr173... appropriate enforcement agencies,⁵5. Mamudu HM, Dadkar S, Veeranki SP, He Y. Tobacco Control in Tennessee: Stakeholder Analysis of the Development of the 2007 Non-Smoker Protection Act. [accessed on February 2016]. Available at: http://www.escholarship.org/uc/item/8z38c04x
http://www.escholarship.org/uc/item/8z38... and support from nongovernmental organizations (NGOs).⁴4. Magzamen S, Glantz SA. The New Battleground: California’s Experience with Smoke-Free Bars. Am J Public Health 2001;91:245-252. https://doi.org/10.2105/AJPH.91.2.245
https://doi.org/10.2105/AJPH.91.2.245... Tobacco companies encourage noncompliance directly and through third parties,⁴4. Magzamen S, Glantz SA. The New Battleground: California’s Experience with Smoke-Free Bars. Am J Public Health 2001;91:245-252. https://doi.org/10.2105/AJPH.91.2.245
https://doi.org/10.2105/AJPH.91.2.245... ,¹¹11. Gonzalez M, Glantz SA. Failure of Policy Regarding Smoke-Free Bars in the Netherlands. Eur J Public Health 2013;23:139-145. https://doi.org/10.1093/eurpub/ckr173
https://doi.org/10.1093/eurpub/ckr173... lobbying,⁶6. Dearlove JV, Bialous SA, Glantz SA. Tobacco Industry Manipulation of the Hospitality Industry to Maintain Smoking in Public Places. Tob Control 2002;11:94-104. https://doi.org/10.1136/tc.11.2.94
https://doi.org/10.1136/tc.11.2.94... ,⁹9. Drope J, Glantz S. British Columbia Capital Regional District 100% Smokefree Bylaw: A Successful Public Health Campaign Despite Industry Opposition. Tob Control 2003;12:264-268. https://doi.org/10.1136/tc.12.3.264
https://doi.org/10.1136/tc.12.3.264... ,¹⁰10. Tsoukalas T, Glantz SA. The Duluth Clean Indoor Air Ordinance: Problems and Success in Fighting the Tobacco Industry at the Local Level in the 21st Century. Am J Public Health 2003;93:1214-1221. https://doi.org/10.2105/AJPH.93.8.1214
https://doi.org/10.2105/AJPH.93.8.1214... ,¹²12. Lee S, Ling PM, Glantz SA. The Vector of the Tobacco Epidemic: Tobacco Industry Practices in Low and Middle-Income Countries. Cancer Causes Control 2012;23(Suppl 1):117-129. https://doi.org/10.1007/s10552-012-9914-0
https://doi.org/10.1007/s10552-012-9914-... litigating,⁷7. Ibrahim JK, Glantz SA. Tobacco Industry Litigation Strategies to Oppose Tobacco Control Media Campaigns. Tob Control 2006;15:50-58. https://doi.org/10.1136/tc.2005.014142
https://doi.org/10.1136/tc.2005.014142... and thwarting the implementation of rules.⁸8. Thomson G, Wilson N. Implementation Failures in the Use of Two New Zealand Laws to Control the Tobacco Industry: 1989-2005. Australia and New Zealand Health Policy 2005;2:32. https://doi.org/10.1186/1743-8462-2-32
https://doi.org/10.1186/1743-8462-2-32... ,¹³13. Crosbie E, Sebrie EM, Glantz SA. Strong Advocacy Led to Successful Implementation of Smokefree Mexico City. Tob Control 2011;20:64-72. https://doi.org/10.1136/tc.2010.037010
https://doi.org/10.1136/tc.2010.037010...

Smoke-free implementation for low and middle-income countries (LMICs) is challenging because tobacco companies often have more resources than the health authorities,¹⁴14. Sebrie E. The Tobacco Industry in Developing Countries. BMJ 2006;332:313-314. https://doi.org/10.1136/bmj.332.7537.313
https://doi.org/10.1136/bmj.332.7537.313... and tobacco industry activities are less controlled,12 making implementation weak or uneven.¹⁵15. Drope J, ed. Tobacco Control in Africa: People, Politics and Policies. London, England: Anthem Press, 2011.,¹⁶16. Griffith G, Cardone A, Jo C, Valdemoro A, Sebrie E. Implementation of Smoke Free Workplaces: Challenges in Latin America. Salud Publica Mex 2010;52(Suppl 2):S347-S354. https://doi.org/10.1590/S0036-36342010000800033
https://doi.org/10.1590/S0036-3634201000... ,¹⁷17. Kaur J, Jain DC. Tobacco Control Policies in India: Implementation and Challenges. Indian Journal of Public Health 2011;55:220-227. https://doi.org/10.4103/0019-557X.89941
https://doi.org/10.4103/0019-557X.89941...

Colombia, with an adult smoking prevalence of 12.8% in 2007,¹⁸18. Ministerio de Salud y Protección Social. Socialización del informe final de evaluación de necesidades para la ampliación del convenio marco de control del tabaco. Bogota, Colombia. [accessed on February 2016]. Available at: http://www.minsalud.gov.co/Documents/General/Cifras-tabaco-Colombia.pdf
http://www.minsalud.gov.co/Documents/Gen... low for Latin America, adopted national smokefree policies before many LMICs.¹⁹19. World Health Organization. Who Report on the Global Tobacco Epidemic, 2013: Enforcing Bans on Tobacco Advertising, Promotion and Sponsorship. Geneva, Switzerland. [accessed on February 2016]. Available at: http://apps.who.int/iris/bitstream/10665/85380/1/9789241505871_eng.pdf
http://apps.who.int/iris/bitstream/10665... In May 2008, the Health Ministry issued Resolución 1956 de 2008 (Ministerial Resolution No. 1956), mandating smokefree indoor public areas. In July 2009, Ley 1335 de 2009, a comprehensive tobacco control law, expanded smokefree coverage to all hospitality venues,²⁰20. República de Colombia. Ley No. 1335. Bogota, Colombia. [accessed on February 2016]. Available at: Available at: http://www.tobaccocontrollaws.org/files/live/Colombia/Colombia%20-%20Law%20No.%201335%20-%20national.pdf
http://www.tobaccocontrollaws.org/files/... making Colombia the country with lowest gross domestic product per capita with such a national smokefree law.²¹21. World Bank. GDP Per Capita (Current US$). [accessed on February 2016]. Available at: http://data.worldbank.org/indicator/NY.GDP.PCAP.CD
http://data.worldbank.org/indicator/NY.G...

Successful implementation of Colombia’s 2008 resolution and 2009 law involved national and local health department efforts, with technical and financial help from domestic and international health NGOs.

Materials and methods

From July 2014 to July 2015, we reviewed Colombian government ministries’ resolutions, administrative orders, government agency webpages, and public documents related to Colombia’s 2008 smokefree resolution and 2009 tobacco control law, articles of daily newspapers with national reach dated between January 2008 and July 2015, and related legislation, court rulings, and local government resolutions, using standard snowball methods.

We conducted interviews with 14 in-country tobacco control advocates, national and local health authorities, and policymakers between October 2014 and December 2014 following protocol IRB #10-01262 approved by the University of California, San Francisco Committee on Human Research (table I.)2222. Pan American Health Organization. Tobacco or Health: Status in the Americas. Scientific Publication No. 536. Washington, D.C. [accessed on February 2016]. Available at: http://ceca.barganibar.net/can-i/tobacco-or-health-status-in-the-americas-a-report-of-the-pan-american-health-organization-paho-scientific-publications-no-536.pdf
http://ceca.barganibar.net/can-i/tobacco... Informed consent was obtained in accordance with ethical principles of medical research involving human subjects of the Helsinki Declaration.

Results

Early attempts at smokefree legislation

Colombia’s 2008 smokefree resolution and 2009 law were adopted after decades of failed attempts²³23. Marín L. Aún quedan muchos cigarrillos por apagar de aprobar la ley antitabaco. Bogotá: La Silla Vacía, 2009.,²⁴24. Garcia-Ruiz MA, Rivera-Rodríguez DE, Marín Y, Gonzalez JC, Murillo Moreno RH. Las Iniciativas para el control del tabaco en el Congreso de Colombia: 1992-2007. Rev Panam Salud Publica 2009;25:471-480. https://doi.org/10.1590/S1020-49892009000600002
https://doi.org/10.1590/S1020-4989200900... that were blocked by tobacco industry interests, tobacco-growing area legislators ^aDeclaration of conflict of interests. The authors declare that they have no conflict of interests. and the Ministry of Agriculture,^aDeclaration of conflict of interests. The authors declare that they have no conflict of interests. despite tobacco being less than 0.1% of Colombia’s exports.²⁵25. Observatory of Economic Complexity. Products Exported by Colombia (2012). Massachussetts, United States: Massachusetts Institute of Technology. [accessed on February 2016]. Available at: https://atlas.media.mit.edu/en/explore/tree_map/hs/export/col/all/show/2012/
https://atlas.media.mit.edu/en/explore/t... In 2006, Sen. Dilian Francisca Toro, a physician allied with President Álvaro Uribe (2002-2010),²⁶26. Montero D. Dilian Francisca Toro, La Baronesa de la Salud. Bogotá: La Silla Vacia, November, 2010. became Senate President and pushed for Colombia to join the FCTC,²⁷27. República de Colombia. Ley No. 1109. Bogota, Colombia. [accessed on February 2016]. Available at: http://www.alcaldiabogota.gov.co/sisjur/normas/Norma1.jsp?i=22663
http://www.alcaldiabogota.gov.co/sisjur/... which it did in April 2008. Health advocates then argued for legislation to comply with the FCTC.^aa Toro Torres DF. Interview of Dilian Francisca Toro Torres, former Colombian senator and former President of the Senate of Colombia, by Randy Uang. Cali, Colombia. 2014.

Colombia’s 2008 smokefree resolution and 2009 law

Resolución 1956 de 2008, issued in May 2008 by the Health Ministry²⁸28. Ministerio de la Protección Social. Resolución 1956. Bogotá, Colombia. [accessed on February 2016]. Available at: http://www.alcaldiabogota.gov.co/sisjur/normas/Norma1.jsp?i=30565
http://www.alcaldiabogota.gov.co/sisjur/... (then called the Ministry of Social Protection), mandated smokefree indoor public areas nationwide.

Ley 1335 de 2009 (“Law 1335 of 2009”), sponsored by Sen. Toro, passed in July 2009 to implement FCTC Articles 8 and 10-16 including smokefree areas, prohibiting tobacco advertising, promotion and sponsorship, and prohibiting individual cigarette sales.^aa Toro Torres DF. Interview of Dilian Francisca Toro Torres, former Colombian senator and former President of the Senate of Colombia, by Randy Uang. Cali, Colombia. 2014. The law went beyond Resolución 1956 de 2008 (table II),²⁹29. Banco de la República. Salario Mínimo legal en Colombia - Serie Histórica En Pesos Colombianos. [accessed on February 2016]. Available at: http://obiee.banrep.gov.co/analytics/
http://obiee.banrep.gov.co/analytics/... by requiring smokefree grounds of educational institutions, cultural institutions such as museums, and health facilities. The Instituto Nacional de Cancerología (National Cancer Institute, part of the Health Ministry), Liga Colombiana Contra el Cáncer (Colombian League Against Cancer), the Colombia-based Latin America branch of Corporate Accountability International, and Sociedad Colombiana de Cardiología (Colombian Society of Cardiology) supported its passage;²³23. Marín L. Aún quedan muchos cigarrillos por apagar de aprobar la ley antitabaco. Bogotá: La Silla Vacía, 2009.,³⁰30. World Heart Federation. Tobacco Control in Colombia: Victory for Heart Health. Geneva, Switzerland. [accessed on February 2016]. Available at: http://www.world-heart-federation.org/publications/heart-beat-e-newsletter/heart-beat-februarymarchapril-2010/in-this-issue/tobacco-control-in-colombia/
http://www.world-heart-federation.org/pu... ,³¹31. Caracol Radio. Aprobación de Ley Antitabaco pone en ‘Jaque’ el futuro de la publicidad de cigarrillos en Colombia. Caracol Radio. Bogotá, Colombia. June, 2009. representatives friendly to the tobacco industry opposed it.²³23. Marín L. Aún quedan muchos cigarrillos por apagar de aprobar la ley antitabaco. Bogotá: La Silla Vacía, 2009. Philip Morris, British American Tobacco, and local tobacco company Protabaco tried unsuccessfully to permit designated smoking areas.²³23. Marín L. Aún quedan muchos cigarrillos por apagar de aprobar la ley antitabaco. Bogotá: La Silla Vacía, 2009.

Implementation of the smokefree provisions did not face the concerted tobacco industry opposition common elsewhere,⁴4. Magzamen S, Glantz SA. The New Battleground: California’s Experience with Smoke-Free Bars. Am J Public Health 2001;91:245-252. https://doi.org/10.2105/AJPH.91.2.245
https://doi.org/10.2105/AJPH.91.2.245... ,⁶6. Dearlove JV, Bialous SA, Glantz SA. Tobacco Industry Manipulation of the Hospitality Industry to Maintain Smoking in Public Places. Tob Control 2002;11:94-104. https://doi.org/10.1136/tc.11.2.94
https://doi.org/10.1136/tc.11.2.94... ,⁹9. Drope J, Glantz S. British Columbia Capital Regional District 100% Smokefree Bylaw: A Successful Public Health Campaign Despite Industry Opposition. Tob Control 2003;12:264-268. https://doi.org/10.1136/tc.12.3.264
https://doi.org/10.1136/tc.12.3.264... ,¹⁰10. Tsoukalas T, Glantz SA. The Duluth Clean Indoor Air Ordinance: Problems and Success in Fighting the Tobacco Industry at the Local Level in the 21st Century. Am J Public Health 2003;93:1214-1221. https://doi.org/10.2105/AJPH.93.8.1214
https://doi.org/10.2105/AJPH.93.8.1214... ,¹¹11. Gonzalez M, Glantz SA. Failure of Policy Regarding Smoke-Free Bars in the Netherlands. Eur J Public Health 2013;23:139-145. https://doi.org/10.1093/eurpub/ckr173
https://doi.org/10.1093/eurpub/ckr173... ,¹²12. Lee S, Ling PM, Glantz SA. The Vector of the Tobacco Epidemic: Tobacco Industry Practices in Low and Middle-Income Countries. Cancer Causes Control 2012;23(Suppl 1):117-129. https://doi.org/10.1007/s10552-012-9914-0
https://doi.org/10.1007/s10552-012-9914-... ,¹³13. Crosbie E, Sebrie EM, Glantz SA. Strong Advocacy Led to Successful Implementation of Smokefree Mexico City. Tob Control 2011;20:64-72. https://doi.org/10.1136/tc.2010.037010
https://doi.org/10.1136/tc.2010.037010... ,¹⁶16. Griffith G, Cardone A, Jo C, Valdemoro A, Sebrie E. Implementation of Smoke Free Workplaces: Challenges in Latin America. Salud Publica Mex 2010;52(Suppl 2):S347-S354. https://doi.org/10.1590/S0036-36342010000800033
https://doi.org/10.1590/S0036-3634201000... ,³²32. Sebrié EM, Glantz SA. Local Smoke-Free Policy Development in Santa Fe, Argentina. Tob Control 2010;19:110-116. likely because the companies seem to have focused on countering the prohibitions on tobacco advertising, promotion and sponsorship.

Processes and results in implementation

The Health Ministry, local health authorities, local police, NGOs, the national barowners’ association (Asobares), and individual establishments, including universities, contributed to implementation. Implementation, with generally good compliance and enforcement, varied regionally. As in high income countries,³³33. Lum K, Glantz SA. The Cost of Caution: Tobacco Industry Political Influence and Tobacco Policy Making in Oregon (1997-2007). San Francisco, United States. [accessed on February 2016]. Available at: http://www.escholarship.org/uc/item/1nb5k688
http://www.escholarship.org/uc/item/1nb5... ,³⁴34. Tung G, Glantz SA. Swimming Upstream: Tobacco Policy Making in Nevada. San Francisco, United States. [accessed on February 2016]. Available at: Available at: http://www.escholarship.org/uc/item/4fn8v32x
http://www.escholarship.org/uc/item/4fn8... ,³⁵35. Hendlin YH, Barnes RL, Glantz SA. Tobacco Control in Transition: Public Support and Governmental Disarray in Arizona (1997-2007). San Francisco, United States. [accessed on February 2016]. Available at: http://www.escholarship.org/uc/item/1nb5k688
http://www.escholarship.org/uc/item/1nb5... 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. In 2015, a survey in large cities found that 92% of nonsmokers and 91% of smokers supported the 2009 law.³⁶36. El Tiempo. Fumadores y no fumadores aprueban normas antitabaco. Bogotá, Colombia. [accessed on February 2016]. Available at: http://www.eltiempo.com/estilo-de-vida/salud/ley-antitabaco-en-colombia-encuesta-muestra-apoyo-a-medidas-para-controlar-el-cigarrillo/16419951
http://www.eltiempo.com/estilo-de-vida/s...

National-local dynamics

Colombia’s low state capacity³⁷37. Marshall MG, Cole BR. Global Report 2014: Conflict, Governance, and State Fragility: Center for Systemic Peace. [accessed on February 2016]. Available at: http://www.systemicpeace.org/vlibrary/GlobalReport2014.pdf
http://www.systemicpeace.org/vlibrary/Gl... meant limited national agency efforts. Health policy implementation was decentralized across local health agencies for Colombia’s major cities, 32 departamentos (departments), and capital district. The Health Ministry provided guidance, but local agencies had autonomy^ab Hernández B. Interview of Blanca Hernández, former tobacco pro gram manager at Ministerio de la Protección Social no longer working on tobacco, by Randy Uang, Bogotá, Colombia. 2014. in educational efforts, and worked with local police on enforcement.

National government activities

To implement the 2008 resolution, in December 2008 the Health Ministry distributed a “circular”,³⁸38. Ministerio de la Protección Social. Circular Externa 80. [accessed on February 2016]. Available at: http://www.alcaldiabogota.gov.co/sisjur/normas/Norma1.jsp?i=34201
http://www.alcaldiabogota.gov.co/sisjur/... i.e. a memo to local health departments, detailing that it expected local public education and enforcement activities, without requiring specific activities.

For the 2009 law, the Health Ministry shared surveillance, education, and enforcement practices among local health departments.^ba Toro Torres DF. Interview of Dilian Francisca Toro Torres, former Colombian senator and former President of the Senate of Colombia, by Randy Uang. Cali, Colombia. 2014. Bogotá included smokefree surveillance in routine health inspections,^bb Hernández B. Interview of Blanca Hernández, former tobacco pro gram manager at Ministerio de la Protección Social no longer working on tobacco, by Randy Uang, Bogotá, Colombia. 2014. resulting in 162,000 inspections in 2009 and 197 000 by 2011,³⁹39. Secretaría Distrital de Salud de Bogotá D.C. Vigilancia Sanitaria y Ambiental: 2006-2011. Bogotá, Colombia. [accessed on February 2016]. Available at: www.saludcapital.gov.co/DSP/Anuario%20Vigilancia%20Sanitaria%20y%20Ambiental/Vigilancia%20Ambiental%20y%20Sanitaria%202006-2011.pdf
www.saludcapital.gov.co/DSP/Anuario%20V... with compliance in a low-income Bogotá neighborhood estimated at 91%.⁴⁰40. Hospital Vista Hermosa. Boletín Epidemiológico y Ambiental, Noviembre 2014: Alcaldía Mayor de Bogotá D.C. [accessed on February 2016]. Available at: http://www.hospitalvistahermosa.gov.co/web/node/sites/default/files/boletines_2014/BOLETINES_EPIDEMIOLOGICOS/EL_BOLETIN_HVH_NOVIEMBRE%202014_FINALSDS.pdf
http://www.hospitalvistahermosa.gov.co/w... The Instituto Nacional de Cancerología provided technical assistance to the Health Ministry, including monitoring.^cc Niño-Bogoya A. Interview of Alejandro Niño Bogoya, public policy director at the Instituto Nacional de Cancerología, by Randy Uang, Bogotá, Colombia. 2014. Limited Health Ministry resources for tobacco control,^dd Calderón L. Interview of Lorena Calderón, tobacco program manager at the Ministerio de Salud y Protección Social, by Randy Uang, Bogotá, Colombia. 2014 however, meant the absence of a strong national smokefree education campaign.⁴¹41. Inter-American Heart Foundation. Framework Convention on Tobacco Control : Challenges for Latin America and the Caribbean. Civil Society Report. Dallas, Tx: Inter-American Health Foundation, 2010.

The Procuraduría General de la Nación (National Inspector General), constitutionally responsible for ensuring compliance with laws by government agencies, did not focus on compelling local smokefree education and enforcement because it was focused on Colombia’s internal armed conflict and conflict-related human rights.⁴²42. Bergquist C, Peñaranda R, Sánchez G. Violence in Colombia 1990-2000: Waging War and Negotiating Peace. Wilmington, Delaware: Scholarly Resources, 2001. The Health Ministry asked the Procuraduría to focus more on local health agency smokefree education and enforcement, and the Procuraduría issued a “circular” memo⁴³43. Procuraduría General de la Nación. Circular 31. [accessed on February 2016]. Available at: http://www.alcaldiabogota.gov.co/sisjur/normas/Norma1.jsp?i=41944#0
http://www.alcaldiabogota.gov.co/sisjur/... requesting local health departments to implement the law, but did little follow-up, which resulted in variations in activity.

Local government bodies’ activities: Regional variation

Implementation was strongest in big cities and in cities with supportive political leadership: Bogotá (population 8 million), Medellín (2.4 million), Cali (2.3 million), Colombia’s most influential cities, and two southwestern cities, Popayán (250 000) and Pasto (480 000), with personally committed mayors. 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^ee Dorado YF. Interview of Yul Francisco Dorado, regional director at Corporate Accountability International, by Randy Uang, Bogotá, Colombia. 2014.. Health advocates had focused on large cities,^ee Dorado YF. Interview of Yul Francisco Dorado, regional director at Corporate Accountability International, by Randy Uang, Bogotá, Colombia. 2014. and the Colombian state had more presence in departmental capitals. Rural and small-city health agencies often knew little of the law^ee Dorado YF. Interview of Yul Francisco Dorado, regional director at Corporate Accountability International, by Randy Uang, Bogotá, Colombia. 2014. or claimed having limited resources and personnel.⁴⁴44. González LE. Denuncian incumplimiento de gobierno en ejecución de ley antitabaco. El Tiempo. March 22, 2011.

Supportive political leadership in Popayán and Pasto resulted in the reiteration of the local health departments’ implementation responsibilities^ff Lagos Campos N. Telephone interview of Nancy Lagos Campos, coordinator of the chronic diseases program at the Secretaría de Salud de Pasto, by Randy Uang. 2014.,^gg Ramos Quilindo, interview. and in crafting educational efforts annually^ff Lagos Campos N. Telephone interview of Nancy Lagos Campos, coordinator of the chronic diseases program at the Secretaría de Salud de Pasto, by Randy Uang. 2014.,^gg Ramos Quilindo, interview. for restaurant, bar, and nightclub owners,^ee Dorado YF. Interview of Yul Francisco Dorado, regional director at Corporate Accountability International, by Randy Uang, Bogotá, Colombia. 2014.,^gg Ramos Quilindo, interview. by the mayors’ offices. Popayán also conducted smokefree education at schools.^ee Dorado YF. Interview of Yul Francisco Dorado, regional director at Corporate Accountability International, by Randy Uang, Bogotá, Colombia. 2014.,^gg Ramos Quilindo, interview.

Local police: Attention to public security

Consistent with FCTC guidelines,³3. World Health Organization. Guidelines on Protection from Exposure to Tobacco Smoke. Geneva, Switzerland. [accessed on February 2016]. Available at: http://www.who.int/entity/fctc/cop/art%208%20guidelines_english.pdf
http://www.who.int/entity/fctc/cop/art%2... the 2009 law authorized enforcement by local police and health authorities. Given Colombia’s armed conflict, many police departments did not prioritize smokefree enforcement; however, Bogotá, Medellín, and Pasto’s health departments convinced local police to carry out enforcement.^bb Hernández B. Interview of Blanca Hernández, former tobacco pro gram manager at Ministerio de la Protección Social no longer working on tobacco, by Randy Uang, Bogotá, Colombia. 2014.

Signage requirements

The 2008 resolution required establishments to post signs with specified smokefree messages (“For the good of your health, this space is free of cigarette or tobacco smoke,” “Breathe easy, this space is free of tobacco smoke,” “Welcome, this establishment is free of tobacco smoke”). The resolution prohibited cigarette brand logos and images “alluding to cigarettes” so the signs did not carry the international “no smoking” symbol. Establishments could post signs referring to smokefree environments (a positive message) without any “no smoking” symbol (a negative message), then optionally could post additional signs carrying the symbol. The 2009 law required signage about smokefree environments, but without a predefined list, allowing for more expansive text (figure 1). Since “no smoking” signs may prime smoking tendencies,⁴⁵45. Earp BD, Dill B, Harris JL, Ackerman JM, Bargh JA. No sign of quitting: incidental exposure to “no smoking” signs ironically boosts cigarette-approach tendencies in smokers. Journal of Applied Social Psychology 2013;43:2158-2162. https://doi.org/10.1111/jasp.12202 Colombia’s positive smokefree messaging may have improved compliance.

Outside funders: Supporting NGO activities

Organizations outside Colombia funded Colombian NGOs to create educational materials and train local health department staff. As elsewhere in Latin America, the US-based Bloomberg Foundation’s Initiative to Reduce Tobacco Use funded Colombian NGOs for smokefree education, training, and monitoring, totaling 501 563 dollars through October 2015.⁴⁶46. Bloomberg Foundation. Bloomberg Initiative to Reduce Tobacco Use Grants Program, 2015. [accessed on February 2016]. Available at: http://www.tobaccocontrolgrants.org/Pages/40/What-we-fund?who_region=PAHO&country_id=&amount=&date_type=&date_from=&date_to=&submit=Search
http://www.tobaccocontrolgrants.org/Page... Corporate Accountability International’s Colombia-based staff highlighted noncompliance starting in 2008 and provided technical assistance to defend the 2009 law against potential industry litigation.^ee Dorado YF. Interview of Yul Francisco Dorado, regional director at Corporate Accountability International, by Randy Uang, Bogotá, Colombia. 2014. The Bogotá-based Universidad Sergio Arboleda improved community involvement in 2010-2012, the Liga Colombiana Contra el Cáncer (Colombian League Against Cancer) conducted smokefree education in 2012,^hh Barón E, Llorente B. Interview of Edwin Barón, director of education at Liga Colombiana Contra el Cáncer, and Blanca Llorente, technical advisor at Fundación Anáas, by Randy Uang, Bogotá, Colombia. 2014. and the health and civic group Fundación FES trained local health departments in 2014.ⁱi Varela A. Interview of Alejandro Varela, executive director of Fundación FES, by Randy Uang, Cali, Colombia. 2014

In particular, the Liga Colombiana Contra el Cáncer and Corporate Accountability International joined Senator Toro in 2011 to highlight noncompliance to the Ministry of Health and news media.⁴²42. Bergquist C, Peñaranda R, Sánchez G. Violence in Colombia 1990-2000: Waging War and Negotiating Peace. Wilmington, Delaware: Scholarly Resources, 2001. Since health advocates in the 2000s had sensitized journalists to tobacco control,^jjRivera Rodríguez DE. Interview of Diana Esperanza Rivera Rodríguez, former public policy director, Instituto Nacional de Cancerología, by Randy Uang, Bogotá, Colombia. 2014. coverage often called for national and local efforts.

Advocates also worked with the Bogotá-based Universidad Sergio Arboleda to create “Opción No Fumar” (the Non-smoking Option) campaign, distributing flyers, postcards, and pamphlets about the law.^hg Ramos Quilindo, interview. By July 2013, “Opción No Fumar” had distributed 29 350 pamphlets.⁴⁷47. Fernández P. Informe Junta Directiva Campañas: Liga Colombiana Contra el Cáncer. [accessed on February 2016]. Available at: https://prezi.com/ozaj-fy6-ns-/untitled-prezi/
https://prezi.com/ozaj-fy6-ns-/untitled-...

Controversy about terraces: The merchants’ federation Fenalco and NGO vigilance

The Federación Nacional de Comerciantes (Colombian Merchants’ Federation, Fenalco) interpreted the 2009 law’s smokefree provisions as not applying to terrace areas of restaurants and bars. Fenalco had cooperated in the past with tobacco industry “youth smoking prevention” programs⁴⁸48. Sebrie EM, Glantz SA. Attempts to Undermine Tobacco Control: Tobacco Industry “Youth Smoking Prevention” Programs to Undermine Meaningful Tobacco Control in Latin America. Am J Public Health 2007;97:1357-1367. https://doi.org/10.2105/AJPH.2006.094128
https://doi.org/10.2105/AJPH.2006.094128... designed to displace government action.⁴⁹49. Landman A, Ling PM, Glantz SA. Tobacco industry youth smoking prevention programs: protecting the industry and hurting tobacco control.> Am J Public Health 2002;92:917-930. https://doi.org/10.2105/AJPH.92.6.917
https://doi.org/10.2105/AJPH.92.6.917...

In 2010 and 2011 Fenalco distributed flyers to business owners and employees claiming smoking in terraces was allowed⁴⁴44. González LE. Denuncian incumplimiento de gobierno en ejecución de ley antitabaco. El Tiempo. March 22, 2011.,⁵⁰50. El Tiempo . Controversia por terrazas para los fumadores. August 2, 2012. because they were not under roofs ⁵¹51. Federación Nacional de Comerciantes. Las Brujas De Salem. [accessed on February 2016]. Available at: http://www.fenalco.com.co/contenido/1421
http://www.fenalco.com.co/contenido/1421... and claimed that health advocates were maligning Fenalco for its interpretation.⁵¹51. Federación Nacional de Comerciantes. Las Brujas De Salem. [accessed on February 2016]. Available at: http://www.fenalco.com.co/contenido/1421
http://www.fenalco.com.co/contenido/1421... Despite the support of the Health Ministry and NGOs,⁴⁴44. González LE. Denuncian incumplimiento de gobierno en ejecución de ley antitabaco. El Tiempo. March 22, 2011.,⁵⁰50. El Tiempo . Controversia por terrazas para los fumadores. August 2, 2012. whether implementation included terraces depended on local health authorities. Medellín only enforced covered terraces,⁵²52. El Espectador. ¿Cómo Va La Ley De Espacios Libre De Humo? El Espectador, (Bogotá, Colombia). April 14, 2011. while in 2011 Bogotá’s health department declared it would enforce all terraces.⁵³53. El Tiempo . ‘Sí está prohibido fumar en terrazas’: Secretario Distrital de Salud. El Tiempo, April 12, 2011.

Strong support from the Bar Owners’ Association (Asobares)

The Asociación de Bares de Colombia (Asobares, Association of Bars of Colombia) supported implementation strongly but initially had opposed the 2008 resolution,^kk Ospina C. Interview of Camilo Ospina, executive director of Asociación de Bares de Colombia (Asobares), by Randy Uang, Bogotá, Colombia. 2014. reflecting the efforts of the tobacco industry to turn hospitality groups against smokefree laws.⁴4. Magzamen S, Glantz SA. The New Battleground: California’s Experience with Smoke-Free Bars. Am J Public Health 2001;91:245-252. https://doi.org/10.2105/AJPH.91.2.245
https://doi.org/10.2105/AJPH.91.2.245... ,⁶6. Dearlove JV, Bialous SA, Glantz SA. Tobacco Industry Manipulation of the Hospitality Industry to Maintain Smoking in Public Places. Tob Control 2002;11:94-104. https://doi.org/10.1136/tc.11.2.94
https://doi.org/10.1136/tc.11.2.94... Some of Asobares’ executive committee were personally affected by secondhand smoke, so Asobares surveyed its members and found that a majority supported the resolution, so shifted to supporting it.^kk Ospina C. Interview of Camilo Ospina, executive director of Asociación de Bares de Colombia (Asobares), by Randy Uang, Bogotá, Colombia. 2014. The tobacco industry did not appear to interfere with this change.

Asobares conducted intensive education for bar owners for six months before the 2008 resolution’s December 4 effective date,^kjRivera Rodríguez DE. Interview of Diana Esperanza Rivera Rodríguez, former public policy director, Instituto Nacional de Cancerología, by Randy Uang, Bogotá, Colombia. 2014. including brochures, and bar coasters co-sponsored by the Health Department of Bogotá, Bogotá Mayor’s Office, and World Heart Federation, reading: “Si va a fumar, hágalo afuera” (“If you are going to smoke, do it outside”).^kjRivera Rodríguez DE. Interview of Diana Esperanza Rivera Rodríguez, former public policy director, Instituto Nacional de Cancerología, by Randy Uang, Bogotá, Colombia. 2014. Asobares provided candy to people who stepped outside to smoke, had models come to bars to give prizes to such people, and worked with the Bogotá government on a protocol for the emergency services number (123), which would summon police to eject patrons who insisted on smoking indoors.^kk Ospina C. Interview of Camilo Ospina, executive director of Asociación de Bares de Colombia (Asobares), by Randy Uang, Bogotá, Colombia. 2014. These activities set a tone of compliance from the start.

University activities: Smokefree outdoors

Universities developed educational campaigns to implement smokefree educational institutions. In Bogotá, 21 universities cooperated to develop similar campaigns, and in Cali, 13 universities joined a local health department network to share information on campaigns.⁵⁴54. Corporación Unificada Nacional de Educación Superior. Se firmó el pacto por las universidades 100% Libres De Humo. [accessed on February 2016]. Available at: www.cun.edu.co/dmdocuments/boletin-de-prensa-pacto-univesidades-libres-de-humo.pdf
www.cun.edu.co/dmdocuments/boletin-de-pr... ,⁵⁵55. Alcaldía de Cali. Universidades libres de humo se abren campo en Cali. [accessed on February 2016]. Available at: http://www.cali.gov.co/publicaciones/universidades_libres_de_humo_se_abren_campo_en_cali_pub
http://www.cali.gov.co/publicaciones/uni... The Pontificia Universidad Javeriana in Bogotá and Cali, with personal interest from the Bogotá campus rector,^ll Ronderos M. Interview of Margarita Ronderos, Professor at Pontificia Universidad Javeriana, by Randy Uang, Bogotá, Colombia. 2014. had the Bogotá campus establish signs at campus entrances and major outdoor locations, including a life-size sign of a student announcing a smokefree campus. The Cali campus put signs throughout, including person-high signs saying, “En la universidad no se fuma” (“At the university, there is no smoking”).⁵⁶56. Pontificia Universidad Javeriana - Cali. Javerianos respiremos, estrategia desarrollada en la Pontificia Universidad Javeriana - Cali, Ley 1335 de 2009 en el contexto de las Universidades. Cali, Colombia: Programa Universidad Saludable, Centro de Bienestar, 2014.

Discussion

Like high income countries,⁴4. Magzamen S, Glantz SA. The New Battleground: California’s Experience with Smoke-Free Bars. Am J Public Health 2001;91:245-252. https://doi.org/10.2105/AJPH.91.2.245
https://doi.org/10.2105/AJPH.91.2.245... ,¹¹11. Gonzalez M, Glantz SA. Failure of Policy Regarding Smoke-Free Bars in the Netherlands. Eur J Public Health 2013;23:139-145. https://doi.org/10.1093/eurpub/ckr173
https://doi.org/10.1093/eurpub/ckr173... ,⁵⁷57. World Health Organization. Protection from Exposure to Second-Hand Tobacco Smoke: Policy Recommendations. Geneva, Switzerland. [accessed on February 2016]. Available at: www.who.int/tobacco/resources/publications/wntd/2007/PR_on_SHS.pdf
www.who.int/tobacco/resources/publicatio... Colombia’s successful smokefree implementation required sustained engagement by national and local health authorities, NGO, external funders, the national bar owners’ association, and universities. 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,¹⁶16. Griffith G, Cardone A, Jo C, Valdemoro A, Sebrie E. Implementation of Smoke Free Workplaces: Challenges in Latin America. Salud Publica Mex 2010;52(Suppl 2):S347-S354. https://doi.org/10.1590/S0036-36342010000800033
https://doi.org/10.1590/S0036-3634201000... but had many vigorous local campaigns.⁴⁵45. Earp BD, Dill B, Harris JL, Ackerman JM, Bargh JA. No sign of quitting: incidental exposure to “no smoking” signs ironically boosts cigarette-approach tendencies in smokers. Journal of Applied Social Psychology 2013;43:2158-2162. https://doi.org/10.1111/jasp.12202 Colombia benefited from national and local agencies and support from legislative champions, and notably has a successful history of public health policies.⁵⁸58. República de Colombia. Ley No. 670. Bogota, Colombia. [accessed on February 2016]. Available at: http://www.alcaldiabogota.gov.co/sisjur/normas/Norma1.jsp?i=4160
http://www.alcaldiabogota.gov.co/sisjur/... ,⁵⁹59. Glassman A. From Few to Many: Ten Years of Health Insurance Expansion in Colombia. Washington D.C., United States: Brookings Institution Press, 2010.

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.⁴4. Magzamen S, Glantz SA. The New Battleground: California’s Experience with Smoke-Free Bars. Am J Public Health 2001;91:245-252. https://doi.org/10.2105/AJPH.91.2.245
https://doi.org/10.2105/AJPH.91.2.245... ,¹³13. Crosbie E, Sebrie EM, Glantz SA. Strong Advocacy Led to Successful Implementation of Smokefree Mexico City. Tob Control 2011;20:64-72. https://doi.org/10.1136/tc.2010.037010
https://doi.org/10.1136/tc.2010.037010... The merchants’ federation argued against applying the law to terraces, creating an ambiguity about patio-like areas that also occurred in the US.⁶6. Dearlove JV, Bialous SA, Glantz SA. Tobacco Industry Manipulation of the Hospitality Industry to Maintain Smoking in Public Places. Tob Control 2002;11:94-104. https://doi.org/10.1136/tc.11.2.94
https://doi.org/10.1136/tc.11.2.94... ,⁹9. Drope J, Glantz S. British Columbia Capital Regional District 100% Smokefree Bylaw: A Successful Public Health Campaign Despite Industry Opposition. Tob Control 2003;12:264-268. https://doi.org/10.1136/tc.12.3.264
https://doi.org/10.1136/tc.12.3.264... ,¹⁰10. Tsoukalas T, Glantz SA. The Duluth Clean Indoor Air Ordinance: Problems and Success in Fighting the Tobacco Industry at the Local Level in the 21st Century. Am J Public Health 2003;93:1214-1221. https://doi.org/10.2105/AJPH.93.8.1214
https://doi.org/10.2105/AJPH.93.8.1214... ,¹¹11. Gonzalez M, Glantz SA. Failure of Policy Regarding Smoke-Free Bars in the Netherlands. Eur J Public Health 2013;23:139-145. https://doi.org/10.1093/eurpub/ckr173
https://doi.org/10.1093/eurpub/ckr173... ,⁶⁰60. Uang R, Barnes R, Glantz S. Tobacco Policymaking in Illinois, 1965-2014: Gaining Ground in a Short Time. San Francisco: University of California Center for Tobacco Control Research and Education, 2014 [accessed on February 2016]. Available at: www.escholarship.org/uc/item/6805h95r
www.escholarship.org/uc/item/6805h95r ...

Second, support by the Bar Owners’ Association set a tone of compliance similar to that of California in the US,⁶¹61. Glantz SA, Balbach ED. Tobacco War: Inside the California Battles. Berkeley, CA: University of California Press, 1999. showing how organizations within the society, not just government agencies, are essential to compliance. Since 2008, Asobares, with the help from the Campaign for Tobacco-Free Kids, visited hospitality associations throughout Latin America to encourage national smokefree laws.^kk Ospina C. Interview of Camilo Ospina, executive director of Asociación de Bares de Colombia (Asobares), by Randy Uang, Bogotá, Colombia. 2014.

Third, international organizations aided implementation, supporting NGOs to provide education and technical assistance.⁶²62. Reimann KD. A View from the Top: International Politics, Norms and the Worldwide Growth of NGOs. International Studies Quarterly 2006;50:45-67. https://doi.org/10.1111/j.1468-2478.2006.00392.x
https://doi.org/10.1111/j.1468-2478.2006... Sustained resources are necessities for long term compliance,⁶³63. Champagne BM, Sebrie E, Schoj V. The role of organized civil society in tobacco control in Latin America and the Caribbean. Salud Publica Mex 2010;52(Suppl 2):S330-S339. https://doi.org/10.1590/S0036-36342010000800031
https://doi.org/10.1590/S0036-3634201000... and external funding often does not last, so international organizations’ support provides a crucial opportunity to help LMIC smokefree implementation.

These factors contributed to robust implementation despite Colombia’s health policy decentralization, weak state capacity, and public security issues.

Policy implications

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.

Limitations

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.

Conclusions

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.

Acknowledgments

This project was supported in part by National Cancer Institute grant CA-087472and UCSF funds from the FAMRI William Cahan Endowment Fund and Dr. Glantz’ American Legacy Foundation Distinguished Professorship. The funding agencies played no role in the selection of the research question, conduct of the research, or preparation of the manuscript.

References

Publication Dates

History