Revista científica digital INSPILIP
Código ISSN 2588-0551
DOI: 10.31790/inspilip.v3i2.240
Acceso abierto
Artículo de Revisión
Citación
Carrillo J. et. al. Tobacco
Consumption Interventions and
Smoke-Free Policy in Ecuador
Revista científica INSPILIP V. (3),
Número 2, Guayaquil, Ecuador.
Correspondencia
Dr. Joffre Carrillo – Pincay
mail:drjoffrecarrillop@hotmail.es
Fecha de ingreso: 17/11/2018
Fecha de aprobación: 30/07/2019
Fecha de publicación: 31/07/2019
Tobacco Consumption Interventions and Smoke-Free Policy
in Ecuador
Intervenciones gubernamentales sobre el consumo de tabaco y
políticas libres de tabaco en Ecuador
Joffre Carrillo-Pincay
1a
; A.P. Fan
1b
*; G.A. Mandell
2a
; R.O. Kosik
2b
; Chiu-Yen Lu
3a
;
D.T. Tran
3b
1a
Universidad de Guayaquil. Universidad Tecnológica Empresarial de Guayaquil, Ecuador.
1b
Faculty of Medicine at National Yang-Ming University, Taiwan.
2a
Senior Foundation Relations Advisor, National and International Programs, American Heart
Association, NY, USA.
2b
Santa Clara Valley Medical Center, San José, CA, USA.
3a
Department of Long-Term Care, Ministry of Health and Welfare in Taiwan.
3b
Department of Nephrology and Endocrinology, Children's Hospital, HoChiMinh City,
Vietnam.
Contributors
Conception and design of the study: JCP, APF; acquisition of data: JCP. Analysis and
interpretation of data: JCP, ROK, GAM, CYL. Drafting the article or revising: JCP, ROK,
GAM, DTT, APF. Final approval of the version: APF
Ethical approval: not required
El autor declara estar libre de cualquier
asociación personal o comercial que
pueda suponer un conflicto de intereses
en conexión con el artículo, así como el
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solicitado las autorizaciones de la
institución donde se realizó el estudio,
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consentimientos informados y en caso de
tratarse de estudio observacionales y
ensayos clínicos, autorización de un
CEISH, ARCSA, DIS, Medio Ambiente,
entre otros. Además la licencia para
publicar imágenes de la o las personas
que aparecen en el manuscrito. Por ello la
revista no se responsabiliza por cualquier
afectación a terceros.
Abstract
Objectives: The World Health Organization Framework Convention on
Tobacco Control Conference of the Parties (WHO-FCTC COP) recognized
Ecuador as a leader in the Latin American region for having increased
tobacco taxation, which is widely considered one of the best government
tools for decreasing tobacco consumption. Despite such efforts, the nation
has a persistent need for high quality tobacco prevention programs,
especially with regards to adolescent smoking and second-hand smoke. In
this study, we identify and describe the tobacco consumption interventions
and policies in Ecuador
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Revista científica digital INSPILIP Código ISSN 2588-0551
DOI: 10.31790/inspilip.v3i1.82.g151
Data Sources: secondary data survey
and analyzed literature.
Methods: Through an extensive search
of the academic literature and of the
current tobacco laws in Ecuador, in this
study we identify and describe the
important interventions regarding
tobacco consumption in Ecuador that
the current administration has instituted.
Results: Rates of lung cancer (5.0%)
and heart disease (19.5%) have been
steadily increasing. Government
interventions have led to a mandatory
150% SCT (Special Consumption Tax)
and a 12% VAT (Value-Added Tax)
being added to the purchase price of all
tobacco products. Following these
interventions, Ecuador has achieved a
tobacco consumption rate of less than
20% among adolescents aged 11 to 15
years old.
Conclusions: The institution of certain
governmental policies, particularly
tobacco taxation, has dramatically
reduced the rate of tobacco consumption
in Ecuador. However, additional
interventions, such as a national tobacco
education program overseen by family
and community-based physicians, would
likely further reduce tobacco
consumption. Finally, the enforcement
and maintenance of smoke-free areas in
Ecuador are needed.
Keywords: Smoke, tobacco
consumption, secondhand smoke, active
surveillance, Ecuador
Resumen
Objetivos: la Conferencia de las Partes
del Convenio Marco de la Organización
Mundial de la Salud para el Control del
Tabaco (CMCT- OMS) reconoció a
Ecuador como líder en la región de
América Latina por haber incrementado
abrumadoramente los impuestos al
tabaco, la cual es considerada como una
de las mejores estrategias
gubernamentales para disminución del
consumo de tabaco. A pesar de estos
esfuerzos, el país tiene una necesidad
persistente de programas de alta calidad
sobre prevención del tabaco,
especialmente con temas relacionados al
tabaquismo en los adolescentes y la
exposición al humo del tabaco. En este
estudio, identificamos y describimos las
intervenciones y políticas
gubernamentales sobre el consumo de
tabaco en Ecuador.
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Fuentes de datos: Datos secundarios,
revisión literaria.
Métodos: a través de una búsqueda
extensa de la literatura académica y de
las leyes de tabaco vigentes en Ecuador,
en este estudio identificamos y
describimos las intervenciones
importantes con respecto al consumo de
tabaco que la administración actual en
Ecuador ha sido constituida.
Resultados: las tasas de cáncer de
pulmón (5,0%) y enfermedad cardíaca
(19,5%) han aumentado constantemente.
Las intervenciones gubernamentales han
dado lugar a un impuesto del 100%
(impuesto especial sobre el consumo)
obligatorio y un IVA del 12% (impuesto
al valor agregado) que se agrega al precio
de compra de todos los productos de
tabaco. Después de estas intervenciones,
Ecuador ha logrado una tasa de consumo
de tabaco de menos del
Introduction
Ecuador is a middle-income country
1
with a population of 14,483,499 people
2
With a 46.6% smoking rate, it is the
fourth highest tobacco-consuming
nation in Latin America. In addition,
exposure to second-hand smoke is one
of the leading causes of morbidity and
mortality in the nation.
3, 4
20% entre los adolescentes de 11 a 15
años de edad.
Conclusiones: La institución de ciertas
políticas gubernamentales, en particular
los impuestos al tabaco, ha reducido
drásticamente la tasa de consumo de
tabaco en el Ecuador. Sin embargo, las
intervenciones adicionales, como un
programa nacional de educación sobre
el consumo de tabaco direccionado por
médicos especialistas en medicina
familiar y comunitaria, probablemente
reducirían aún más el consumo de
tabaco. Finalmente, se requiere de la
aplicación y el mantenimiento de áreas
libres de humo de tabaco en el Ecuador.
Palabras clave: consumo de tabaco,
exposición al humo del tabaco,
vigilancia activa, Ecuador.
The percentage of Ecuadorian adults
who smoke has increased from 18.4% in
2007 to 22% in 2010. Meanwhile, in
adolescents aged 13 to 15 years old,
smoking rates have dropped from
27.9% to 26.0% (Table 1).
3
In terms of gender, approximately
22% of males and 9% of females in 2010
were cigarette smokers
5
. Males smoked
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60% more cigarettes per day than
females
6
. Tobacco consumption related
cardiovascular and respiratory disorders
were the principal causes of death,
accounting for about 4000 per year.
Increasing rates of lung cancer (5.0%)
and heart disease (19.5%) were reported
in 2010, while other respiratory diseases
have slightly decreased over the past
five years (Table 1). In addition, the
national tumor registries, provided by
the Sociedad de Lucha contra el Cancer
(SOLCA), show that cancer rates have
increased from approximately 6% in
1980 to 14% in 2010.
5
WHO/NCD-2008 estimated that males
are more likely than females to develop
both cancer and chronic respiratory
diseases.
7
Moreover, in 2011 the WHO
reported that the most common cancers
among Ecuadorian cigarette smokers
were breast cancer (<14%) and
gastric/colorectal cancer (<7%).
Further, both breast and
gastric/colorectal cancer rank in the top
thirteen causes of death.
8
The World Health Organization
Framework Convention on Tobacco
Control Conference of the Parties
(WHO-FCTC COP) recognized to
Ecuador as a leader in the Latin
American region for having increased
tobacco taxation, which is widely
considered one of the best government
tools for decreasing tobacco
consumption. Despite such efforts, the
nation has a persistent need for high
quality tobacco prevention programs,
especially with regards to adolescent
smoking and second-hand smoke.
This study shows how tobacco-
free policies stablished by local
government in Ecuador has made
important changes in controlling
tobacco consumption and increasing
tobacco taxation as leading tobacco
control country in Latin America (LA).
Cigarette packages pictorial warnings in
Ecuador have challenged strong
psychological impact on potential
customers; such a strategy not only is
printed on at least 70% both side of the
package, but also is a pioneer strategy in
decreasing young people tobacco use in
the LA region, which is considered as
the major public health problem even in
developed countries.
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Código ISSN 2588-0551
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Table 1 Smoking Profile in Ecuador between 2005-2010.
(%)
2005
2006
2007
2008
2009
2010
Adolescent smoking prevalence ( 13-
27.9*
26.0**
15 years old) in both sexes
Adult smoking prevalence by gender
Male
21.5
21.6
21.8
21.9
22.2
22.3
Female
10.5
9.5
9.5
9.5
9.5
9.6
Total
15.9
15.5
18.4*
15.7
15.8
22.0**
Deaths
Respiratory disease
36.9
36.2
36.3
35.7
35.5
34.2
Heart disease
19.2
19.1
19.2
19.4
19.4
19.5
Lung cancer
4.7
4.7
4.8
4.9
4.9
5.0
Total
60.7
60.0
60.3
60.0
59.9
58.7
Special Consumption Tax (SCT)
98.0
98.0
98.0
98.0
150.0
150.0
Value-Added Tax /Sales tax
12.0
12.0
12.0
12.0
12.0
12.0
Cigarettes-Imported
104.5
123.0
173.1
96.5
117.0
101.6
Cigarettes-Exported
87.8
90.0
231.2
160.1
177.6
144.7
Cigarette-Production (million/kilos)
3,479.0
3,534.0
3,547.0
3,393.0
3,325.0
3,098.0
Legal sales
3,307.1
3,116.9
2,749.0
2,931.8
2,872.9
2,822.5
(million/sticks)
Illicit trade
25.5
26.3
29.9
29.5
28.8
31.1
Sources: WHO*, Euromonitor International, USDA, Internal Revenue Service , Society against
Cancer , Ministry of Public Health**, Central Bank of Ecuador, NCNPS, Productivity Ministry,
PAHO, United Nations.
Methods
Through an extensive search of
the academic literature and of the current
tobacco laws in Ecuador; Search strategy
and terms were used to identify studies on
smoke-free policies worldwide in
Pubmed, using the EndNote X7 software.
MeSH entry terms used on this
study were (((“tobacco smoke
pollution”) AND “smoke-free policy”)
OR “tobacco use cessation”).
Ecuadorian goverment
documents were searched on Google
Academic (GA). Keyword searches for
GA were “World Health Organization
tobacco control” and “anti-tobacco
policies in Ecuador”. EndNote software
was also used to manage references. In
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this study, we identify and describe the
important interventions regarding
tobacco consumption in Ecuador that
the current administration has instituted.
Results
Tobacco consumption in adolescents
In Ecuador, cigarette smoking
among adolescents is a significant public
health problem, especially for those aged
11 to 13.
5,18
The increasing use of
tobacco in this age group, in Ecuador’s
largest cities Guayaquil (from 7% in 2001
to 14 % in 2007) and Quito (from 13% in
2001 to 16% in 2007), is compounded by
the fact that 24% of young people overall
are considered smokers. Moreover, 46%
of high school students living in rural
areas were classified as beginner and/or
first time tobacco users, this includes the
Andean (58% smokers) and Amazon
(56% smokers) regions, areas where
tobacco prevention legislation was
specifically enacted in an attempt to
reduce tobacco use. Migration of
adolescents and young people from rural
areas to developed
cities was also shown to be an
influential factor for the initiation of
tobacco consumption.
5
Despite the fact that female tobacco
consumption remains less than its male
counterpart, both sexes show an
increasing propensity for tobacco
consumption, particularly adolescents,
who often perceive cigarettes as a
symbol of independence, glamor, and a
feature of a modern lifestyle. Research
has shown that cigarette smoke contains
up to forty carcinogens, including high
levels of carbon monoxide.
4,9
Further,
due to the toxic substances present in
tar, tobacco smoke is harmful for both
smokers and non-smokers, and there is
no safe level of exposure.
10,11
Thus, adolescent smokers and non-
smokers alike who experience long-
term smoke exposure are more likely to
develop disorders such as asthma,
middle ear infections, lymphoma,
leukemia as an adult, stroke, sinus
disease, breast and lung cancer,
atherosclerosis, COPD, and to deliver
low birth weight children.
12
Tobacco supply
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Tobacco companies from the
United States, Brazil, Argentina,
Colombia, the Dominican Republic, and
Cuba supply the cigarette market in
Ecuador through both legal and illegal
trade.
4
The WHO–FCTC/COP’s official
position is that the protocol for the
eradication of the illicit trade of tobacco
products should rely on gaining control
of tobacco smuggling and other forms
of illicit tobacco trade executed by
tobacco companies in developed and
developing countries alike. In direct
opposition to the WHO’s protocol, an
agreement between the European Union
(EU) and tobacco companies
encourages illicit trade through a system
developed by Phillip Morris. This
system grants tobacco companies
control of tobacco supply chains. The
system was also recently implemented
by the British American Tobacco (BAT)
group as well as the Japan Tobacco Inc.
(JTI), and it appears to be expanding to
developing countries as well.
13
Ecuadorian tobacco regulations and
policies
The Interinstitutional Committee
against Smuggling and for Anti-Tobacco
(ICSAT), created by Ministerial
Agreement No. 955 in 1989, has launched
numerous tobacco prevention
and control programs aimed at
decreasing the prevalence of smokers
and the rate of exposure to second-hand
smoke, with the ultimate goal of
reducing tobacco related morbidity and
mortality. ICSAT has been managed by
government authorities from different
ministries, governmental and non-
governmental organizations
(WHO/PAHO), and various civil
society leaders. ICSAT has recently
continued its efforts to promote tobacco
control through the creation and
subsequent passage of the Organic Law
for Tobacco Regulation and Control
(OLTRC) in July 2011, when tobacco
consumption was deemed a major
public health problem in Ecuador.
13
The OLTRC (legislative resolution No.
R-26-123/ official registry No. 287)
promotes programs that encourage
smokers to attempt tobacco cessation and
offers smokers free treatment and
rehabilitation. In addition, Articles 1 and
2 of the OLTRC together with official
WHO-FCTC policies regulate tobacco
advertising and promotions on the
national level. Further, tobacco sales are
strictly banned for those under 18 years
old.
5, 14,15
According to Articles 5 and 6 of the
OLTRC, the Ministries of Industry,
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Agriculture, and the Environment, in
coordination with the Internal Revenue
Service (IRS/SRI) and private
institutions, have oversight over the
control of all forms of illicit tobacco
trade and smuggling in Ecuador.
14
The National Council on Narcotic
Drugs and Psychotropic Substances
(NCNPS) is in charge of implementing
tobacco-related regulations and
controlling tobacco consumption.
5
Designated smoking areas and smoke-
free areas
Title 3 of the OLTRC states that
smoking is banned in public and private
places and where social activities take
place including in educational and
healthcare institutions, sporting clubs,
cultural and art centers, recreational and
entertainment centers, cinemas, malls,
hotels, restaurants, offices, public
transportation, libraries, and at fairs, in
order to protect non-smokers’ rights.
Moreover, according to Title 5 of the
OLTRC, fines from US $264 to US
$1320 may be levied upon any individual
or institution that breaks this law. The law
is intended to protect adolescents, young
adults, and non-smokers from exposure to
second-hand smoke.
5
The only places where tobacco use is
currently permitted are bars, nightclubs,
and casinos, but those places are
required to have an approved ventilation
system in place in order to reduce the
levels of ambient tobacco smoke. For
those businesses found in violation of
this law, a fine of US $264 for the first
offense and US $436 for the second
offense will be assessed.
5
Tobacco taxation
In addition, Title 2 of the OLTRC
states that the government (2012) must
impose a progressive tax per unit of
approximately US $0.075 (US $0.08 in
2013) (Table 1). Meanwhile, in 2012
Ecuador’s neighboring countries,
Colombia and Peru, charge a tobacco
tax of US $0.034 per unit and US
$0.041 per unit respectively.
5
Ecuador was recognized by the
WHO-FCTC/COP5 as a leader in the
Latin American region for increasing
tobacco taxation to 150% in 2012, up
from 98% in 2008, which “represents an
increase of 63% per unit for middle-
priced brands” and up to 200% for
lower-priced brands. Additionally, the
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OLTRC, under the national tobacco
policy, requires that the consumer price
index (CPI) and the value-added tax be
adjusted every six months to reflect the
current price of all brands of cigarettes.
This policy has single handedly prevented
tobacco companies from reducing the
total price of a package of cigarettes, one
of the industry's major strategies to recruit
new consumers. Since 2010, the IRS has
required a 150% Special Consumption
Tax (SCT or ICE) on all tobacco
products. Further, if tobacco companies’
sales margins exceed 25%, an additional
12% Value-Added Tax must be assessed
as a part of
the final price. Ecuador’s signature
strategy to reduce tobacco consumption
is in direct concordance with the WHO-
FCTC’s recommendations, which state
that increased taxation is the most
effective mechanism to deter tobacco
retail sales and to therefore reduce
tobacco consumption.
5
Moreover, there is only one tobacco
corporation in Ecuador, Tabacalera
Andina SA, which is an affiliate and a
subsidiary of Philip Morris International
Inc. This corporation is responsible for
all of the major tobacco brands in
Ecuador including Lider, Lark,
Marlboro, Belmont, and Philip Morris.
The tobacco taxation regulations imposed
by the current Ecuadorian government
have had an impact on both imported
brands such as Kool and Lucky strike, as
well as domestic brands. One effect has
been an overall decrease in tobacco
consumption. However, another effect has
been a change in consumer consumption
habits, with a majority of consumers
switching from high priced to mid-priced
and low priced brands. Additionally, due
to the low prices of tobacco products in
neighboring Peru and Colombia, Ecuador
has seen an increase in the smuggling and
illicit trade of tobacco over the past seven
years. Finally, Ecuador has seen a
decrease in the legal trade of tobacco
related goods as well as a drop in tobacco
production by 11% in 2010 (Table 1).
5
Advertising and promotion
The OLTRC prohibits both
advertising of tobacco products on the
radio from six o´clock in the morning to
nine o´clock in the evening and
advertising of tobacco products on
television at any time. Further, any form
of outdoor advertising may not be
present within 200 meters of an
educational institution. Moreover,
tobacco prevention media campaigns
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have recently been shown to be much
more effective on younger smokers than
on adult smokers.
5, 16
In 2009, a three-year study of the
effects of television and radio
advertisements on health promotion
revealed minimal to no effect of such
advertising on tobacco consumption, as
was expected by the Ecuadorian
government. Further, during this period
tobacco retail sales continued to show
strong growth. The study concluded that
brand identification and product
preferences are strongly established, and
changing consumption patterns is very
difficult to accomplish.
16
Discussion
The Ecuadorian government has
taken significant actions to deter the
growth of the tobacco market in
Ecuador. Chief among these has been
strict tobacco legislation, backed by
health authorities and enforced by the
Ecuadorian Assembly as well as the
Interagency Committee on Smoking
Control and Department of Guidance
and Student Welfare. With further input
from non-government anti-tobacco
organizations and the civil sector
Ecuador has managed to reach the
WHO-FCTC anti-tobacco objectives.
However, despite overwhelming
financial support from the government,
efforts to control illicit trade have not
been sufficient.
20
Corrupt import
operations continue to occur along both
the northern and southern borders, and
the government has no immediate plans
to provide further resources to
counteract them.
Despite strong anti-tobacco laws in
Ecuador, strict enforcement of those laws
remains elusive. For example, the
OLTRC stipulates that all cigarette brands
must include pictorial warnings regarding
the harmful effects of tobacco, and that
those warnings must occupy at least 60%
of the front and back of the package.
Additionally, the law states that health
information must be printed on at least
70% of both sides of the package, which
is in accordance with Article 6 of the
WHO/FCTC.
14
However, currently on
the majority of cigarette packages
pictorial warnings only occupy 40% of
the front and back of the package, and
health information is only printed on one
side of the package. At this time there are
no cigarette brands that have images of
diseased organs on the package, as occurs
in some countries and which has been
shown to have a strong psychological
impact on potential customers.
16
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In 2011, the Ecuadorian Congress
legislated a new project that was
purported to be a much more effective
means at reducing tobacco consumption
and preventing non-smokers from
exposure to second-hand smoke.
13,21
This project included resources for the
building of treatment centers for tobacco
addicts, the creation of smoke-free areas,
and the enforcement and promotion of the
OLTRC. Such efforts have led to
increased awareness of the harmful
effects of exposure to tobacco smoke as
well as the widespread implementation of
preventive measures aimed at reducing
exposure.
19
An additional benefit has
been the accumulation of significant data,
which has allowed health officials to both
monitor and research tobacco trends in
Ecuador.
22
Since 2006, 100% smoke-free areas as
well as established smoking areas were
established by the Reformatory Consumer
Defense Law (RCDL),
5
which focuses on
decreasing exposure to second-hand
smoke.
22,23
However, laws mandating
smoke-free areas are loosely followed and
rarely enforced, especially at restaurants
and bars, parks, musical concerts,
sporting events, cultural and recreational
events, and night clubs, where street
vendors are able to sell tobacco freely to
all persons even those
under 18 years old. Thus retail point of
sale restrictions may be a necessary next
step and should be considered by
legislators. Finally, enforcing smoke-
free area laws is particularly challenging
in rural areas, where smokers are less
likely to be familiar with the law and
enforcement agents are few in number.
Expensive therapies and devices such
as nicotine replacement therapy and
electronic cigarettes are only affordable to
a small number of high-income
consumers, who are for the most part
motivated by medical recommendations
to quit smoking. Future legislation should
consider making the most efficacious of
these devices available to
lower income consumers. Finally,
Ecuadorian legislation has as of yet not
specified regulations regarding
maximum levels of tar in cigarettes.
Tar, which contains the highest
number of carcinogenic compounds in
tobacco smoke, should be highly
regulated in order to reduce the incidence
of tobacco related malignancies.
15
Conclusions
Given the high adult male tobacco
consumption rate in Ecuador, women
and children are particularly prone to
second-hand smoke exposure, 17 and
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thus the timely institution of policies to
protect these populations is needed.
Despite strong anti-tobacco
legislation, including the RCDL and the
OLTRC, enforcement of the law has
been difficult. For example, the above
legislation includes mandates for the
creation and institution of tobacco
education programs and campaigns
taught by community-based healthcare
medical doctors at the high school and
university level throughout the entire
country. Yet currently such programs
are minimal both in number and extent.
A stricter adherence to already
enacted legislation will not only result in
a large reduction in exposure to second-
hand smoke for the people of Ecuador but
will also decrease the incidence of
respiratory disorders, cardiovascular
disorders, and low birth weight as well as
improve mortality rates.
Another important measure to
reduce exposure to second-hand smoke
is the institution and maintenance of
isolated smoking areas and proper
ventilation in those areas. These
measures should be clearly stated in the
law and enforced adequately.
Proper smoke-free policy should
establish limits on corporations as well as
on consumers including the restriction of
advertisements and the assessment of
fines for those who break the law, as
occurs in developed countries.
Ecuador has prioritized increased
tobacco taxation, which according to the
WHO-FCTC/COP, is the best tool for
decreasing tobacco consumption.
However, the Ecuadorian government
must increase its fight against the
smuggling of tobacco products over its
borders.
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DOI: 10.31790/inspilip.v3i1.82.g151
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Declaration:
This research received no specific grant from any funding agency in the public,
commercial or not-for-profit sectors
There is nothing to declare in terms of ethical concern or competing interest
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