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Abstract

Chile currently has a relatively robust tobacco control policy approach. Nonetheless, it has one of the highest tobacco consumption prevalence rates among adults worldwide. Better knowledge regarding changes in tobacco control policy over time may provide a comprehensive understanding of the observed changes in the prevalence of tobacco consumption. We aimed to carry out a scoping review to explore the evolution of Chile’s tobacco control consumption policies. We searched legal instruments, including laws and decrees, in the Chilean National Library of Congress from inception to December 2018. One author screened potential legal instruments; two authors independently systematized research records found. We included any legal instrument issued by the President of the Republic or the Chilean National Congress. We used the MPOWER strategy as a guideline to classify interventions. The institutional change theory proposed by van der Heijden and Kuhlmann was applied to interpret policy changes. We identified 499 legal instruments related to tobacco. Of these, three laws and ten decrees were included for analysis. We observed an uneven implementation of measures recommended by the WHO over time. The dimensions Protect, Warn, and Enforce showed consistent progress, measures in the Monitor and Raise dimensions were unsustained, and no measures for the dimension Offer were found. In Chile, measures to tackle tobacco consumption over the last three decades have focused predominantly on regulating individual choices rather than on the tobacco industry. Future research assessing the effects of Chile’s tobacco control consumption policies should account for their multifaceted and heterogeneous implementation.

Keywords

tobacco health legislation World Health Organization policy analysis scoping review Chile

Introduction

Tobacco use has adverse health and economic consequences (Goodchild et al., 2018). Tobacco use is among the four major risk factors for death and disability globally, in high-income countries and the Region of the Americas across all ages (Institute for Health Metrics and Evaluation, 2019). The cost of smoking-attributable diseases to the healthcare system has been estimated at 5.7% of global health expenditure. The total economic cost is equivalent to 1.8% of the global annual gross domestic product (GDP) (Goodchild et al., 2018). The extent of health losses caused by tobacco use has been recognized worldwide epidemic(Goodchild et al., 2018). To tackle this burden, the World Health Organization (WHO) (World Health Organization, 2017, 2021c), along with multiple scientific and professional organizations such as the American Cancer Society Cancer Action Network (The American Cancer Society Cancer Action Network, 2022), Action on Smoking & Health (Action on Smoking & Health, 2012), the Centers for Disease Control and Prevention (Center for Disease Control and Prevention, 2022), and the World Bank (World bank, 2009) have spurred the promotion of comprehensive and cost-effective responses across the world.

In 2008, the WHO Framework Convention on Tobacco Control (FCTC) and its parties committed themselves to assisting the country-level implementation of effective measures to reduce the offer and demand for tobacco through a set of six tobacco control policies domains (World Health Organization, 2009), known as the MPOWER strategy (see Figure 1). MPOWER is the acronym for these measures: 1) monitor tobacco use and prevention policies; 2) protect people from tobacco smoke; 3) offer help to quit smoking; 4) warn about the dangers of tobacco; 5) enforce bans on tobacco advertising, promotion, and sponsorship; and 6) raise taxes on tobacco (World Health Organization, 2009).

Figure 1.

MPOWER World Health Organization strategy (2017).

The overall implementation of these country-level tobacco control measures has been steady (World Health Organization, 2021c). Currently, three-quarters of all countries are covered by at least one of these measures (World Health Organization, 2021c). Notably, it has been estimated that around 37 million lives have been saved by adopting the MPOWER strategy (World Health Organization, 2021c). However, more information is needed about how countries have progressed in implementing the measures associated with this strategy over time. Moreover, the extent to which a combination of international and national forces can influence the configuration of these measures has yet to be studied.

Reviews of national tobacco policies using the MPOWER strategy have been performed at global, regional, and national levels (Abascal & Lorenzo, 2017; Ahluwalia et al., 2019; Calikoglu & Koycegiz, 2019; Glahn et al., 2018; Guindon et al., 2019; Husain et al., 2016; Kaur et al., 2021; Martins et al., 2021; Sandoval et al., 2021; Sanna et al., 2020; Saxena et al., 2020; Suárez-Lugo et al., 2018). Previous studies, however, have only provided a partial account by focusing on existing policies rather than observing when measures have been implemented and under what conditions. Even further, very few studies have included countries in the Region of the Americas (Abascal & Lorenzo, 2017; Guindon et al., 2019; Martins et al., 2021; Sandoval et al., 2021; Suárez-Lugo et al., 2018), region with one of the highest per capita tobacco consumption worldwide (World Population Review, 2022).

This article focuses on Chile, a high-income Latin American country according to the MPOWER standards one of the world’s most robust tobacco control policies (World Health Organization, 2021a, 2021c). However, Chile has the highest tobacco consumption prevalence rate among the adult population (38.7%) in the Region of the Americas (Instituto de políticas públicas en Salud, 2022). In addition, Chile’s health system spends approximately 1.15 trillion pesos annually (approximately USD$1.8 billion) on treating illnesses caused by smoking tobacco, (this is equivalent to 0.6% of its GDP in 2017) (Castillo-Riquelme et al., 2020).

To the best of our knowledge, this study presents the first overview of the historical changes in Chile’s national tobacco strategy, which is further complemented by considering the implementation of the MPOWER strategy measures. The status of the tobacco control policy, its degree of adherence to the MPOWER strategy, and the extent to which its different domains have been unfolding will allow future inquiries into the effectiveness of each component in tobacco control in Chile. Our study aims to carry out a scoping review to explore the evolution of Chile’s tobacco control consumption policies displayed in Chile its legal instruments.

Review Question

What is the evolution of Chile’s tobacco control consumption policies displayed in its legal instruments?

Sub-questions

What is the evolution of Chile’s tobacco control consumption policies over time, considering de MPOWER strategy?

What is the historical-political evolution of Chile’s tobacco control consumption policies?

Methods

The proposed scoping review was conducted following the JBI methodology for scoping reviews (Peters et al., 2020, p.406–451; Tricco et al., 2018).

Eligibility Criteria

We deemed legal documents (i.e., laws and decrees) issued by the President of the Republic or the Chilean National Congress, that is, enacted by the central government, as eligible if (i) they were targeted at the general Chilean population or specific groups of the population or public or private organizations based in Chile; and (ii) they referred to tobacco control measures as per the six domains of the MPOWER strategy (Figure 1). The analyzed documents are in Spanish. The laws and decrees will be those available in the Chilean National Library of Congress (Biblioteca del Congreso Nacional de Chile, 2014) (https://www.bcn.cl/portal/) from the database inception to March 2023. In this manner, this scoping review will consider gray literature as a focus.

Additional details regarding the definitions of the different legal documents (Biblioteca del Congreso Nacional de Chile, n.d.) considered for inclusion are provided in the Supplemental Table S1.

Information Sources

We searched for eligible legal documents using the Chilean National Library of Congress (Biblioteca del Congreso Nacional de Chile, 2014; Peña et al., 2021) (https://www.bcn.cl/portal/). This database allows tracing the origin of each Law and decree and their subsequent modifications since 1818 and contains more than 260,000 regulations from inception to the present. We searched the database from inception to March 30, 2023.

Search Strategy

We used an all-encompassing search strategy based on free-text words in the basic search engine available in the Chilean National Library of Congress (BCN). For the development of the search strategy, we considered two elements: 1) the definition of tobacco products declared on the legal documents that regulate tobacco consumption in Chile (Biblioteca del congreso Nacional, 1995); and 2) the current approach of the main instruments to monitor tobacco consumption (Ministerio de Salud, 2023; Servicio Nacional para la Prevención y Rehabilitación del Consumo de Drogas y Alcohol, 2023). In the first case, tobacco products are “any product containing or prepared wholly or in part using tobacco leaves as a raw material.” The regulatory framework, therefore, considers all types of tobacco-derived products within its indications. On the other hand, the principal instruments to monitor tobacco consumption are focused on cigarette use since this is the country’s main format of tobacco consumption. According to the last National Health Survey, only 1.5% of the population reported tobacco consumption through e-cigarettes (Ministerio de Salud, 2023); on the other hand, e-cigarettes were not integrated into the questionnaires of the biannual National Survey of Drug Consumption for the general population which is carried out since 1994 (Servicio Nacional para la Prevención y Rehabilitación del Consumo de Drogas y Alcohol, 2023). In order to achieve an exhaustive search, we use all possible terms associated with the specific consumption of cigarettes since this, unlike other alternative tobacco products, can be identified by different names in the Country.

Thus, in the basic engine of BCN, we used the terms in Spanish “tabaco” (tobacco), “cigarro” (cigar), “cigarros” (cigars), “cigarrillo” (cigarette), and “cigarrillos” (cigarettes) in an independent manner. The search allowed us to identify legal documents containing these keywords in the title or full text. In the database, we applied the filter “legislación” (legislation), discarding other sources of information (detailed search strategy in Supplemental Table S2).

To further improve the applied search strategy, we performed an advanced search focused on laws and decrees (detailed search strategy in Supplemental Table S3).

Selection of Sources of Evidence

One author (KADC) identified and uploaded all the legal documents in a spreadsheet to facilitate a full review. After the manual removal of duplicates, the titles of each record were screened to judge their inclusion or exclusion. When the title was not providing enough information to identify the main theme regulated by the legal document, one author revised the entire document to perform content analysis. The documents that passed the screening phase were retrieved and read in full to assess their eligibility. When a decree that directly regulates the production, sales, and consumption of tobacco products was modified by a law, we followed up the modification of the decree by performing a manual search in the database of the previous version for the same document. Regulations associated with general dispositions on taxation, customs, national funding or subventions, transportation, and environmental protection, among others (Figure 2), were excluded (see Supplemental Tables S2, S3, and S4 for more details). We limited the eligible document to those enacted between 1960 (legal documents enacted before this date are discontinued) and 2018.

Figure 2.

Categories for incremental institutional change adopted from van der Heijden and Kuhlmann (2017)

Data Charting Process

Two authors (KADC and PM) extracted the name of the Law or decree, the date of enactment, and key messages included in the legal documents that regulated tobacco production, sales, and consumption according to the recommended measures of the MPOWER strategy (Monitor, Protection, Offer, Warn, and Raise) in an independent manner. The charting process was performed iteratively, with discussions about the content as a main calibration method. The information was organized in two spreadsheets, one for laws and another for decrees, and presented chronologically. A third author (JINM) resolved disagreements between the two authors in a joint meeting by consensus.

Data Items

Data items were extracted with attention to the following elements: Law or decree identification number or name if it existed; date of enactment; date of modification; tobacco policies interventions. It is noteworthy that legal documents contain information that went further the focus of the study. As such, the authors performed a thematic analysis of the content of legal documents with the MPOWER strategy as a framework to identify the tobacco policies interventions. No other variables were considered.

Synthesis of Results

We initially performed a content analysis to identify the main themes of each screened document and a thematic analysis of the legal documents considering the MPOWER strategy domains as a guideline to identify the tobacco control interventions. This approach was applied to ensure convergence and exhaustion of the topics to be classified.

Next, we organized the information in chronological order to trace changes over time in each dimension. The evolution of tobacco control policies is analyzed and described in a narrative way considering three periods: March 1990 to February 2000, March 2000 to February 2010, and March 2010 to February 2018. The previous periods were selected given their historical-political implications for developing policies in the country (Table 1). From a historical-political point of view, we tagged the three periods as: “Return to democracy,”“Center-left governments,” and “Intermittent center-right-wing and center-left-wing governments.”

Table 1.

Historical-Political Periods for Analysis.

Period	President	Presidential mandate	Political party
March 1990 to February 2000. “Return to democracy”	Patricio Aylwin Azocar	From March 1990 to February 1994	Cristian democratic party (DC)
	Patricio Aylwin Azocar	From March 1990 to February 1994	Center-to-center-left party
	Eduardo Frei Ruiz-Tagle	From March 1994 to February 2000	Cristian democratic party (DC)
	Eduardo Frei Ruiz-Tagle	From March 1994 to February 2000	Center-to-center-left party
March 2000 to February 2010. “Center-left governments”	Ricardo Lagos Escobar	From March 2000 to February 2006	Socialist party (PS).
	Ricardo Lagos Escobar	From March 2000 to February 2006	Center-left party.
	Michelle Bachelet Jeria	From March 2006 to February 2010	Socialist party (PS).
	Michelle Bachelet Jeria	From March 2006 to February 2010	Center-left party.
March 2010 to February 2018. “Intermittent center-right-wing and center-left-wing governments”	Sebastian Piñera Echeñique	From March 2010 to February 2014	National renewal party (RN)
	Sebastian Piñera Echeñique	From March 2010 to February 2014	Center-right to the right-wing party
	Michelle Bachelet Jeria	From March 2014 to February 2018	Socialist party (PS).
	Michelle Bachelet Jeria	From March 2014 to February 2018	Center-left party.

Subsequently, we classify the observed changes using four values: (−) absent, in which no reference was found to identify measures in a given dimension; (+) incipient, in which evidence of existent measures is partially associated with the WHO’s recommendations; (++) developed, in which measures are partially associated with the WHO’s recommendation, however, improves an incipient past related set of measures; and (+++) consolidated, in which a group of measures strongly aligns with the WHO’s recommendations. The values used to evaluate compliance with the recommendations consider the progressive contribution represented by each legal instrument analyzed. To facilitate the lecture on results, we added a figure with circles representing the contribution of each document (low, medium, and high) to the final classification per analyzed period.

Additionally, we applied the incremental institutional change framework proposed by van der Heijden and Kuhlmann (van der Heijden & Kuhlmann, 2017) (Figure 2) to better understand the evolution of laws and decrees of tobacco policies. The framework considers the categories: layering, conversion, drift and displacement. We added two categories to the framework (un-sustained and absent) to contrast layering and displacement. Un-sustained refers to the absence of changes required after introducing an initial change. For example, an initial shift in tobacco taxes is not followed by more progressive increases over time. Absent refers to the total absence of a policy in any realm of interest—for example, the absence of tobacco taxes.

Results

Selection of Sources of Evidence

With the basic engine of BCN, we found 499 documents (including 41 laws and 70 decrees). After removing duplicates and excluding bulletins, resolutions, and instructions or news, we proceeded to screen 45 documents. Thirty-two documents were deemed eligible, and from this selection, three laws and nine decrees were selected for synthesis (Figure 3) (Supplemental Table S2). To supplement this first search, we then applied an “advance search” method. With this alternative we identified 58 laws and 287 decrees. After removing duplicates and excluding documents not related to tobacco, the same previous three laws and eight decrees were re-identified. The “advanced search” method helped us to identify one more decree which was associated with a regulation that re-organized the health system in Chile in 1979 (Law 2 763).

Figure 3.

Flow diagram of the literature search for enacted laws and decrees.

Characteristics of Sources of Evidence

Considering the recommendations included in the MPOWER strategy, we charted both the name of the Law or decree, from enactment, and what the policy was about.

Results of Individual Sources of Evidence

The results of each legal document included in the revision are presented in Table 2. We provide a graphical representation of each enacted Law (Biblioteca del congreso Nacional, 1995, 2006, 2013) or decree(Biblioteca del congreso Nacional, 1974, 1975a, 1975b, 1977, 1986, 1994, 1997, 1998, 2003, 2005, 2010, 2014, 2016a, 2016b) in chronological order, from 1990 to 2018 (Figure 4). We added all identified sources to observe a longer historical account in the Supplemental Figure S1.

Table 2.

Data Extracted from Tobacco Control Policies in Chile Considering the MPOWER Strategy.

Law or decree	When started	What is the policy about the recommendations included in the MPOWER strategy
Decree 828	December 1974	Raise It established the growing, elaboration, commercialization, and tobacco taxation norms. It indicates that the sales prices of cigars, cigarettes, and tobacco must include the added value tax (IVA); defines a pack of cigarettes as a set of cigarettes that do not exceed 20 units nor weigh more than 100 g; indicates that tobacco manufacturers, importers, and merchants must register before starting their business in the records of the Internal Revenue Service and are obliged to keep the accounting determined by the President of the Republic and to exhibit their books when requested by the Internal Revenue Service (Biblioteca del congreso Nacional, 1974).
Decree 238	April 1975	Raise Approves regulations for the implementation of decree 828, reinforcing indications related to taxes applied to tobacco products, registration, accounting, manufacturing, and packaging, among others (Biblioteca del congreso Nacional, 1975a).
Decree 494	June 1975	Raise Set at 0.5% of the amount of the gross monthly income the provisional income tax payments to be made by the distributors of cigarettes and related products (Biblioteca del congreso Nacional, 1975b).
Decree 63	January 1977	Raise It reduced the additional tax of 5% for manufactured tobacco products derived from a modification of decree 828 of 1974 by decree 1 024 for the year 1975 (Biblioteca del congreso Nacional, 1977).
Decree 1	January 1986	Monitor It creates a National Commission for the Control of Smoking composed of an intersectoral team physically located on the premises of the Ministry of Health. The commission aimed to study tobacco-related matters and propose measures to control and reduce them (Biblioteca del Congreso Nacional de Chile, 1986).
Decree 399	March 1994	Raise Exemption from withholding added value tax on the commercialization of cigars in a supermarket to a specific sales place in the North of Chile (Biblioteca del congreso Nacional, 1994).
Law 19 419	October 1995	Monitor Health services across the Country were empowered to demand information about additives and substances used in tobacco manufacturing. The Ministry of Health had the authority to prohibit some additives and substances that increase health risks (Biblioteca del congreso Nacional, 1995). Protect Smoking was prohibited in public transportation, school classrooms, and elevators. In addition, smoking was forbidden in hospitals, clinics, doctor’s offices, theaters, and cinemas, except in the areas or spaces designated for such purposes and in public offices, including municipal offices; smoking was banned in places where attention to the public was provided. This prohibition is absolute in areas where explosives, inflammable materials, medicines, and food are manufactured, processed, deposited, or handled until today. Furthermore, restaurants, bars, hotels, and other similar establishments had to indicate if there were separate spaces for smokers and non-smokers (Biblioteca del congreso Nacional, 1995). Warning Every package of products made with tobacco and every advertising action in any way or mean had to contain clear and precise warnings about the specific risk of tobacco consumption. The period of rotation of the warning had to be 12 months at maximum. This Law established educational plans and programs for primary and secondary with objectives and contents aimed at educating and instructing schoolchildren on the damage caused by tobacco consumption and the diseases it generates (Biblioteca del congreso Nacional, 1995). Enforce Advertising, propaganda, or promotion of products made with tobacco was prohibited for people under 18 years old. In the case of television, it was only allowed from the timetable established by the National Television Council for programs intended for persons over 18 years of age and concerning the cinema, when films for persons over 18 years of age were shown. This Law also prohibited the offering, distribution, or delivery free of charge of products made with tobacco to minors under 16 years of age in public places or sites (Biblioteca del congreso Nacional, 1995).
Decree 18	June 1997	Monitor Health services were empowered to request detailed information on additives and substances added to products made with tobacco or used for the treatment of it from parent companies, manufacturers, or importers and established that the information should be sent to the Ministry of Health in a period no longer than 15 days from the moment Health Services count with this information (Biblioteca del congreso Nacional, 1997). Warn This decree introduced a deadline—the school year of 1997- to incorporate educational content. The subjects of the programs are defined: benefits of non-smoking, prevention of smoking behavior, harm of inhalation of tobacco combustion that includes “passive smoking” and the diseases derived from this, and orientations to quit smoking. Program development had to be supported by the Ministry of Health, which provided updated information in October of each year. For this purpose, the Ministry of Health could request information from scientific societies or other organizations related to this area (Biblioteca del congreso Nacional, 1997, p. 18).
Decree 828	November 1998	Raise The modification indicated that cigarettes had to pay a tax of 50.4% on their sale price to the consumer, including taxes, for each pack, box, or wrapper. It also indicates that any fraction of the taxation of less than one escudo (1 CLP = E°1,000) must be considered a whole. This article also points out that the President of the Republic was empowered to establish an additional surtax of up to 10% (Biblioteca del congreso Nacional, 1998).
Decree 828	August 2003	Raise This adds to the requirements to move tobacco products from customs by obtaining a clearance certificate for the movement of the merchandise and a resolution from the Ministry of Health authorizing the marketing of the merchandise (Biblioteca del congreso Nacional, 2003).
Decree 143	September 2005	Monitor This decree includes recommendations related to a) the development of research; b) monitoring and exchange of information; c) scientific, technical, and legal cooperation; d) provision of specialized advice. In addition, it proposes measures such as conducting analysis and measurement of the contents and emissions of tobacco products and the regulation of such contents and emissions; to implement effective measures to require tobacco product manufacturers and importers to disclose to government authorities information regarding the contents and emissions of tobacco products (Biblioteca del congreso Nacional, 2005). Protect The decree proposes to implement effective measures to protect against exposure to tobacco smoke in indoor workplaces, public transport, indoor public places, and other public places (Biblioteca del congreso Nacional, 2005). Offer The document proposes to implement effective tobacco cessation promotion programs in places such as educational institutions, health units, workplaces, and sports settings; incorporate tobacco dependence diagnosis and treatment and cessation counseling services into national health and education programs, plans, and strategies involving health professionals, community workers, and social workers; establish tobacco dependence diagnosis, counseling, prevention and treatment programs, including access to medication, in health and rehabilitation facilities (Biblioteca del congreso Nacional, 2005). Warn It provides recommendations about education, communication, training and public awareness, packaging, and labeling of tobacco products. Specifically, it proposes to: 1) implement measures to ensure that tobacco product packages and labels do not promote a tobacco product in a false, misleading, or deceptive manner with terms such as “low-tar,”“light,”“ultra-light,” or “mild”; 2) incorporates external packaging and labeling large, clear, conspicuous, visible, and legible, using 50% or more of the principal exposed surfaces and presenting information on the relevant constituents of tobacco products and their emissions as defined by national authorities; 3) have a comprehensive and effective public education and awareness program on the health risks of tobacco use and exposure to tobacco smoke; 4) have public access to information on the tobacco industry following national legislation; 5) effective and appropriate training or sensitization and awareness programs on tobacco control for individuals such as health professionals, community workers, social workers, communication professionals, educators, policymakers, administrators and other interested persons; among others (Biblioteca del congreso Nacional, 2005). Enforce Provides recommendations such as the total prohibition of any form of publicity, promotion, and sponsorship of cross-border transactions in its territory. Some of the measures included: 1) prohibit advertising, promotion, and sponsorship by radio, television, media, print, and, as appropriate, other media, such as the Internet, among others; 2) the advertising must be accompanied by a health warning or message; 3) restricting the use of direct or indirect incentives that encourage the purchase of tobacco products by the population; 4) 5) the prohibition of the sale of tobacco products to minors and, in case of doubt, require each tobacco buyer to prove that he or she has reached the age of majority; 6) prohibit tobacco products for sale from being directly accessible, such as on store shelves; 7) banning the manufacture and sale of candy, snacks, toys and other objects that are shaped like tobacco products and may be attractive to minors (Biblioteca del congreso Nacional, 2005). Raise It indicates that measures adopted related to prices and taxes must reconcile the recommendations of the WHO and the regulations at the national level, understanding each Country as a sovereign territory (Biblioteca del congreso Nacional, 2005).
Law 20 105	May 2006	Monitor This Law indicates that the quality and quantity of constituents, additives, and substances used for tobacco treatment had to be directly and annually reported to the Ministry of Health (Biblioteca del congreso Nacional, 2006). Protect This Law prohibited smoking in public places like higher educational establishments, healthcare establishments, airports, theaters, cinemas, gymnasiums, sports facilities, supermarkets, areas where cultural and musical acts were performed, health centers or services open to the public, malls, and other similar establishments of free access to the public unless they counted with open spaces or patios. In the case of bars, restaurants, discos, and other authorized places, they needed to have more than 100 m² of space for customer service to allow smoking in specific areas dividing them between smokers and non-smokers; the latter should not represent less than 60% of the total space use to customer service. The separation between spaces had to be carried out through mechanisms that prevent the passage of smoke to the rest of the enclosure, such as outdoor ventilation or air extractors. Establishments smaller than 100 m² had to choose between being for smokers o non-smokers. This limitation was less strict in the case of discos or cabarets, considering the sale of alcohol being reserved for people older than 18 years. Both types of establishments had to count with notorious signs and warnings. The entrance of people under 18 was prohibited in smoking establishments, and places that did not comply with the regulations were sanctioned with a fine. It also prohibited offering or providing any compensation, direct or indirect, for the purchase of tobacco products, such as the donation, bonus, or reimbursement of cash or the right to participate in games, sweepstakes, or contests, as well as the distribution of said products without monetary compensation (Biblioteca del congreso Nacional, 2006). Warn Considering the WHO recommendations, it introduced a health hazard warning on all tobacco product packaging due to consumption or exposure. The warning was valid for 12 months, designed by the Ministry of Health, and established by decree. The Law indicated that the label should be printed on the packs or any packaging and not be removable. In the case of imported products, it had to adhere so that it could not be easily removed. For cigarette or cigar packages, this warning must appear on both main sides, occupy 50% of each side, and be placed on the lower part of each side. It indicates that the Ministry of Health is responsible for establishing the rules on disseminating information on the additives and substances incorporated in tobacco and their effects on the health consumer, being included on cigarette packages clearly and visibly on one of the sides faces. The use of the terms light, mild, light, low-tar, low-nicotine, low-nicotine, carbon monoxide, or similar, associated with the brand name of cigars or cigarettes, was prohibited. On the other hand, advertising notices might not be larger than 2 m², and the warning must occupy 50% of the advertisement. This Law also strengthened Decree 18 with educational plans and programs about the effects of the use of products made with tobacco and exposition to tobacco smoke, adding their addictive nature (Biblioteca del congreso Nacional, 2006). Enforce The Law provided specific measures with the prohibition about: a) advertising of tobacco or brand elements related to such product outside the places of sale, or communication to the public of the sale of products made with tobacco outside the places of sale; b) advertising 300 m away from primary and secondary educational establishments and sales 100 m away from these establishments, c) advertising of tobacco products, whether domestic or imported, for distribution within the national territory, regardless of the form or medium in which it is carried out, omitting the warning established by Law, d) advertising in the international signals of the Chilean media or Internet pages whose domains correspond to the ending “dot cl,” e) offering or providing any compensation, directly or indirectly, for the purchase of tobacco products, f) marketing, offering, distributing or giving away free tobacco products to minors under 18 years of age, g) installation of vending machines for tobacco products in establishments, places or enclosures to which access by minors is not prohibited by Law, j) selling cigarettes individually or in packs containing less than ten cigarettes, and k) allowing minors under 18 years of age to enter places designated for smokers—indications currently in force (Biblioteca del congreso Nacional, 2006).
Decree 147	September 2008	Warn It established a specific communicational design of billboards placed outside the stores, with horizontal and vertical announcements that must comply with specific characteristics (dimensions, background, and font, among others) (Biblioteca del congreso Nacional, 2008).
Decree 828	August 2010	Raise Modification on the applied taxes. It indicates that cigarette packages, boxes, or wrappers had to pay a specific tax equivalent to 0.0000675 monthly tax units (MTU) for each cigarette contained therein; and, in addition, a tax of 62.3%, which had to be applied on the sale price to the consumer, including taxes, for each package, box or wrapper, considering as whole any fraction of the taxation of less than one CLP. This was the first inclusion of specific tones in tobacco products. The specific tax is calculated based on the MTU in force at the time of the determination of the tax (Biblioteca del congreso Nacional, 2010)
Law 20 660	February 2013	Monitor It reinforces the measures described in Law 20 105, adding prohibitions to the sale, purchase for sale, commercialization in any form, distribution, transport, and storage of tobacco products of any form, kind, or nature that do not comply with the legal obligations in sanitary, customs, tax and intellectual property matters (Biblioteca del congreso Nacional, 2013). Protect Smoking in any close space used for public or commercial purposes was prohibited. Compared to the previous Law, one modification prohibits smoking in grandstands or other public use sports spaces, gyms or stadiums, and beaches, rivers, or lakes. Added to this, the separation between smokers and non-smokers areas in pubs or restaurants is not allowed, and open spaces or patios are needed to smoke. Places not complying with the regulations are sanctioned with a fine (Biblioteca del congreso Nacional, 2006). Warn They were established between two and six warnings designed with drawings, photographs, and legends. Producers, marketers, or distributors must incorporate the warnings, for such purpose, at the beginning of the validity warnings’ validity. Furthermore, they must inform the Ministry of Health in writing of the respective tobacco products and their distribution of the warnings. Furthermore, any modification to the information above must be communicated to the Ministry of Health immediately. This Law also reinforces educational measures with a national education that must be updated every five years (Biblioteca del congreso Nacional, 2006). Enforce Prohibits advertising of tobacco or brand elements related to such products is prohibited, except inside the places of sale. Outside such places, the sale of products made with tobacco may only be communicated to the public by means of notices designed by the Ministry of Health and established by supreme decree. Thus, this Law indicates that all types of publicity that advertise tobacco and elements of the brands related to this product are forbidden, including the appearance of people smoking or pointing out characteristics favorable to tobacco consumption on programs broadcast live on television or radio during the hours allowed for minors. This Law also forbids the sale of tobacco products inside health facilities, whether public or private (Biblioteca del congreso Nacional, 2006).
Decree 828	October 2014	Raise The specific tax increased to 0.000128803 with a decrease of the tax applied to the consumer to 60.5% per package (Biblioteca del congreso Nacional, 2014).
Decree 828	February 2016	Raise The specific tax increased again to 0.0010304240 MTU plus a 30% to the consumer sale, including taxes. This last modification performed by Law 20 899 also changes the way to perceive the taxes from special bands attached in customs that bearded the maximum price at which the goods had to be sold (procedure determinate from 1974) to demand vouchers or payment orders payable to the order of the General Treasury of the Republic, in cash or by any other form of payment that duly protects the tax interest, as determined by the Regional Director of the Internal Revenue Service (Biblioteca del congreso Nacional, 2016a).
Decree 1027	December 2016	Raise A traceability system was approved to protect the fiscal interest determined by the Internal Revenue Service on the production, distribution, and importation of goods subject to the specific tobacco tax (Biblioteca del congreso Nacional, 2016b).

Figure 4.

graphical representation of the evolution of tobacco control policies in Chile considering the MPOWER strategy.

Synthesis of Results

To synthesize results, we present the evolution of each dimension of the MPOWER strategy in three historical-political periods of the country, consolidating the findings by applying the incremental theory of change. This process allows us to answer our two sub-questions.

March 1990 to February 2000: “Return to Democracy.”

One Law and two decrees set the foundation for tobacco control policies (Law 19 419 and decrees 18 and 828). We observed an incipient development of five of the six dimensions analyzed and the only dimension classified as “absent” was Offer (Table 3).

Table 3.

Ordinal Categorical Classification of Measures Per Dimension and Period.

	March 1990 to February 2000	March 2000 to February 2010	March 2010 to February 2018	Policy evolution classification
	“Return to democracy.”	“Center-left governments.”	"Intermittent center-right-wing and center-left-wing governments.”	Policy evolution classification
M	(+) Incipient Request information about additives and substances used in tobacco manufacturing. The Ministry of Health can prohibit using some additives and substances that increase health risks. Fines between USD$6,727.61 and USD$66,610.0.	(++) Developed Request information specifying the quality and quantity of constituents, additives, and substances used for tobacco treatment; annually reported to the Ministry of Health. WHO frame with measures pointed to obtain information regarding the contents and emissions of tobacco products. Same fines.	(++) Developed No new regulations. Fines between USD$1,998.3 to USD$66,610.0. Individual sanctions are included.	Un-sustained
P	(+) Incipient Absolute prohibition of smoking in dangerous places (i.e., inflammable places). A partial ban on smoking in public places. Separate spaces for smokers and non-smokers in bars and restaurants were requested. Fines between USD$33.30 and USD$333.05.	(++) Developed Absolute prohibitions of smoking in school and public transportation were added. More places were added to the partial prohibition as gymnasiums and sports facilities. Obligatory separated areas for smokers and non-smokers in bars, restaurants, and discos, depending on the size of the establishment. Individual penalties of USD$33.30. The fine for owners, directors, or managers was USD$66.61 per offender.	(+++) Consolidated Prohibition of smoking in grandstands or other public use sports spaces, gyms or stadiums and beaches, rivers, or lakes. The separation between smokers and non-smokers areas in pubs or restaurants is not allowed, and open spaces or patios are needed to smoke. Individual penalties from USD$66.61 to USD$266.44. For owners, directors, or managers, fines are USD$133.22 per offender.	Layered
O	(−) Absent	(+) Incipient WHO framework with measures educational interventions and screening and treatment for tobacco dependence.	(−) Absent	Absent
W	(+) Incipient Warnings about the specific risk that tobacco consumption implies in every tobacco product. Educational programs on tobacco risk consumption in schools. Fines between USD$666.10 to USD$1,665.25.	(++) Developed WHO framework with measures about education, communication, training and public awareness, packaging and labeling of tobacco products. It is labeled with warnings that occupy 50% of the surface of any packaging of tobacco products. Communicational design of billboards placed outside the stores. Inclusion of the effect of second-hand smoke in educational programs. Penalties for legal entities in the tobacco industry between USD$3,330.5 and USD$33,305.0, for owners, directors, or managers, fines from USD$199.83 to USD$1,332.2, and individuals fines from USD$66.61 to USD3,330.5.	(+++) Consolidated Publication of graphic norms for the use of warnings in packaging. They are updated on school programs. Same fines.	Layered
E	(+) Incipient Prohibition of advertising, propaganda, or promotion of products made with tobacco for people under 18 years old, including television and cinema. Prohibition of offering, distribution, or delivery free of charge of products made with tobacco to minors under 16 years of age in public places or sites. Fines between USD$666.10 to USD$1,665.25.	(++) Developed WHO framework with measures about prohibiting any form of publicity, promotion, and sponsorship. Publicity and sales restrictions near educational establishments. Prohibition of tobacco advertising in public places or the Internet, except inside places of sale. Penalties for legal entities belonging to the tobacco industry between USD$66.1 and USD$33,305.0, for owners, directors, or managers, fines from USD$133.22 to USD$6,661.0, and individuals fines from USD$66.61 to USD$3,330.5.	(++) Developed Prohibition of sales of tobacco products inside health facilities, whether public or private. Same fines	Layered
R	(+) Incipient Registration to sell. 50.4% ad valorem taxes (AVT) per package plus Value Added Taxes (VAT) (all to consumer). Fines between USD$666.10 to USD$1,665.25.	(+) Incipient Minor modifications. Tobacco products can only be commercialized from customs if tobacco importers comply with the regulations of the Internal Revenue Service.	(++) Developed Specific taxes were added for the first time with 62.3% VAT plus VAT, then in 2014 for the second time with 60.5% VAT plus VAT, and in 2016 for the third time 30% AVT plus VAT plus specific taxes per cigarette. Traceability system.	Un-sustained

Monitor

The legal documents established information flows regarding the composition of tobacco products to be monitored. The Ministry of Health is responsible for this activity to date. Non-compliance with regulations of this dimension was penalized with fines (Supplemental Table S5).

Protect

Smoking was prohibited in high-risk locations. In addition, partial measures for places such as bars and restaurants were enacted. Individuals who did not comply with the regulations were penalized with fines (Supplemental Table S5).

Offer

We did not find legal documents for this dimension in this period.

Warn

Warnings about the risks related to tobacco consumption in every package of product made with tobacco were implemented. Educational programs were included in both primary and secondary education curricula. Non-compliance with regulations by legal entities in the tobacco industry was penalized with fines (Supplemental Table S5).

Enforce

The measures were focused on the prevention of exposure to advertising, propaganda, or promotion of products made with tobacco in minors. In addition, offering, distributing, or free delivery in public places of products made with tobacco to individuals under 16 years old was prohibited. Non-compliance with the abovementioned regulations was penalized with fines (Supplemental Table S5).

Raise

Since tobacco products correspond to a consumer good, Chile enacted tobacco trade and taxation regulations before the analyzed decade, laying the foundations for regulating their purchase and sale. Between 1990 and 2000, adjustments were made to the taxes associated with the goods, especially those presented as a pack of cigarettes. At the end of this decade, cigarettes had to pay a tax of 50.4% on their sale price to the consumer for each pack, box, or wrapper. Non-compliance with regulations of this dimension was penalized with fines (Supplemental Table S5).

March 2000 to February 2010: “Center-left Governments.”

One decree and one Law were crucial to initiate an important change in tobacco control policies (decree 143 and law 20 105). We observed a developed status in four dimensions (Monitor, Protect, Warn and Enforce) with an incipient development other two (Offer and Raise) (Table 3).

Monitor

Advances related to the monitorization of the composition of tobacco products were observed, specifically in the quality and quantity of constituents, additives, and substances used for tobacco treatment. In addition, the FCTC introduced measures in research and scientific, technical, and legal cooperation. Non-compliance with these regulations was penalized with fines higher than those observed in the previous period (Supplemental Table S6).

Protect

Measures were implemented to protect against tobacco smoke exposure, particularly in indoor workplaces, public transport, and other public places. Prohibitions on smoking in higher education institutions, gymnasiums, sports facilities, and others were established. During this decade, regulation of tobacco consumption in recreational spaces such as bars and restaurants begin. Non-compliance with these regulations was penalized with fines higher than those observed in the previous period (Supplemental Table S6).

Offer

This is the only decade that shows an advance in this dimension, with the recommendations in the context of enacting the FCTC.

Warn

The regulation of the labeling of tobacco products is strengthened following the recommendations of the FCTC. These interventions were accompanied by changes in advertising tobacco products at stores and some modifications in measures related to educational programs. Non-compliance with regulations of this dimension was penalized with fines higher than those observed in the previous period (Supplemental Table S6).

Enforce

Broad prohibitions toward publicity on tobacco products were established. Publicity and sales restrictions near educational establishments were in place. Non-compliance with regulations of this dimension was penalized with fines higher than those observed in the previous period (Supplemental Table S6).

Raise

During this period, minor modifications to the current legal documents were established. However, no changes in taxation were identified.

March 2010 to February 2018: “Intermittent Center-Right-Wing and Center-Left-Wing Governments.”

In the last analyzed period, one decree and one Law represented significant advances in tobacco control policies (decree 825 and law 20 660). We observed a developed status in three dimensions (Monitor, Enforce and Raise) and a consolidation of two (Protect and Warn) (Table 3).

Monitor

On this dimension, we observed an increase in the fines than those observed in the previous period (see Supplemental Table S7) without changes in the measures.

Protect

During this period, the protective measures were strengthened by extending the bans to various public places, including the absolute prohibition of smoking in enclosed areas of bars and restaurants, public sports spaces, gyms, stadiums, beaches, rivers, or lakes. Not complying with these prohibitions was penalized with fines higher than those observed in the previous period (Supplemental Table S7).

Offer

We did not find legal documents for this dimension in this period.

Warn

Several warning designs are established. Educational measures with a national education plan are reinforced. Fines remained unchanged compared to the previous period.

Enforce

As a new measure, we identified the prohibition of sales of tobacco products inside health facilities. The cost of fines remained unchanged compared to the previous period.

Raise

The specific taxation for cigarette packages, boxes, or wrappers is introduced. This measure suffers three changes between 2010 and 2018. In addition, a traceability system was approved to protect the fiscal interest determined by the Internal Revenue Service on goods subject to the specific tobacco tax.

Progress of enacted laws and decrees of national tobacco policies in Chile

Table 3 presents a comprehensive analysis of the evolution of Chile’s tobacco control consumption policies displayed in its legal instruments considering the recommendations of the MPOWER strategy.

In general, we observed uneven progress in the adoption of anti-smoking measures over time, with three dimensions that experienced changes considered layered (protect, warn, and enforce), two unsustained (monitor and raise), and one absent (offer). Adopting measures recommended by the MPOWER strategy has been heterogeneous, with a marked progression since the FCTC enactment. This progression continued in the third period in the case of the dimensions protect and raise. Free smoke environments and the increase of specific taxes with a decrease of ad valorem taxation are the most robust measures adopted by Chile.

Discussion

We conducted a scoping review to explore the evolution of Chile’s tobacco control consumption policies with attention to the FCTC. The observed policy changes were analyzed using theoretical concepts proposed by van der Heijden and Kuhlmann (2017).

In general terms, Chile has enacted regulations related to tobacco trade and taxation since 1814(Biblioteca del Congreso Nacional de Chile, 2014). However, it was not until the mid-1990s that regulations included in legal documents—with the exception of the dimension Offer, only incorporated in 2005—that Chile begins a considerable but uneven effort to enact FCTC measures. More specifically, the dimensions Protect, Warn and Enforce were classified as layered, whereas Monitor and Raise, and Offer were considered as unsustained and absent respectively.

A turning point in tobacco policy development can be associated with the enactment of the FCTC in 2005. More specifically, a sustained progression is observed for Protect and Warn dimensions, where many measures were enacted between 2006 and 2018. Relatedly, measures associated with the Raise dimension are only developed more clearly in the last analysis period. Interestingly a government that one could have expected to have less aggressive measures towards the tobacco industry was the one which increased their taxes in 2016. In sum, we observe a relatively progressive construction of tobacco policy with a predominance of measures focusing on individual behavior/choices rather than targeting per se the tobacco industry.

While our findings confirm the evaluation made by the WHO in its global tobacco epidemic report (World Health Organization, 2021b), there are various nuances that deserve a lengthier discussion. First, interventions in the Monitor dimension are not necessarily defined by Laws. As such, measures reported depend on how governments respond to the questionnaires sent by WHO when writing these types of reports. In the case of Chile, the global report considered surveys and ad-hoc studies, which are not necessarily part of a tobacco monitoring strategy formally institutionalized by the country. Regarding the absent dimension Offer, this observation is consistent with other authors (Acuña, 2017; Bambs et al., 2020; Castillo-Riquelme et al., 2020; Feigl et al., 2015). The WHO report indicates pharmacological treatment is available; however, it must be clarified that the public health system does not cover this. With regards to the toll-free telephone quit line, this is a generic number that is used to respond to any health inquiry (“Salud responde”)(Ministerio de Salud, 2021). In addition to the above, the report indicates that smoking cessation programs are unavailable. The latter is interesting, considering that in 2003 a guideline on Tobacco Cessation for Primary Health Care professionals (Ministerio de Salud, 2003), developed with the collaboration of the Pan American Health Organization, was available. However, these interventions focused on counseling, a small part of cessation treatment. This guideline was discontinued later, and the interventions were moved to the Preventive Medical Examen for Adults (Ministerio de Salud, 2015).

Strengths and Limitations

Our scoping review has been reported following the PRISMA-ScR statement, contributing to its findings’ reliability and replicability. Likewise, the WHO MPOWER strategy is a standard reference for judging progress in cost-effective tobacco control measures. Complementarily, one of our study’s main strengths is bringing together the analytical framework provided by the WHO with a historical-political view to account for how local and global processes may intertwine to shape tobacco control measures over time at the national level.

Complementarily, our review is limited to tobacco policies endorsed in Chilean legislation, which is relevant in two directions. On the one hand, we only have data on law enforcement capacities within the specific legal provisions and penalties associated with their transgression. Thus, we cannot reject the possibility that we are in the presence of a “dead letter.” On the other, we have yet to consider tobacco control strategies not supported by legal documents. That is, the range of strategies and the extent of progress in tobacco control in Chile may be greater than that we have reported. Moreover, because we focused on documents enacted by the central government, local regulations issued by the municipalities (Chile has 345 municipalities to date) were left unexplored. In summary, a more comprehensive view of the progress of tobacco policies in Chile requires further research that contrasts various sources and the inclusion of legal documents issued by local governments.

Although the official legal documents in Chile are stored in a centralized database, making them easily accessible, our interpretation of tobacco-related legislation should consider the involvement of legal professionals to increase the precision of our results.

Future research on this topic could include other policy documents to complement the current evidence presented in this study and consider interviews with stakeholders internationally and locally involved in the evolution of this Chile’s frame, strategies that can provide more information about the use of alternative tobacco products such as the e-cigarettes.

Our revision highlights a series of policy changes that can be used to understand tobacco prevalence changes from a population-level perspective comprehensively. In addition, better research designs can be advanced since Chile’s tobacco policies have been multifaceted and heterogeneous.

Supplemental Material

sj-docx-1-sgo-10.1177_21582440231181392 – Supplemental material for Chile’s Tobacco Strategy: A Scoping Review of Tobacco Measures Over Time

Supplemental material, sj-docx-1-sgo-10.1177_21582440231181392 for Chile’s Tobacco Strategy: A Scoping Review of Tobacco Measures Over Time by Karen A. Domínguez-Cancino, Pablo Martínez and Josí Ignacio Nazif-Munoz in SAGE Open

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Fonds de recherche Santé, grant # 269540.

ORCID iDs

Karen A. Domínguez-Cancino

José Ignacio Nazif-Munoz

Supplemental Material

Supplemental material for this article is available online.

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