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Effect of tobacco control policies on perinatal and child health: What's the evidence?

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Health Evidence™ hosted a 60 minute webinar examining the effect of tobacco control policies on perinatal and child health. Click here for access to the audio recording for this webinar: https://youtu.be/pPXVfmJuLX0

Dr. Jasper Been, Consultant Neonatologist at the Erasmus University MC-Sophia Children’s Hospital and Honorary Research Fellow in the Centre for Medical Informatics at the University of Edinburgh led the session and presented findings from their recent systematic review and meta-analysis:

Faber T, Kumar A, Mackenbach J, Millett C, Basu S, Sheikh A, & Been JV. (2017). Effect of tobacco control policies on perinatal and child health: A systematic review and meta-analysis. The Lancet Public Health, 2(9), e420-e437.

Tobacco smoking and smoke exposure during pregnancy and childhood cause considerable childhood morbidity and mortality. This review examines the effect of tobacco control policies on perinatal and child health. Forty-one studies were included in the review. Implementation of smoke-free legislation was associated with reductions in rates of preterm birth, rates of hospital attendance for asthma exacerbations and rates of hospital attendance for all respiratory tract infections and for lower respiratory tract infections. Among two studies assessing the association between smoke-free legislation and perinatal mortality, one showed significant reductions in stillbirth and neonatal mortality but did not report the overall effect on perinatal mortality, while the other showed no change in perinatal mortality. Meta-analysis of studies on other MPOWER policies was not possible; all four studies on increasing tobacco taxation and one of two on offering disadvantaged pregnant women help to quit smoking that reported on our primary outcomes had positive findings. These findings provide strong support for implementation of such policies comprehensively across the world.

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Effect of tobacco control policies on perinatal and child health: What's the evidence?

  1. 1. Welcome! Effect of tobacco control policies on perinatal and child health: What's the evidence? You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.
  2. 2. Poll Questions: Consent • Participation in the webinar poll questions is voluntary • Names are not recorded and persons will not be identified in any way • Participation in the anonymous polling questions is accepted as an indication of your consent to participate Benefits: • Results inform improvement of the current and future webinars • Enable engagement; stimulate discussion. This session is intended for professional development. Some data may be used for program evaluation and research purposes (e.g., exploring opinion change) • Results may also be used to inform the production of systematic reviews and overviews Risks: None beyond day-to-day living
  3. 3. After Today • The PowerPoint presentation and audio recording will be made available • These resources are available at: – PowerPoint: http://www.slideshare.net/HealthEvidence – Audio Recording: https://www.youtube.com/user/healthevidence /videos 3
  4. 4. What’s the evidence? Faber T, Kumar A, Mackenbach JP, Millett C, Basu S, Sheikh A, & Been JV. (2017). Effect of tobacco control policies on perinatal and child health: A systematic review and meta-analysis. The Lancet Public Health, 2(9), e420-e437. https://healthevidence.org/view- article.aspx?a=effect-tobacco-control- policies-perinatal-child-health-systematic- review-meta-32781
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  6. 6. Housekeeping (cont’d) • Audio – Listen through your speakers – Go to ‘Communicate > Audio Broadcast’ • WebEx 24/7 help line – 1-866-229-3239
  7. 7. Poll Question #1 How many people are watching today’s session with you? A. Just me B. 2-3 C. 4-5 D. 6-10 E. >10
  8. 8. Students: Sarah Neil-Sztramko (Postdoctoral fellow) Emily Belita (PhD candidate) Patricia Burnett (PhD candidate) Grace Thomas Research Assistant Rawan Farran Research Assistant Kristin Read Research Coordinator Heather Husson Administrative Director The Health Evidence™ Team Maureen Dobbins Scientific Director Olivia Marquez Research Coordinator Maureen Dobbins Scientific Director Claire Howarth Research Coordinator Liz Kamler Research Assistant Emily Sully Research Assistant
  9. 9. What is www.healthevidence.org? Evidence Decision Making inform
  10. 10. Why use www.healthevidence.org? 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use
  11. 11. A Model for Evidence- Informed Decision Making National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
  12. 12. Stages in the process of Evidence-Informed Public Health National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. [http://www.nccmt.ca/eiph/index-eng.html]
  13. 13. Poll Question #2 Have you heard of PICO(S) before? A. Yes B. No
  14. 14. Searchable Questions Think “PICOS” 1.Population (situation) 2.Intervention (exposure) 3.Comparison (other group) 4.Outcomes 5.Setting
  15. 15. How often do you use systematic reviews to inform a program/services? A. Always B. Often C. Sometimes D. Never E. I don’t know what a systematic review is Poll Question #3
  16. 16. Jasper V. Been MD MPH PhD, Consultant Neonatologist at the Erasmus University MC-Sophia Children’s Hospital and Honorary Research Fellow in the Centre for Medical Informatics at The University of Edinburgh
  17. 17. WHO / NCIS 2017 1.100.000.000
  18. 18. 7.000.000 WHO / NCIS 2017 1.100.000.000
  19. 19. 7.000.000 1.300.000.000.000 WHO / NCIS 2017 1.100.000.000
  20. 20. up to 20% Faber et al. npj Prim Care Respir Med 2016
  21. 21. 40-50% up to 20% Faber et al. npj Prim Care Respir Med 2016
  22. 22. preterm birth +30% Faber et al. npj Prim Care Respir Med 2016
  23. 23. preterm birth low birth weight +30% +30% Faber et al. npj Prim Care Respir Med 2016
  24. 24. preterm birth low birth weight congenital anomalies +30% +30% +10-30% Faber et al. npj Prim Care Respir Med 2016
  25. 25. preterm birth low birth weight congenital anomalies stillbirth +30% +30% +10-30% +45% Faber et al. npj Prim Care Respir Med 2016
  26. 26. preterm birth low birth weight congenital anomalies stillbirth neonatal mortality +30% +30% +10-30% +45% +20% Faber et al. npj Prim Care Respir Med 2016 Pineles et al. Am J Epidemiol 2016
  27. 27. SIDS / SUDI +125% Faber et al. npj Prim Care Respir Med 2016
  28. 28. SIDS / SUDI asthma attacks +125% +85% Faber et al. npj Prim Care Respir Med 2016
  29. 29. SIDS / SUDI asthma attacks lower respiratory tract infections +125% +85% +55% Faber et al. npj Prim Care Respir Med 2016
  30. 30. SIDS / SUDI asthma attacks lower respiratory tract infections invasive meningococcal disease +125% +85% +55% +100% Faber et al. npj Prim Care Respir Med 2016
  31. 31. SIDS / SUDI asthma attacks lower respiratory tract infections invasive meningococcal disease +125% +85% +55% +100% Faber et al. npj Prim Care Respir Med 2016
  32. 32. Monitor tobacco use and prevention policies
  33. 33. Protect people from tobacco smoke
  34. 34. Offer help to quit smoking
  35. 35. Warn about the dangers of tobacco
  36. 36. Enforce bans on tobacco advertising, promotion, and sponsorship
  37. 37. Raise taxes on tobacco
  38. 38. ~250K asthma admissions ~2.5M births
  39. 39. ~250K asthma admissions ~2.5M births preterm birth10%
  40. 40. ~250K asthma admissions ~2.5M births preterm birth asthma admissions 10% 10%
  41. 41. Eligible studies: - MPOWER policies → perinatal / child health - (Quasi)experimental design (EPOC) Search (up to 22 June 2017): - 14 online databases (incl. grey literature) + WHO trial registry - Hand search of references + citations - Expert consultation
  42. 42. Primary outcomes: - Perinatal mortality - Preterm birth - Asthma admissions - Respiratory infection admissions
  43. 43. - Two independent reviewers - Customised data extraction forms - Author contact if necessary - Risk of bias: EPOC criteria - Random-effects meta-analysis - Overlapping populations excluded
  44. 44. - Sensitivity analyses - Excluding high-risk-of-bias studies - Including non-EPOC studies - Subgroup analyses - According to comprehensiveness of each policy - Stratified by socioeconomic status
  45. 45. local policy national policy • 57M births • 4.6M GP consultations • 2.7M hospital admissions
  46. 46. Smoke-free legislation Outcome: perinatal mortality 1.9 million births (2000-2011) Smoke-free workplace (2004) Smoke-free bars+restaurants (2008) 10.3 million births (1995-2011) Comprehensive smoke-free law (2007) Peelen et al. Sci Rep 2016 Been et al. Sci Rep 2015 -7.8% reduction in stillbirths -7.6% reduction in neonatal deaths
  47. 47. -3.8% Smoke-free legislation Outcome: preterm birth
  48. 48. Smoke-free legislation Outcome: asthma admissions -9.8%
  49. 49. Smoke-free legislation Outcome: asthma admissions -5.9% /y
  50. 50. Smoke-free legislation Outcome: lower respiratory tract infection admissions -18%
  51. 51. Health impact larger if legislation more comprehensive • Preterm birth-4% • Asthma hospitalisations-10% • Lower respiratory tract infection hospitalisations -18%
  52. 52. Health impact larger if legislation more comprehensive • Preterm birth-4% • Asthma hospitalisations-10% • Lower respiratory tract infection hospitalisations -18% -5% -12%
  53. 53. From: Global and National Burden of Diseases and Injuries Among Children and Adolescents Between 1990 and 2013: Findings From the Global Burden of Disease 2013 Study JAMA Pediatr 2016 -18% -5%
  54. 54. Smoke-free legislation Secondary outcomes - Very preterm birth: –10.0% (95%CI –15.7 to –4.2) - Low birth weight: –2.8% (95%CI –4.4 to –1.2) - Small for gestational age: –1.8% (95%CI –3.2 to –0.5) - Very small for gestational age: –0.6% (95%CI –0.6 to –0.6) - Birth weight: +12.5g (95%CI +2.1 to +22.8) Other secondary outcomes: no significant association
  55. 55. Help to quit tobacco use Hawkins et al. Prev Med 2016 Jarlenski et al. Health Aff 2014 Massachusetts: tobacco cessation coverage for Medicaid recipients (2006) USA: optional medical enrollment policies providing low-income women with stop smoking services (among others) – 6% decrease in upper respiratory tract infection admissions – No change in preterm birth
  56. 56. Tobacco taxation Hawkins et al. Prev Med 2016Jarlenski et al. Health Aff 2014 Hawkins et al. JAMA Ped 2014Markowitz et al. J Hum Cap 2013 Landers. Am J Public Health 2014 Ma et al. Prev Chronic Dis 2013 Reduction in preterm birth among deprived mothers in one of two studies Reduction in asthma hospitalisations in two out of three studies –9% reduction in lower but not upper respiratory tract infections per US$ increase in state excise tax
  57. 57. Other policies and secondary outcomes • Smoking cessation services for low-income pregnant women – Increased gestation length; no impact on SGA • Tobacco taxation – Reductions in LBW, SGA, increases in BW and gestation – Not consistent across studies – Reductions in infant mortality in two studies Adams et al. Medicaid Medicare Res Rev 2013 Jarlenski et al. Health Aff 2014 Hawkins et al. JAMA Ped 2014 Markowitz et al. J Hum Cap 2013Evans et al. J Public Econ 1999 Sen et al. Can Public Policy 2011 Patrick et al. Pediatrics 2016
  58. 58. Sensitivity/subgroup analyses • Inclusion of non-EPOC studies • Exclusion of high-risk-of-bias studies • Some variation in association according to SES, all showing pro-equity effect
  59. 59. Summary • Smoke-free legislation associated with reductions in preterm birth and asthma/respiratory infection admissions • Some studies also show reductions in these outcomes following tax increases • Very little information on child health impact of other MPOWER policies
  60. 60. Strengths/limitations • Strengths – Pre-specified and peer-reviewed protocol – Highly comprehensive search strategy – Considerable number of studies + participants/events – Findings in line with previous syst review – Findings robust in sensitivity analyses • Limitations – Based on quasi-experimental studies – Little evidence on policies other than smoke-free legislation – Findings not always consistent – Unable to assess publication bias
  61. 61. second-hand smoke exposure smoke-free legislation SHS exposure during pregnancy perinatal outcomes SHS exposure during childhood child health outcomes Faber et al. npj Prim Care Respir Med 2016
  62. 62. second-hand smoke exposure smoking cessation and initiation smoke-free legislation smoking during pregnancy SHS exposure during pregnancy perinatal outcomes SHS exposure during childhood child health outcomes Faber et al. npj Prim Care Respir Med 2016
  63. 63. second-hand smoke exposure social norm changes smoking cessation and initiation smoke-free legislation smoking during pregnancy SHS exposure during pregnancy perinatal outcomes SHS exposure during childhood child health outcomes Faber et al. npj Prim Care Respir Med 2016
  64. 64. second-hand smoke exposure social norm changes smoking cessation and initiation smoke-free legislation smoking during pregnancy SHS exposure during pregnancy perinatal outcomes SHS exposure during childhood child health outcomes Faber et al. npj Prim Care Respir Med 2016 Thirdhand smoke?
  65. 65. Knowledge gaps • Impact of several MPOWER / endgame policies on child health not known • Synergistic effect of policies? • Impact on inequalities? • Cost-effectiveness? • Low and middle income countries?
  66. 66. Implications • Smoke-free legislation needs to be implemented across the globe • Comprehensiveness is important • Other tobacco control policies also likely to benefit child health and therefore supported • Child health angle important for advocacy • Continuous impact monitoring is essential
  67. 67. WHO 2017
  68. 68. Prof. Aziz Sheikh Prof. Chris Millett Prof. Johan Mackenbach Dr. Sanjay Basu Timor Faber Funders: Arun Kumar
  69. 69. • Infant mortality decreased by – 0.23 per 1,000 (95%CI 0.37, 0.09) per 1€ increase in cig price – 0.16 per 1,000 (95%CI 0.30, 0.03) per 1€ increase in cig price in previous year • Infant mortality increased by – 0.07 per 1,000 (95%CI 0.01, 0.13) for every 10% increase in minimum- median cig price differential in previous year • Infant deaths avoided by price increase (2005-2014): 9,208 (95%CI 8,601 to 9,814) • Infant deaths avoidable by reducing price differential (2005-2014): 3,195 (95%CI 3,017 to 3,372)
  70. 70. Poll Question #4 The information presented today was helpful A. Strongly agree B. Agree C. Neutral D. Disagree E. Strongly disagree
  71. 71. What can I do now? Visit the website; a repository of over 5,000+ quality-rated systematic reviews related to the effectiveness of public health interventions. Health Evidence™ is FREE to use. Register to receive monthly tailored registry updates AND monthly newsletter to keep you up to date on upcoming events and public health news. Tell your colleagues about Health Evidence™: helping you use best evidence to inform public health practice, program planning, and policy decisions! Follow us @HealthEvidence on Twitter and receive daily public health review- related Tweets, receive information about our monthly webinars, as well as announcements and events relevant to public health. Encourage your organization to use Health Evidence™ to search for and apply quality-rated review level evidence to inform program planning and policy decisions. Contact us to suggest topics or provide feedback. info@healthevidence.org
  72. 72. Poll Question #5 What are your next steps? [Check all that apply] A. Access the full text systematic review B. Access the quality assessment for the review on www.healthevidence.org C. Consider using the evidence D. Tell a colleague about the evidence
  73. 73. Thank you! Contact us: info@healthevidence.org For a copy of the presentation please visit: http://www.healthevidence.org/webinars.aspx

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