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

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

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Evidence
Decision
Making
inform

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

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]

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]

Poll Question #2
Have you heard of PICO(S) before?
A. Yes
B. No

Searchable Questions Think “PICOS”
1.Population (situation)
2.Intervention (exposure)
3.Comparison (other group)
4.Outcomes
5.Setting

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

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

7.000.000
WHO / NCIS 2017
1.100.000.000

7.000.000
1.300.000.000.000
WHO / NCIS 2017
1.100.000.000

up to 20%
Faber et al. npj Prim Care Respir Med 2016

40-50%
up to 20%

preterm birth
+30%

preterm birth
low birth weight
+30%
+30%

preterm birth
low birth weight
congenital anomalies
+30%
+30%
+10-30%

preterm birth
low birth weight
congenital anomalies stillbirth
+30%
+30%
+10-30% +45%

preterm birth
low birth weight
congenital anomalies stillbirth neonatal mortality
+30%
+30%
+10-30% +45% +20%
Pineles et al. Am J Epidemiol 2016

SIDS / SUDI
+125%

SIDS / SUDI
asthma attacks
+125%
+85%

SIDS / SUDI
asthma attacks
lower respiratory tract infections
+125%
+85%
+55%

SIDS / SUDI
asthma attacks
lower respiratory tract infections
invasive meningococcal disease
+125%
+85%
+55%
+100%

Monitor tobacco use
and prevention
policies

Protect people from
tobacco smoke

Warn about the
dangers of tobacco

Enforce bans on
tobacco advertising,
promotion, and
sponsorship

~250K asthma admissions
~2.5M births

~2.5M births
preterm birth10%

~2.5M births
preterm birth
asthma
admissions
10%
10%

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

Primary outcomes:
- Perinatal mortality
- Preterm birth
- Asthma admissions
- Respiratory infection admissions

- Two independent reviewers
- Customised data extraction forms
- Author contact if necessary
- Risk of bias: EPOC criteria
- Random-effects meta-analysis
- Overlapping populations excluded

- Sensitivity analyses
- Excluding high-risk-of-bias studies
- Including non-EPOC studies
- Subgroup analyses
- According to comprehensiveness of each policy
- Stratified by socioeconomic status

local policy
national policy
• 57M births
• 4.6M GP consultations
• 2.7M hospital admissions

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

-3.8%
Outcome: preterm birth

Outcome: asthma admissions
-9.8%

Outcome: asthma admissions
-5.9% /y

Outcome: lower respiratory
tract infection admissions
-18%

Health impact larger if legislation
more comprehensive
• Preterm birth-4%
• Asthma hospitalisations-10%
• Lower respiratory tract infection
hospitalisations
-18%

Health impact larger if legislation
more comprehensive
• Preterm birth-4%
• Asthma hospitalisations-10%
• Lower respiratory tract infection
hospitalisations
-18%
-5%
-12%

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%

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

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

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

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

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

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

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

second-hand
smoke exposure
smoke-free
legislation
SHS exposure
during pregnancy
perinatal
outcomes
SHS exposure
during childhood
child health
outcomes

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

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

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
Thirdhand smoke?

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?

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

Prof. Aziz Sheikh
Prof. Chris Millett
Prof. Johan Mackenbach
Dr. Sanjay Basu
Timor Faber
Funders:
Arun Kumar

• 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)

Poll Question #4
The information presented today was
helpful
A. Strongly agree
B. Agree
C. Neutral
D. Disagree
E. Strongly disagree

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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

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

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