Smoke-free legislation and neonatal and infant mortality in Brazil: longitudinal quasi-experimental study

Abstract

ObjectiveTo examine the associations of partial and comprehensive smoke-free legislation with neonatal and infant mortality in Brazil using a quasi-experimental study design.DesignMonthly longitudinal (panel) ecological study from January 2000 to December 2016.SettingAll Brazilian municipalities (n=5565).ParticipantsInfant populations.InterventionSmoke-free legislation in effect in each municipality and month. Legislation was encoded as basic (allowing smoking areas), partial (segregated smoking rooms) or comprehensive (no smoking in public buildings). Associations were quantified by immediate step and longer term slope/trend changes in outcomes.Statistical analysesMunicipal-level linear fixed-effects regression models.Main outcomes measuresInfant and neonatal mortality.ResultsImplementation of partial smoke-free legislation was associated with a −3.3 % (95% CI −6.2% to −0.4%) step reduction in the municipal infant mortality rate, but no step change in neonatal mortality. Comprehensive smoke-free legislation implementation was associated with −5.2 % (95% CI −8.3% to −2.1%) and −3.4 % (95% CI −6.7% to −0.1%) step reductions in infant and neonatal mortality, respectively, and a −0.36 (95% CI −0.66 to−0.06) annual decline in the infant mortality rate. We estimated that had all smoke-free legislation introduced since 2004 been comprehensive, an additional 10 091 infant deaths (95% CI 1196 to 21 761) could have been averted.ConclusionsStrengthening smoke-free legislation in Brazil is associated with improvements in infant health outcomes—particularly under comprehensive legislation. Governments should accelerate implementation of comprehensive smoke-free legislation to protect infant health and achieve the United Nation’s Sustainable Development Goal three.

Investigating the effects of comprehensive smoke-free legislation on neonatal and infant mortality in Thailand using the synthetic control method

“…At present, the evidence on the early-life health impact of smoke-free legislation is almost entirely derived from evaluations in high-income countries (HICs) [ 7 , 9 ]. These findings may not easily be generalized to low- and middle-income countries (LMICs) for a number of reasons – for example, outdoor air pollution, indoor air pollution due to biomass used for cooking and heating, household tobacco smoke exposure, and tobacco smoke exposure among pregnant women are significantly higher, whereas awareness of tobacco-related harms is significantly lower in LMICs than in HICs [10] , [11] , [12] Moreover, pregnancy outcomes are generally poorer in LMICs than in HICs due to reduced antenatal care capacities [13] .…”

“…These findings may not easily be generalized to low- and middle-income countries (LMICs) for a number of reasons – for example, outdoor air pollution, indoor air pollution due to biomass used for cooking and heating, household tobacco smoke exposure, and tobacco smoke exposure among pregnant women are significantly higher, whereas awareness of tobacco-related harms is significantly lower in LMICs than in HICs [10] , [11] , [12] Moreover, pregnancy outcomes are generally poorer in LMICs than in HICs due to reduced antenatal care capacities [13] . We are aware of only one study that investigated the effectiveness of smoke-free legislation on infant health from a middle-income country (MIC), namely Brazil [9] . Based on this study, the implementation of smoke-free laws across Brazil was estimated to have prevented 15,068 infant deaths over 12 years [9] .…”

“…We are aware of only one study that investigated the effectiveness of smoke-free legislation on infant health from a middle-income country (MIC), namely Brazil [9] . Based on this study, the implementation of smoke-free laws across Brazil was estimated to have prevented 15,068 infant deaths over 12 years [9] .…”

Impact of the Programa Mais médicos (more doctors Programme) on primary care doctor supply and amenable mortality: quasi-experimental study of 5565 Brazilian municipalities

“…Firstly, the analytical approach was ecological, prohibiting individual inference and limiting causal interpretation. However, the approach was robust, has been employed by similar studies [10,11,21,28,29,43], exploits the quasi-experimental nature of the programme, and provides stronger evidence over most other observational studies. Sensitivity analyses demonstrate the robustness of the findings to alternative specifications in covariates and time trends.…”

Impact of expanding smoke-free policies beyond enclosed public places and workplaces on children’s tobacco smoke exposure and respiratory health: protocol for a systematic review and meta-analysis

“…[4][5][6][7][8] Although in low-income and middle-income countries high background air pollution, poor economic conditions and low awareness of tobacco-related harm might obscure the positive effects of smoke-free legislation, evidence suggests that smokefree policies can have a similarly positive impact in these countries as in high-income countries. [9][10][11] As a result, smoke-free legislation is increasingly recognised as an important policy tool to protect children from the adverse health effects of TSE (eg, incorporated in Sustainable Development Goals 3.2, 3.4, 3.9 and 3.A that aim to improve health and well-being). 3 Recently, policies to provide additional protection of children to TSE beyond enclosed public places have been implemented in a number of places, both at a national and a subnational level.…”