The impact of anti-tobacco legislation on birth weight in Peru

A comprehensive analysis of cardiovascular mortality trends in Peru from 2017 to 2022: Insights from 183,386 deaths of the national death registry

Background/objectives

Cardiovascular diseases are the leading cause of global mortality. Systematic studies on cardiovascular-related mortality at national and subnational levels in Peru are lacking. We aimed to describe the trends in cardiovascular-related mortality between 2017 and 2022 in Peru at national and subnational levels and by socioeconomic indicators.

Subjects/methods

We used data from the Peruvian death registry 2017-2022. Using ICD-10 codes, mortality was categorized into: hypertensive-, coronary-, and cerebrovascular- related deaths. We estimated age-standardized cardiovascular-related mortality rates by sex at national and regional levels, and by natural regions (Coast, Highlands, Amazon). We estimated the change in mortality rates between 2017-2019 and 2020-2022 and explored factors that contributed to such a change. We explored ecological relationships between mortality rates and socioeconomic indicators.

Findings

Overall 183,386 cardiovascular-related deaths were identified. Coronary-related deaths (37.2 %) were followed by hypertensive-related (25.1 %) and cerebrovascular-related deaths (22.6 %). Peru showed a marked increasing trend in cardiovascular-related mortality in 2020-2022 (77.8 %). The increase clustered in the Coast and Highlands, with the highest change observed in Lima (132.1 %). Mortality was highest in subjects with lower education and subjects with public health insurance. Gini coefficient was associated with lower mortality rates while unemployment was associated with higher mortality rates.

Interpretation

There was a notable rise in cardiovascular-related mortality in Peru, particularly during the Covid-19 pandemic with a slight decrease in 2022. Gaining a comprehensive understanding of the factors that contribute to the increase in cardiovascular deaths in Peru will facilitate the development of precise interventions at both the national and regional levels.

Evaluation of Population-Level Tobacco Control Interventions and Health Outcomes: A Systematic Review and Meta-Analysis

Importance

Smoking causes considerable noncommunicable diseases, perinatal morbidity, and mortality.

Objective

To investigate the associations of population-level tobacco-control policies with health outcomes.

Data Sources

PubMed, EMBASE, Web of Science, Cumulated Index to Nursing and Allied Health Literature, and EconLit were searched from inception to March 2021 (updated on 1 March 2022). References were manually searched.

Study Selection

Studies reporting on associations of population-level tobacco control policies with health-related outcomes were included. Data were analyzed from May to July 2022.

Data Extraction and Synthesis

Data were extracted by 1 investigator and cross-checked by a second investigator. Analyses were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline.

Main Outcomes and Measures

The primary outcomes were respiratory system disease (RSD), cardiovascular disease (CVD), cancer, mortality, hospitalization, and health care utilization. The secondary outcomes were adverse birth outcomes, such as low birth weight and preterm birth. Random-effects meta-analysis was used to estimate pooled odds ratios (ORs) and 95% CIs.

Results

Of 4952 records identified, 144 population-level studies were included in the final analysis; 126 studies (87.5%) were of high or moderate quality. The most frequently reported policies were smoke-free legislation (126 studies), followed by tax or price increases (14 studies), multicomponent tobacco control programs (12 studies), and a minimum cigarette purchase age law (1 study). Smoke-free legislation was associated with decreased risk of all CVD events (OR, 0.90; 95% CI, 0.86-0.94), RSD events (OR, 0.83; 95% CI, 0.72-0.96), hospitalization due to CVD or RSD (OR, 0.91; 95% CI, 0.87-0.95), and adverse birth outcomes (OR, 0.94; 95% CI, 0.92-0.96). These associations persisted in all sensitivity and subgroup analyses, except for the country income category, for which a significant reduction was only observed in high-income countries. In meta-analysis, there was no clear association of tax or price increases with adverse health outcomes. However, for the narrative synthesis, all 8 studies reported statistically significant associations between tax increases and decreases in adverse health events.

Conclusions and Relevance

In this systematic review and meta-analysis, smoke-free legislation was associated with significant reductions in morbidity and mortality related to CVD, RSD, and perinatal outcomes. These findings support the need to accelerate the implementation of smoke-free laws to protect populations against smoking-related harm.

Smoking and Smoking Cessation in the Risk for Fetal Growth Restriction and Low Birth Weight and Additive Effect of Maternal Obesity

Many studies have shown that neonates of smoking mothers have a lower birth weight, but several issues remain poorly studied, e.g., the effects of giving up smoking or the combined effects of smoking and maternal obesity. Therefore, we evaluated a prospective cohort of 912 mothers in a single pregnancy, recruited in Poland, in 2015−2016. In the cohort, we recorded 72 (7.9%) newborns with birth weight <10th percentile, 21 (2.3%) fetal growth restriction (FGR) cases, and 60 (6.6%) low birth weight (LBW, <2500 g) newborns. In the cohort, 168 (18.4%) women smoked before pregnancy; the mean number of cigarettes/day was 10.8 (1–30), and the mean number of years of cigarette smoking was 8.5 (1–25). Among smokers, 57 (6.3%) women smoked in the first trimester. Adjusted odds ratio (AOR) of newborn outcomes (with 95% confidence intervals, CI) was calculated in multi-dimensional logistic regressions. Compared to participants who had never smoked, smoking before pregnancy was associated with a higher odds ratio of birth weight <10th percentile (AOR = 1.93, CI: 1.08–3.44, p = 0.027), but the result for LBW (AOR = 2.76, CI: 1.05–7.26, p = 0.039) and FGR (AOR = 1.13, CI: 0.38–3.36, p = 0.822) had the wider confidence interval or was insignificant. Effects of smoking cessation before pregnancy were statistically insignificant for the studied outcomes. Smoking in the first trimester was associated with a higher risk of birth weight <10th percentile (AOR = 4.68, CI: 2.28–9.62, p < 0.001), LBW (AOR = 6.42, CI: 1.84–22.36, p = 0.004), and FGR (AOR = 3.60, CI: 0.96–13.49, p = 0.057). Smoking cessation in the second/third trimester was associated with a higher odds ratio of birth weight <10th percentile (AOR = 4.54, CI: 1.58–13.02, p = 0.005), FGR (AOR = 3.36, CI: 0.6–18.74, p = 0.167), and LBW (AOR = 2.14, CI: 0.62–7.36), p = 0.229), to a similar degree to smoking in the first trimester. The odds ratios were higher in the subgroup of pre-pregnancy body mass index ≥25 kg/m² for the risk of birth weight <10th percentile (AOR = 6.39, CI: 2.01–20.34, p = 0.002) and FGR (AOR = 6.25, CI: 0.86–45.59, p = 0.071). The length of cigarette smoking time was also the risk factor for studied outcomes. Conclusions: Smoking in the first trimester increased the studied risks, and the coexistence of excessive maternal weight increased the effects. Smoking cessation during the second/third trimester did not have a protective effect.