Use of interrupted time-series method to evaluate the impact of cigarette excise tax increases in Pennsylvania, 2000-2009

Macroeconomic impact of tobacco taxation in Indonesia

BACKGROUND

A significant tobacco tax increase has long been advocated to reduce Indonesia's high smoking prevalence. However, implementing such a policy remains challenging due to the tobacco industry's argument that it would negatively impact the economy.

OBJECTIVE

This study aims to provide a comprehensive estimate of the net impact of tobacco taxation on Indonesia's economy.

METHOD

The impact of the tax hike on the economy is simulated through a change in cigarette demand and reallocation of household's budget and allocation government spending from additional tobacco tax revenue. Input-output analysis is employed to estimate the net effect of the tobacco tax rise on the total economic output, income and employment in Indonesia.

FINDING

Increasing the tobacco tax would generate a net positive impact on the economy as it would increase economic output, household income and employment. The positive impact is mainly driven by government spending from additional revenue from increased tobacco taxes. Spending tax revenue using the current structure of government spending has the potential to generate the optimal economic effect. Increasing tobacco tax by 45% from the 2019 tax level would increase economic output, household income and employment by Rp84.2 trillion, Rp24.1 trillion and 400.3 thousand jobs, respectively.

Quality Improvement Campaign Improved Utilization of Rapid Sequence MRI for Diagnosis of Pediatric Appendicitis

INTRODUCTION

Appendicitis is the most common indication for emergency general surgery in the pediatric population. Computed tomography (CT) or magnetic resonance imaging (MRI) may be used for diagnosis when ultrasound findings are equivocal. However, CT involves unnecessary radiation exposure if MRI is available. After introducing a rapid sequence MRI (rsMRI) appendicitis protocol at our institution, CT was still preferentially used. We therefore implemented a quality improvement (QI) campaign to reduce the rate of CTs and increase the rate of rsMRI. Here, we assess the effectiveness of the QI campaign while evaluating potential barriers to using rsMRI.

METHODS

We conducted a mixed methods study, first performing stakeholder interviews which informed the design of a QI campaign initiated in May 2021 and a midway feedback survey in December 2021. A retrospective cohort study was then performed of children evaluated for appendicitis at our institution between January 1, 2016, and April 30, 2022. CT and rsMRI rates were compared before and after QI campaign implementation.

RESULTS

There was a significant decrease in rate of CTs and increase in rate of rsMRIs performed following the initiation of the QI campaign (p < 0.0001). The rate of CT scans decreased by a factor of 0.4 while the rate of rsMRI increased by a factor of 9.5.

CONCLUSION

A successful QI campaign was initiated at our institution, resulting in decreased utilization of CT and increased use of rsMRI for the evaluation of suspected appendicitis. These results highlight the potential impact of QI projects.

LEVEL OF EVIDENCE

III.

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.

Effects of municipal smoke-free ordinances on secondhand smoke exposure in the Republic of Korea

Objective

To reduce premature deaths due to secondhand smoke (SHS) exposure among non-smokers, the Republic of Korea (ROK) adopted changes to the National Health Promotion Act, which allowed local governments to enact municipal ordinances to strengthen their authority to designate smoke-free areas and levy penalty fines. In this study, we examined national trends in SHS exposure after the introduction of these municipal ordinances at the city level in 2010.

Methods

We used interrupted time series analysis to assess whether the trends of SHS exposure in the workplace and at home, and the primary cigarette smoking rate changed following the policy adjustment in the national legislation in ROK. Population-standardized data for selected variables were retrieved from a nationally representative survey dataset and used to study the policy action’s effectiveness.

Results

Following the change in the legislation, SHS exposure in the workplace reversed course from an increasing (18% per year) trend prior to the introduction of these smoke-free ordinances to a decreasing (−10% per year) trend after adoption and enforcement of these laws (β2 = 0.18, p-value = 0.07; β3 = −0.10, p-value = 0.02). SHS exposure at home (β2 = 0.10, p-value = 0.09; β3 = −0.03, p-value = 0.14) and the primary cigarette smoking rate (β2 = 0.03, p-value = 0.10; β3 = 0.008, p-value = 0.15) showed no significant changes in the sampled period. Although analyses stratified by sex showed that the allowance of municipal ordinances resulted in reduced SHS exposure in the workplace for both males and females, they did not affect the primary cigarette smoking rate as much, especially among females.

Conclusion

Strengthening the role of local governments by giving them the authority to enact and enforce penalties on SHS exposure violation helped ROK to reduce SHS exposure in the workplace. However, smoking behaviors and related activities seemed to shift to less restrictive areas such as on the streets and in apartment hallways, negating some of the effects due to these ordinances. Future studies should investigate how smoke-free policies beyond public places can further reduce the SHS exposure in ROK.

Smoking prevalence following the announcement of tobacco tax increases in England between 2007 and 2019: an interrupted time-series analysis

AIMS

This study aimed to evaluate the impact of announcement of tax increases on factory-made (FM) and roll-your own (RYO) cigarettes in England.

DESIGN, SETTING AND PARTICIPANTS

Autoregressive integrated moving average with exogeneous input (ARIMAX) time-series modelling in England, UK. Data were aggregated monthly on 274 890 participants between 2007 and 2019 taking part in the Smoking Toolkit Study (STS).

MEASUREMENTS

The association of sustained step level changes for tax rises for FM cigarettes and temporary pulse effects for tax rises for RYO cigarettes with smoking, quit attempt and quit success prevalence as well as per-capita self-reported cigarette consumption and cost per cigarette was assessed.

FINDINGS

A 10% rise in tax on RYO cigarettes was associated with a temporary 21.1% decline [95% confidence interval (CI) = -30.4 to -10.7] in smoking prevalence, and 20.7% decline (95% CI = -32.4 to -7.0) in per-capita self-reported cigarette consumption; while a 3% rise of tax on RYO cigarettes was associated with a temporary 20.7% decline (95% CI = -33.3 to -5.8) in the amount paid per RYO cigarette. For tax increases on FM cigarettes, a 5% above inflation tax rise was associated with a step-level increase of 33.1% (95% CI = 18.4-49.5) in quit success rates. However, some of the findings were sensitive to model specification and temporally specific.

CONCLUSION

The announcements of tax increases for cigarettes in England between 2010 and 2019 were inconsistently associated with temporary reductions in smoking prevalence, per-capita self-reported cigarette consumption and improved quit success. Paradoxically, reductions in the cost for roll-your-own cigarettes were also found. The results were not robust in all sensitivity analyses.

Principles and methods of global legal epidemiology

Although the theory and methods of legal epidemiology-the scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury in a population-have been well developed in the context of domestic law, the challenges posed by shifting the frame of analysis to the global legal space have not yet been fully explored. While legal epidemiology rests on the foundational principles that law acts as an intervention, that law can be an object of scientific study and that law has impacts that should be evaluated, its application to the global level requires the recognition that international laws, policies and norms can cause effects independently from their legal implementation within countries. The global legal space blurs distinctions between 'hard' and 'soft' law, often operating through pathways of global agenda setting, legal language, political pressures, social mobilisation and trade pressures to have direct impacts on people, places and products. Despite these complexities, international law has been overwhelmingly studied as operating solely through national policy change, with only one global quasi-experimental evaluation of an international law's impact on health published to date. To promote greater adoption of global legal epidemiology, we expand on an existing typology of public health law studies with examples of policymaking, mapping, implementation, intervention and mechanism studies. Global legal epidemiology holds great promise as a way to produce rigorous and impactful research on the international laws, policies and norms that shape our collective health, equity and well-being.

Association between tobacco control policies and hospital admissions for acute myocardial infarction in Thailand, 2006-2017: A time series analysis

Introduction

Studies in many countries have documented reductions of acute myocardial infarction (AMI) hospitalizations with smokefree policies. However, evidence on the association of cigarette tax with AMI events is unclear. There have been no studies of the associations between these two policies and AMI hospitalizations in Thailand.

Methods

We used negative binomial time series analyses of AMI hospitalizations (ICD-10 codes I21.0-I21.9), stratified by sex and age groups, from October 2006 to September 2017 to determine whether there was a change in AMI hospitalizations as a result of the changes in cigarette prices and the implementation of a 100% smokefree law.

Results

Cigarette price increases were associated with a significant 4.7% drop in AMI hospitalizations among adults younger than 45 (incidence rate ratio [IRR], 0.953; 95% confidence interval [CI], 0.914–0.993; p = 0.021). Implementation of the 100% smokefree law was followed by a significant 13.1% drop in AMI hospitalizations among adults younger than 45 (IRR, 0.869; 95% CI, 0.801–0.993; P = 0.001). There were not significant associations in older age groups.

Conclusions

The Thai cigarette tax policy and the smokefree law were associated with reduced AMI hospitalizations among younger adults. To improve effectiveness of the policies, taxes should be high enough to increase cigarette price above inflation rates, making cigarettes less likely to be purchased; smokefree laws should be strictly enforced.

Effects of a Safety Letter on Metoclopramide Use in Korea: An Interrupted Time-Series Analysis

BACKGROUND

The Korean Ministry of Food and Drug Safety (MFDS) issued a safety letter regarding metoclopramide use and its adverse drug event of extrapyramidal disorder in October 2013. However, this safety letter had controversial effects on pharmacovigilance and management policies. The objective of this study was to estimate the impact of this government safety letter on the use of metoclopramide.

PATIENTS AND METHODS

We conducted an interrupted time-series analysis using national claims data from January 2011 to December 2015 to assess the difference in metoclopramide utilization (ie, the total number of prescriptions per month, the average administration period per prescription per month, and the average dose per prescription per month) before and after the publication of the safety letter in October 2013.

RESULTS

The number of prescriptions, the average administration period per prescription, and the average dose per prescription of metoclopramide decreased after the publication of the safety letter. Notably, the decrease in the average administration period per prescription after the safety letter was statistically significant.

CONCLUSION

Our results indicate that the changes in the number of prescriptions, dose, and the duration of prescription may have occurred as a result of the restrictions and recommendations in the safety letter. Further research is needed to optimize the use of metoclopramide and to identify the risk of adverse drug events since the safety letter was issued.

Longitudinal Associations of Cigarette Prices With Smoking Cessation: The Coronary Artery Risk Development in Young Adults Study

INTRODUCTION

Few studies have used longitudinal cohort data to examine associations of cigarette prices with smoking cessation or whether price sensitivity varies by income or education. This study examines these associations in a multicenter US cohort and explores whether associations vary by education and income.

METHODS

Longitudinal data from baseline daily cigarette smokers aged 18-30 years in the Coronary Artery Risk Development in Young Adults study were linked to inflation-adjusted cigarette carton prices from the Council for Community and Economic Research Cost of Living Index based on residential address at baseline and in years 7, 10, and 15 (1985-2001). Multivariable Cox models estimated hazard ratios (HRs) of first (any) smoking cessation and sustained smoking cessation (no relapse) associated with each $1 increase in time-dependent cigarette price over 15 years of follow-up. Models were adjusted for sociodemographic, health-related, and policy covariates. We assessed effect modification by education and household income.

RESULTS

Among 1489 participants, a $1.00 higher cigarette carton price was associated with a 16% higher likelihood of first smoking cessation (HR = 1.16, 95% CI = 1.11 to 1.21) and an 8% higher likelihood of sustained smoking cessation (HR = 1.08, 95% CI = 1.02 to 1.14). Associations were strongest among participants with lower income for first cessation, and among those with higher income for sustained cessation. Associations were strongest for participants with less than a high school degree for both outcomes.

CONCLUSIONS

Results suggest higher cigarette prices promote smoking cessation among young to middle-aged adults, and that price sensitivity may differ by socioeconomic status.

IMPLICATIONS

Few studies have examined longitudinal associations of cigarette prices with smoking cessation, and findings are mixed on whether price sensitivity varies by education or income. In a cohort of US adult daily smokers, cigarette prices were associated with greater likelihood of both a first cessation and sustained cessation. Price associations with first cessation were stronger among low-income smokers, but associations with sustained cessation were stronger among high-income smokers. Results suggest that although higher cigarette prices may promote short-term smoking cessation among smokers at all income levels, additional supports may be needed to facilitate sustained smoking cessation among low-income smokers.

Sustained fall in inpatient MRSA prevalence after a video-reflexive ethnography project; an observational study

BACKGROUND

Maintaining optimal infection prevention and control (IPC) in a busy, clinical environment is challenging. Video-reflexive ethnography (VRE) is a collaborative, interventionist approach to practice improvement. We hypothesised that giving clinicians opportunities to view and reflect on video footage of everyday ward activities would raise awareness of, and suggest strategies to reduce, pathogen transmission risks. We undertook a VRE project, between March and September 2013, in two tertiary hospital surgical wards, with persistently high methicillin resistant Staphylococcus aureus (MRSA) endemicity, despite previous IPC interventions.

METHODS

This study was a retrospective/prospective observational study, using interrupted time-series analyses, to assess the effects of the VRE project on hand hygiene compliance, inpatient MRSA infections (newly infected patients, per 1000 occupied bed days) and inpatient MRSA colonisation prevalence, measured by serial point prevalence surveys. Follow-up continued until June 2016.

RESULTS

The VRE project was associated with changes in IPC behaviour and outcomes. Hand hygiene compliance increased (from 62% to 75%; p < 0.0001) and MRSA colonisation prevalence decreased significantly, in both wards (baseline 42%; average post-VRE 12%; p=<0.0001), MRSA infection rate decreased in one ward. Interpretation of results was complicated by a potential confounding effect of unplanned environmental hydrogen peroxide decontamination (HPD). Improved hand hygiene compliance was a predicted outcome of VRE, but also a potential contributor to reduced MRSA transmission.

CONCLUSION

Separate contributions of VRE (the intervention), HPD and hand hygiene compliance were uncertain, but their combined effect was significantly reduced MRSA endemicity, which previously had been resistant to attempted IPC interventions.

UC Care Check-A Postoperative Neurosurgery Operating Room Checklist: An Interrupted Time Series Study

BACKGROUND

The effectiveness of neurosurgical operating room (OR) checklists to improve communication, safety attitudes, and clinical outcomes is uncertain.

PURPOSE

To develop, implement, and evaluate a post-operative neurosurgery operating room checklist.

METHODS

Four large academic medical centers participated in this study. We developed an evidence-based checklist to be performed at the end of every adult-planned or emergent surgery in which all team members pause to discuss key elements of the case. We used a prospective interrupted time series study design to assess trends in clinical and cost outcomes. Safety attitudes and communication among OR providers were also assessed.

RESULTS

There were 11,447 neurosurgical patients in the preintervention and 10,973 in the postintervention periods. After implementation, survey respondents perceived that postoperative checklists were regularly performed, important issues were communicated at the end of each case, and patient safety was consistently reinforced. Observed to expected (O/E) overall mortality rates remained less than one, and 30-day readmission rate, length of stay index, direct cost index, and perioperative venous thromboembolism and hematoma rates remained unchanged as a result of checklist implementation.

CONCLUSION

A neurosurgical checklist can improve OR team communication; however, improvements in safety attitudes, clinical outcomes, and health system costs were not observed.

Smoking prevalence following tobacco tax increases in Australia between 2001 and 2017: an interrupted time-series analysis

BACKGROUND

Building on substantial tobacco control action over the previous decade, Australia increased the taxes on tobacco by 25% without forewarning on April 30, 2010. Australia then became one of a few countries to pre-announce a series of increases in tobacco taxes, with annual 12·5% increases starting from December, 2013. We aimed to examine the effects of both tax increases on smoking prevalence.

METHODS

By use of survey data from Australians aged 14 years and older in five capital cities, we did an interrupted time-series analysis to model the monthly prevalence of smoking (overall, of factory-made cigarettes [FMC], and of roll-your-own tobacco [RYO]), in the total sample and stratified by socioeconomic status subgroups. We measured outcomes in May, 2001-April, 2010; May, 2010-November, 2013; and December, 2013-April, 2017.

FINDINGS

The 25% tax increase was associated with immediate (-0·745 percentage points; 95% CI -1·378 to -0·112) and sustained reductions in prevalence (monthly trend -0·023 percentage points; -0·044 to -0·003), which were driven by reductions in the prevalence of smoking of FMC. The prevalence of smoking of RYO increased between May, 2010, and November, 2013, after the 25% tax increase. At the start of the pre-announced annual 12·5% increases, we observed an immediate reduction in smoking (-0·997 percentage points; -1·632 to -0·362), followed by decreasing overall prevalence (monthly trend -0·044 percentage points; -0·063 to -0·026) due to ongoing decreases in the prevalence of FMC smoking and a cessation of increases in the prevalence of smoking of RYO. Immediate decreases in smoking and changing trends in the prevalence of smoking of RYO were most evident among groups with a lower socioeconomic status.

INTERPRETATION

Large tax increases are effective in reducing smoking prevalence, both as a single increase without forewarning and as a pre-announced series of increases. However, taxes on tobacco are best structured to apply equally to FMC and RYO products. Tobacco control policies should prohibit price marketing that otherwise erodes the full impact of such tax increases.

FUNDING

Cancer Council Victoria.

Are national suicide prevention programs effective? A comparison of 4 verum and 4 control countries over 30 years

BACKGROUND

Suicide and non-fatal suicidal behavior are significant public health issues worldwide requiring effective preventive interventions.

METHODS

The aim of the present study was to analyze the effectiveness of national suicide prevention programs taking a statistical approach involving the segmented regression analysis of interrupted time series data.

RESULTS

This study demonstrates that National Suicide Prevention Programs are effective, but this effect seems to correlate with age and sex. Our data have shown a statistical significant decline in suicide rates in the verum countries in males, with the strongest effects in groups aged 25-to-44 years and 45-to-64 years.

CONCLUSION

Our study implies that the implementation of a national strategy is an effective tool to reduce suicide rates.

Trends of case-fatality rate by acute coronary syndrome in Portugal: Impact of a fast track to the coronary unit

INTRODUCTION

Efforts were made to improve management of coronary disease as the fast-track system to the Coronary Unit. We aim to analyse case-fatality rates by acute coronary syndrome in Portugal from 2000 to 2016, mainly the impact of the fast-track system and the proportion of patients that activate the fast-track system.

METHODS

We analysed monthly acute coronary syndrome case-fatality before and after the implementation of the fast-track system in 2007. Impact of the system was assessed through regression models for interrupted time-series. We calculated annual proportion of fast-track system admissions.

RESULTS

After 2007 case-fatality by acute coronary syndrome decreased (β=-1.27, p-value < 0.01). The estimates obtained for ST Elevation Myocardial Infarction suggest a reduction of nearly 86 monthly deaths prevented after 2007. The highest percentage of patients admitted through the fast-track system was 35%.

CONCLUSIONS

Our results suggest fast-track system may have contributed to a decline in acute coronary syndrome case-fatality. However, more than half of patients were not admitted through the system. This should encourage health authorities to make efforts to ensure compliance.

Cardiovascular disease and high blood pressure trend analyses from 2002 to 2016: after the implementation of a salt reduction strategy

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death around the world; however, many CVD events could be prevented if we focused on modification of the main risk factors. Increased salt consumption is estimated to have caused millions of deaths, mostly related to CVD, particularly stroke, which is the leading cause of death in Portugal. In our study, we aim to assess trends in the proportion of high blood pressure (HBP) in Acute Coronary Syndrome (ACS) patients as well as the trends in stroke and ACS in Portugal, especially after a set of public health initiatives were implemented to reduce salt intake.

METHODS

The monthly proportion of ACS patients presenting with previously diagnosed HBP and the monthly rate of CVD admissions into public hospitals in Portugal were calculated. CVD rates were stratified into ACS rate and stroke rates. Data were stratified by demographics variables. An interrupted time-series model was used to assess changes over time.

RESULTS

Breakpoint analysis revealed an estimated breakpoint around the year 2013 for the proportion of HBP patients, the following year there was a decreasing trend, however it was not significant. Analyses showed the trend before 2013 was increasing and started to decrease after this year. This decreased in proportion of HBP patients can be translated into a reduction of 555 people per year presenting with HBP in the ACS population. We analysed trends for ACS and stroke and tested the significance for a breakpoint in the year 2013. Although none of the remaining trends were significant for ACS crude rates and stroke crude rate, a decreasing trend was observed.

CONCLUSIONS

This research provides an indication about the impact a population-wide approach to CVD risk factors has on CVD trends themselves. Our results suggest that population-wide approaches can have an impact on the prevention and improvement of CVD control, reducing the number of CVD events, and eventually reducing premature death by CVD. As more restrictions on salt intake are being planned in Portugal in the next years, it is highly relevant to assess what is the current panorama and what further reductions we can expect.

Tobacco Control Laws and Pediatric Asthma

BACKGROUND

Exposure to environmental tobacco smoke increases pediatric asthma severity. Strict, state-level tobacco control reduces smoking. The Child Asthma Call-Back Survey (Child ACBS) is a nationally representative survey of the guardians of children with asthma. The American Lung Association's annual State of Tobacco Control report grades tobacco control laws in each state including a tax grade (cigarette excise tax relative to the national mean), and a smoke-free air grade (number of locations where smoking is prohibited).

METHODS

We joined Child ACBS data from 2006 to 2010 with corresponding state and year tobacco grades. In the primary analysis, we investigated the effect of state tax grades on a child's asthma severity by using a logistic regression model adjusting for year. A secondary analysis assessed the impact of smoke-free air grades on in-home smoking.

RESULTS

Our analysis included 12 860 Child ACBS interviews from 35 states over 5 years, representing over 24 million individuals. We merged 112 unique State of Tobacco Control grades with patient data by state and year. A higher tax grade was associated with reduced severity (adjusted odds ratio = 1.40; P = .007, 95% confidence interval: 1.10-1.80). A better smoke-free air grade was not associated with decreased in-home smoking after adjusting for confounding by income and type of residence.

CONCLUSIONS

A stronger tobacco tax is associated with reduced asthma severity. Further study is needed to determine the effect of smoke-free air laws on in-home environmental. This work supports ongoing efforts to strengthen tobacco control through federal and state regulations.

Smoke-free legislation and paediatric hospitalisations for acute respiratory tract infections: national quasi-experimental study with unexpected findings and important methodological implications

Objectives

We investigated whether Scottish implementation of smoke-free legislation was associated with a reduction in unplanned hospitalisations or deaths (‘events’) due to respiratory tract infections (RTIs) among children.

Design

Interrupted time series (ITS).

Setting/participants

Children aged 0–12 years living in Scotland during 1996–2012.

Intervention

National comprehensive smoke-free legislation (March 2006).

Main outcome measure

Acute RTI events in the Scottish Morbidity Record-01 and/or National Records of Scotland Death Records.

Results

135 134 RTI events were observed over 155 million patient-months. In our prespecified negative binomial regression model accounting for underlying temporal trends, seasonality, sex, age group, region, urbanisation level, socioeconomic status and seven-valent pneumococcal vaccination status, smoke-free legislation was associated with an immediate rise in RTI events (incidence rate ratio (IRR)=1.24, 95% CI 1.20 to 1.28) and an additional gradual increase (IRR=1.05/year, 95% CI 1.05 to 1.06). Given this unanticipated finding, we conducted a number of post hoc exploratory analyses. Among these, automatic break point detection indicated that the rise in RTI events actually preceded the smoke-free law by 16 months. When accounting for this break point, smoke-free legislation was associated with a gradual decrease in acute RTI events: IRR=0.91/year, 95% CI 0.87 to 0.96.

Conclusions

Our prespecified ITS approach suggested that implementation of smoke-free legislation in Scotland was associated with an increase in paediatric RTI events. We were concerned that this result, which contradicted published evidence, was spurious. The association was indeed reversed when accounting for an unanticipated antecedent break point in the temporal trend, suggesting that the legislation may in fact be protective. ITS analyses should be subjected to comprehensive robustness checks to assess consistency.

Effect of tobacco control policies on perinatal and child health: a systematic review and meta-analysis

BACKGROUND

Tobacco smoking and smoke exposure during pregnancy and childhood cause considerable childhood morbidity and mortality. We did a systematic review and meta-analysis to investigate whether implementation of WHO's recommended tobacco control policies (MPOWER) was of benefit to perinatal and child health.

METHODS

We searched 19 electronic databases, hand-searched references and citations, and consulted experts to identify studies assessing the association between implementation of MPOWER policies and child health. We did not apply any language restrictions, and searched the full time period available for each database, up to June 22, 2017. Our primary outcomes of interest were perinatal mortality, preterm birth, hospital attendance for asthma exacerbations, and hospital attendance for respiratory tract infections. Where possible and appropriate, we combined data from different studies in random-effects meta-analyses. This study is registered with PROSPERO, number CRD42015023448.

FINDINGS

We identified 41 eligible studies (24 from North America, 16 from Europe, and one from China) that assessed combinations of the following MPOWER policies: smoke-free legislation (n=35), tobacco taxation (n=11), and smoking cessation services (n=3). Risk of bias was low in 23 studies, moderate in 16, and high in two. Implementation of smoke-free legislation was associated with reductions in rates of preterm birth (-3·77% [95% CI -6·37 to -1·16]; ten studies, 27 530 183 individuals), rates of hospital attendance for asthma exacerbations (-9·83% [-16·62 to -3·04]; five studies, 684 826 events), and rates of hospital attendance for all respiratory tract infections (-3·45% [-4·64 to -2·25]; two studies, 1 681 020 events) and for lower respiratory tract infections (-18·48% [-32·79 to -4·17]; three studies, 887 414 events). Associations appeared to be stronger when comprehensive smoke-free laws were implemented than when partial smoke-free laws were implemented. 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. Assessment of publication bias was only possible for studies assessing the association between smoke-free legislation and preterm birth, showing some degree of bias.

INTERPRETATION

Smoke-free legislation is associated with substantial benefits to child health. The majority of studies on other MPOWER policies also indicated a positive effect. These findings provide strong support for implementation of such policies comprehensively across the world.

FUNDING

Chief Scientist Office Scotland, Farr Institute, Netherlands Lung Foundation, Erasmus MC.

Longitudinal Impact of the Smoking Ban Legislation in Acute Coronary Syndrome Admissions

Background and Purpose. The association between smoking and CV has been proved; however smoking is still the first preventable cause of death in the EU. We aim to evaluate the potential impact of the smoke ban on the number of ACS events in the Portuguese population. In addition, we evaluate the longitudinal effects of the smoking ban several years after its implementation. Methods. We analyzed the admission rate for ACS before and after the ban using data from hospital admission. Monthly crude rate was computed, using the Portuguese population as the denominator. Data concerning the proportion of smokers among ACS patients were obtained from the NRACS. Interrupted time series were used to assess changes over time. Results. A decline of −5.8% was found for ACS crude rate after the smoking ban. The decreasing trend was observed even after years since the law. The effect of the ban was higher in men and for people over 65 years. The most significant reduction of ACS rate was found in Lisbon. Conclusions. Our results suggest that smoking ban is related to a decline in ACS admissions, supporting the importance of smoke legislation as a public health measure, contributing to the reduction of ACS rate.

Association between Florida's smoke-free policy and acute myocardial infarction by race: A time series analysis, 2000-2013

INTRODUCTION

Racial disparities in acute myocardial infarctions (AMIs) are increasing over time. Previous studies have shown that the implementation of smoke-free policies is associated with reduced AMI rates. The objective of this study was to determine the association between smoke-free policy and AMI hospitalization rates and smoking by race.

METHODS

Healthcare Cost and Utilization Project data from Florida from 2000-2013 were analyzed using interrupted time series analysis to determine the relationship between Florida's smoke-free restaurant and workplace laws and AMI among the total adult population (aged ≥18years), by age, race, and gender. Behavioral Risk Factor Surveillance System data from Florida from 2000 to 2010 were analyzed using logistic regression to determine the association between policy and the adult smoking prevalence.

RESULTS

After implementation of the smoke-free policy, no statistically significant associations between AMI hospitalization rates or smoking prevalence were detected in the total population. In the subgroup analysis, the policy was associated with declines in AMI hospitalization rates among non-Hispanic white adults aged 18-44years (β=-0.001 per 10,000, p-value=0.0083). No other relationships with AMI hospitalization rates and smoking prevalence were found in the subgroup analysis.

CONCLUSIONS

More comprehensive smoke-free and tobacco control policies are needed to further reduce AMI hospitalization rates, particularly among minority populations. Further research is needed to understand and address how the implementation of smoke-free policies affects secondhand smoke exposure among racial and ethnic minorities.

Changes in Prices After an Excise Tax to Sweetened Sugar Beverages Was Implemented in Mexico: Evidence from Urban Areas

In 2014 an excise tax to non-alcoholic sweetened beverages (SSB) was implemented in Mexico. The objective of this paper is to study whether and to what degree these taxes passed-through onto SSB prices in urban areas overall and by region, type of beverage and package size. Prices were obtained from the National Institute of Statistics and Geography from 2011 to 2014. We applied a pre-post quasi-experimental approach using fixed effects models. In sensitivity analysis we applied other model specifications to test the robustness of the findings and we also present weighted estimations based on household purchases. The dependent variables are real prices of a specific beverage category; the main independent variables are dummies for each month of 2014, and the models adjust for time trends and seasonality. Results suggest that the SSB tax passed along to consumers for all SSBs and we found overshifting for the carbonated SSBs. A greater effect is seen among the small package sizes, and we see heterogeneous effects by region. Estimating the effect of the tax on prices is important to understand the potential effect on consumption.

Assessing the Expected Impact of Global Health Treaties: Evidence From 90 Quantitative Evaluations

We assessed what impact can be expected from global health treaties on the basis of 90 quantitative evaluations of existing treaties on trade, finance, human rights, conflict, and the environment. It appears treaties consistently succeed in shaping economic matters and consistently fail in achieving social progress. There are at least 3 differences between these domains that point to design characteristics that new global health treaties can incorporate to achieve positive impact: (1) incentives for those with power to act on them; (2) institutions designed to bring edicts into effect; and (3) interests advocating their negotiation, adoption, ratification, and domestic implementation. Experimental and quasiexperimental evaluations of treaties would provide more information about what can be expected from this type of global intervention.