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Background There are few quantitative studies into the effect of comprehensive smoke-free legislation on neonatal and infant mortality in middle-income countries. We aimed to estimate the effects of implementing comprehensive smoke-free legislation on neonatal mortality and infant mortality across all middle-income countries. Methods We applied the synthetic control method using 1990-2018 country-level panel data for 106 middle-income countries from the WHO, World Bank, and Penn World datasets. Outcome variables were neonatal (age 0-28 days) mortality and infant (age 0-12 months) mortality rates per 1000 livebirths per year. For each middle-income country with comprehensive smoke-free legislation, a synthetic control country was constructed from middle-income countries without comprehensive smoke-free legislation, but with similar prelegislation trends in the outcome and predictor variables. Overall legislation effect was the mean average of country-specific effects weighted by the number of livebirths. We compared the distribution of the legislation effects with that of the placebo effects to assess the likelihood that the observed effect was related to the implementation of smoke-free legislation and not merely influenced by other processes. Findings 31 (29%) of 106 middle-income countries introduced comprehensive smoke-free legislation and had outcome data for at least 3 years after the intervention. We were able to construct a synthetic control country for 18 countries for neonatal mortality and for 15 countries for infant mortality. Comprehensive smoke-free legislation was followed by a mean yearly decrease of 1.63% in neonatal mortality and a mean yearly decrease of 1.33% in infant mortality. An estimated 12 392 neonatal deaths in 18 countries and 8932 infant deaths in 15 countries were avoided over 3 years following the implementation of comprehensive smoke-free legislation. We estimated that an additional 104 063 infant deaths (including 95 850 neonatal deaths) could have been avoided over 3 years if the 72 control middle-income countries had introduced this legislation in 2015. 220 (43%) of 514 placebo effects for neonatal mortality and 112 (39%) of 289 for infant mortality were larger than the estimated aggregated legislation effect, indicating a degree of uncertainty around our estimates. Sensitivity analyses showed results that were consistent with the main analysis and suggested a dose-response association related to comprehensiveness of the legislation. Interpretation Implementing comprehensive smoke-free legislation in middle-income countries could substantially reduce preventable deaths in neonates and infants. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd. Funding Agencies|Dutch Heart Foundation; Lung Foundation Netherlands; Dutch Cancer Society; Dutch Diabetes Research Foundation; Netherlands Thrombosis Foundation; Health Data Research UK

SamenvattingIn Nederland staan rookvrije (kind)omgevingen op de politieke agenda. Dit multidisciplinaire onderzoek geeft een overzicht van rookvrij beleid voor auto’s en speeltuinen dat in andere landen ingevoerd is. We beschrijven de juridische kaders die invoering mogelijk maakten, de gezondheidsimpact en de mate van publieke steun voor deze vernieuwende rookvrije maatregelen, en de ervaringen van sleutelfiguren die betrokken zijn bij de implementatie van dit rookvrije beleid in het buitenland. Vanuit de volksgezondheid en de rechten van het kind zijn rookvrije maatregelen gerechtvaardigd. Na invoering van rookvrij beleid voor auto’s elders daalde de blootstelling aan tabaksrook bij kinderen met ruim 30%. In Schotland nam na implementatie ook het aantal ziekenhuisopnamen van kinderen met astma af. De gezondheidswinst van rookvrije speeltuinen is nog niet gekwantificeerd. Publieke steun voor deze uitbreidingen van rookvrij beleid is hoog, ook onder rokers. Uit interviews kwam naar voren dat het centraal stellen van de gezondheid van het kind belangrijk is, en dat een alomvattend landelijk tabaksontmoedigingsbeleid wordt geadviseerd. Dit project biedt handvatten om ook in Nederland verdere stappen te nemen om blootstelling aan tabaksrook en de bijkomende schadelijke gevolgen voor kinderen te verminderen. Op basis van de ervaringen uit het buitenland lijkt uitbreiding van landelijke wetgeving naar rookvrije auto’s en speeltuinen een kansrijke bijdragende stap richting een Rookvrije Generatie.

IntroductionOn September 2, 2019, Rotterdam’s first inner-city outdoor smoke-free zone encompassing the Erasmus MC, a large university hospital in the Netherlands, the Erasmiaans high school, the Rotterdam University of Applied Sciences and the public road in between, was implemented.Aims and MethodsWe aimed to assess spatiotemporal patterning of smoking before and after implementation of this outdoor smoke-free zone. We performed a before–after observational field study. We systematically observed the number of smokers, and their locations and characteristics over 37 days before and after implementation of the smoke-free zone.ResultsBefore implementation of the smoke-free zone, 4098 people smoked in the area every weekday during working hours. After implementation, the daily number of smokers was 2241, a 45% reduction (p = .007). There was an increase of 432 smokers per day near and just outside the borders of the zone. At baseline, 31% of the smokers were categorized as employee, 22% as student and 3% as patient. Following implementation of the smoke-free zone, the largest decreases in smokers were observed among employees (–67%, p value .004) and patients (–70%, p value .049). Before and after implementation, 21 and 20 smokers were visibly addressed and asked to smoke elsewhere.ConclusionsImplementation of an inner-city smoke-free zone was associated with a substantial decline in the number of smokers in the zone and an overall reduction of smoking in the larger area. Further research should focus on optimizing implementation of and compliance with outdoor smoke-free zones.ImplicationsA smoke-free outdoor policy has the potential to denormalize and discourage smoking, support smokers who want to quit, and to protect people from secondhand smoke exposure. Implementation of an inner-city smoke-free zone encompassing a large tertiary hospital and two educational institutions was associated with a substantial decline in the number of smokers in the zone, as well as in the larger area. Voluntary outdoor smoke-free zones can help reduce the number of smokers in the area and protect people from secondhand smoke. There is a need to explore effectiveness of additional measures to further improve compliance.

Background: Smoke-free policies in outdoor areas and semi-private and private places (eg, cars) might reduce the health harms caused by tobacco smoke exposure (TSE). We aimed to investigate the effect of smoke-free policies covering outdoor areas or semi-private and private places on TSE and respiratory health in children, to inform policy. Methods: In this systematic review and meta-analysis, we searched 13 electronic databases from date of inception to Jan 29, 2021, for published studies that assessed the effects of smoke-free policies in outdoor areas or semi-private or private places on TSE, respiratory health outcomes, or both, in children. Non-randomised and randomised trials, interrupted time series, and controlled before–after studies, without restrictions to the observational period, publication date, or language, were eligible for the main analysis. Two reviewers independently extracted data, including adjusted test statistics from each study using a prespecified form, and assessed risk of bias for effect estimates from each study using the Risk of Bias in Non-Randomised Studies of Interventions tool. Primary outcomes were TSE in places covered by the policy, unplanned hospital attendance for wheezing or asthma, and unplanned hospital attendance for respiratory tract infections, in children younger than 17 years. Random-effects meta-analyses were done when at least two studies evaluated policies that regulated smoking in similar places and reported on the same outcome. This study is registered with PROSPERO, CRD42020190563. Findings: We identified 5745 records and assessed 204 full-text articles for eligibility, of which 11 studies met the inclusion criteria and were included in the qualitative synthesis. Of these studies, seven fit prespecified robustness criteria as recommended by the Cochrane Effective Practice and Organization of Care group, assessing smoke-free cars (n=5), schools (n=1), and a comprehensive policy covering multiple areas (n=1). Risk of bias was low in three studies, moderate in three, and critical in one. In the meta-analysis of ten effect estimates from four studies, smoke-free car policies were associated with an immediate TSE reduction in cars (risk ratio 0·69, 95% CI 0·55–0·87; 161 466 participants); heterogeneity was substantial (I2 80·7%; p

IntroductionE-cigarette use remains a controversial topic, with questions over how people transition between e-cigarette use and cigarette smoking. This paper examined transitions into and out of nicotine product use in a representative sample of UK youth.MethodsWe used Markov multistate transition probability models on data from 10 229 participants (10–25 years old) in the UK Household Longitudinal Study (2015–2021). We used four product use states (‘never’, ‘non-current use’, ‘e-cigarette only’ and ‘smoking and dual use’) and estimated likelihood of transitions according to sociodemographic characteristics.ResultsAmong participants who had never used nicotine products, most were still non-users a year later (92.9% probability; 95% CI 92.6%, 93.2%); a small proportion transitioned to using e-cigarettes only (4.0%; 95% CI 3.7%, 4.2%) and cigarettes (2.2%; 95% CI 2.0%, 2.4%). Those aged 14–17 years were the most likely to start using a nicotine product. E-cigarette use was less persistent overtime than cigarette smoking, with a 59.1% probability (95% CI 56.9%, 61.0%) of e-cigarette users still using after 1 year compared with 73.8% (95% CI 72.1%, 75.4%) for cigarette smoking. However, there was a 14% probability (95% CI 12.8%, 16.2%) that e-cigarette users went onto smoke cigarettes after 1 year, rising to 25% (95% CI 23%, 27%) after 3 years.ConclusionThis study found that although overall nicotine product use was relatively rare, participants were more likely to experiment with e-cigarette use than cigarette smoking. This was mostly not persistent over time; however, approximately one in seven transitioned to cigarette smoking. Regulators should aim to deter all nicotine product use among children.

Evaluating whether social policies reduce health inequalities is complicated by the fact that these upstream determinants may also change the socioeconomic distribution. Failure to account for these compositional changes may severely bias the effect estimation procedure. In this article, we illustrate how a health inequality impact assessment of a policy that (also) changes the socioeconomic distribution may produce biased results. First, we show why analyses that do not account for compositional changes fail to estimate the correct counterfactual outcome. This problem most notably occurs when using repeated cross-sectional data, often the only available option to evaluate the health effect of large-scale policies. Second, we conducted a microsimulation study to estimate the magnitude of the bias under various conditions. The results showed that the actual impact of the policy on health inequalities is often underestimated and may even produce results that are in the opposite direction of the actual causal effect of the policy. Future studies should explore new strategies, such as simulation methods, to assess the impact of policies that (also) cause changes in the socioeconomic composition of the population, to enable researchers to accurately estimate their effect on health inequalities.

Background: Almost all of the evidence on the benefits of smoke-free legislation on child health comes from evaluations in high-income countries. We investigated the effects of Thailand’s 2010 comprehensive smoke-free legislation on neonatal and infant mortality. Methods: To overcome some of the methodological issues inherent to traditional quasi-experimental methods, we applied the novel synthetic control approach. Using 2001–2017 country-level panel data from the World Bank and Penn World datasets, we estimated the effects of smoke-free legislation as the difference between the outcome trends in Thailand versus those in a synthetic control country. The synthetic control country was composed of ‘control’ middle-income countries without comprehensive smoke-free legislation to recreate trends in Thailand in the 2001–2009 pre-legislation outcomes and covariates. We compared the legislation effects to ‘placebo effects’ obtained for each control country by fictitiously assuming that comprehensive smoke-free legislation was introduced there in 2010, similar to Thailand. Findings: Neonatal and infant mortality decreased by 2·9% and 2·8%/year respectively following smoke-free legislation, with an estimated 7,463 infant deaths (including 4,623 neonatal deaths) having been averted over eight years. The results were robust to different specifications of the control countries. Comparison with placebo effects indicated that the findings were unlikely to be attributable to factors other than the smoke-free legislation. Interpretation: Expanding comprehensive smoke-free policies to middle-income countries can support national efforts to achieve Sustainable Development Goal 3.2 for reducing preventable early-life deaths. Funding: Netherlands Lung Foundation, HDRUK, Asthma UK Centre for Applied Research and NIHR Global Respiratory Health Unit (RESPIRE).

IntroductionTobacco smoke exposure (TSE) has considerable adverse respiratory health impact among children. Smoke-free policies covering enclosed public places are known to reduce child TSE and benefit child health. An increasing number of jurisdictions are now expanding smoke-free policies to also cover outdoor areas and/or (semi)private spaces (indoor and/or outdoor). We aim to systematically review the evidence on the impact of these ‘novel smoke-free policies’ on children’s TSE and respiratory health.Methods and analysis13 electronic databases will be searched by two independent reviewers for eligible studies. We will consult experts from the field and hand-search references and citations to identify additional published and unpublished studies. Study designs recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group are eligible, without restrictions on the observational period, publication date or language. Our primary outcomes are: self-reported or parental-reported TSE in places covered by the policy; unplanned hospital attendance for wheezing/asthma and unplanned hospital attendance for respiratory infections. We will assess risk of bias of individual studies following the EPOC or Risk Of Bias In Non-randomised Studies of Interventions tool, as appropriate. We will conduct separate random effects meta-analyses for smoke-free policies covering (1) indoor private places, (2) indoor semiprivate places, (3) outdoor (semi)private places and (4) outdoor public places. We will assess whether the policies were associated with changes in TSE in other locations (eg, displacement). Subgroup analyses will be conducted based on country income classification (ie, high, middle or low income) and by socioeconomic status. Sensitivity analyses will be undertaken via broadening our study design eligibility criteria (ie, including non-EPOC designs) or via excluding studies with a high risk of bias. This review will inform policymakers regarding the implementation of extended smoke-free policies to safeguard children’s health.Ethics and disseminationEthical approval is not required. Findings will be disseminated to academics and the general public.PROSPERO registration numberCRD42020190563.

The low perceived subjective well-being of potential parents has been put forward as an explanation for the low fertility rates in developed countries. Accordingly, research about the effect of parenthood on life satisfaction is increasing, although the related studies are mostly restricted to western countries. The case of Hungary represents a great opportunity to extend the scope of the related research as this country has one of the lowest fertility rates in Europe, along with an exceptionally long and extensively utilised system of parental leave. The issue is examined here with a genetic matching method using longitudinal data from the Turning Points of Life Course survey (Hungarian GGS). Overall, the research described in this paper finds that fertility has a positive effect on subjective well-being in general. Moreover, not only a first child but also a second one increase subjective well-being. However, observation of the moderating effect of gender reveals that women benefit from having children both in the short and long term, whereas men benefit only in the short term. To sum up, this paper finds that pre-existing theory that uses the link between parenthood and subjective well-being to explain fertility trends makes a limited contribution to the discussion about the Hungarian situation.