Tobacco control campaign in Uruguay: Impact on smoking cessation during pregnancy and birth weight

Multiple births and low birth weight: Evidence from South Korea

OBJECTIVE

The proportion of multiple births has risen rapidly worldwide. Multiple births are likely to affect birth weight, which results in low birth weight (LBW) of less than 2500 g, possibly, because multiples are more likely to be born prematurely or less than 37 weeks into pregnancy. Using data from South Korea, this study aims to estimate the contribution of the rise in multiples to the rise in LBW incidence.

METHODS

Based on data from 2000 to 2017, we estimated the effect of multiples on LBW rates using linear regression analysis. Based on the regression analysis and the change in the proportion of multiples during this period, we calculated the contribution of the rise in multiples to the rise in LBW incidence using the total differential. In other words, we divided the change in LBW during the period due to the change in multiples by the total change during the period. The data are from the birth registry of the National Statistical Office, which contains information on the 8.4 million live births during the period 2000-2017.

RESULTS

We found that a 1 percentage point increase in multiples increases the proportion of LBWs by 0.495 percentage points. In addition, because the changes in the proportion of multiples and LBWs from 2000 to 2017 are 2.2 and 2.4 percentage points, respectively, 1.1 percentage points or 45.8% of the increase in LBWs over the period is due to the increase in multiples.

CONCLUSION

Since the Korean government introduced a measure to reduce the number of transferred embryos recently, one may expect that multiples in Korea would reduce in the near future, as it did in other countries. Subsequently, the incidence of LBW children is also likely to reduce, which is desirable in terms of the children's health outcomes.

The effects of expanded social health insurance on young mothers: Lessons from a pro-choice reform in Uruguay

With the implementation of the National Integrated Health System in 2007, the Uruguayan government extended social health insurance (SHI) to groups of individuals previously covered by the public safety net (PSN) or that paid for private insurance out-of-pocket. The policy allowed new beneficiaries to choose care from a set of private providers. In this study, we focus on the extension of SHI to adolescent mothers previously covered by the PSN. Exploiting the gradual incorporation of children of formal workers during the 2008-2013 period, and the geographic variation in the intensity of the reform, we find suggestive evidence that the increase in choice associated to the expansion of SHI decreased adolescent fertility, improved prenatal care and birthweight, and decreased first year mortality among low birthweight infants. These effects were only observed in the medium run, suggesting initial choice frictions and input shortage. We provide evidence that families increased their choice of private providers and that market concentration decreased in certain areas of the country, supporting the hypothesis that choice, and possibly competition, were the main mechanisms behind the findings.

Parenthood and smoking

Parents' smoking is harmful to infants' health. While it is well established that the fraction of mothers smoking during pregnancy is non-negligible, it is an open question of how many parents actually quit smoking to account for the adverse health effects accruing to their offspring. It is also unknown for how long smoking is reduced after first childbirth. This paper investigates these questions in a longitudinal analysis. The analyzed time period covers smoking patterns several years before childbirth and up to twenty years afterwards. Women's smoking probability already drops several years before first childbirth and it remains reduced until the first child turns 18 years old. In the second and third trimester of pregnancy, the drop is largest by around 75 percent.

Trends of mortality due to oral and oropharyngeal cancers in Uruguay from 1997 to 2014

Background

To analyze the trends of oral and oropharyngeal cancer mortality in Uruguay between 1997 and 2014 according to sex and age groups and its possible association with sociodemographic factors.

Material and Methods

A time-series ecological study using secondary data was performed. The data about mortality due to oral and oropharyngeal cancers were obtained from the Statistics Vitals Department of the Public Health Ministry of Uruguay. To estimate the mortality trends of the historical series, by sex, anatomical site and age groups, linear regressions generated by the Prais-Winsten procedure were used.

Results

The analysis of mortality trends for oral cavity and oropharyngeal cancers in Uruguay indicated that the global mortality rate was stable over the studied period. The women's mortality rate increased from 0.51 per 100,000 in 1997 to 0.65 per 100,000 in 2014 while for men, rates per 100,000 went from 3.22 in 1997 to 2.20 per 100,000 in 2014. Mortality from oral cancer in men decreased between 1997 and 2014. Mortality by oropharyngeal cancer, irrespective of sex, remained stable. Analysis by cancer site revealed decreasing trends tumors situated in the base of the tongue and gum. Years of education, unemployment, smoking and Gini index were not associated with mortality trends.

Conclusions

The overall mortality from oral and oropharyngeal cancer in Uruguay has remained constant in the period between 1997 and 2014. Oral cancer mortality decreased in men and increased in women and decreased at the base of the tongue. It’s necessary to continue monitoring the behavior of these diseases.

Key words:Mortality, oral cancer, oropharyngeal cancer, tongue cancer.

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

Background

Tobacco exposure remains a significant issue for public health, especially for pregnant women. It increases the risk for premature labor, low birth weight and small for gestational age (SGA), among other effects. To reduce these risks, many countries have enacted public policies to curb tobacco exposure. Peru enacted anti-tobacco laws that forbid smoking in public places, require prevention text and images in products and publicity, along with restriction of sales to adults. We evaluated the effect of the implementation of this law on newborn outcomes: birth weight, prematurity and SGA.

Methods

This was a quasi-experimental study that utilized data from the Peruvian Live Birth Registry. Children born to mothers from urban areas were the intervention group, while children born to mothers from rural areas were considered the control group. Only singletons with information on birth weight and gestational age, born to mothers aged 12 to 49 years were included in the study. In addition, newborns with birth weights greater than + 4 standard deviations (SD) or less than - 4 SD from the gestational age-specific mean were excluded. To measure the effect of legislation on birth weight we performed a difference in differences analysis.

Results

A total of 2,029,975 births were included in the analysis. After adjusting for characteristics of the mother and the child, and contextual variables, the anti-tobacco law in Peru reduced the incidence of prematurity by 30 cases per 10,000 live births (95% CI: 19 to 42).

Conclusions

The reform had negligible effects on overall birth weights and on the incidence of SGA. This modest result suggests the need for a more aggressive fight against tobacco, prohibiting all types of advertising and promotion of tobacco products, among others measures.

Neonatal health of parents and cognitive development of children

It is well-established that neonatal health is a strong predictor of socioeconomic outcomes later in life, but does neonatal health also predict key outcomes of the next generation? This paper documents a surprisingly strong relationship between birth weight of parents and school test scores of their children. The association between maternal birth weight and child test scores corresponds to 50-80 percent of the association between the child's own birth weight and test scores across various empirical specifications, for example including grandmother fixed effects that isolate within-family differences between mothers. Paternal and maternal birth weights are equally important in predicting child test scores. Our intergenerational results suggest that inequality in neonatal health is important for inequality in key outcomes of the next generation.

Impact of tobacco-pack pictorial warnings on youth and young adults: A systematic review of experimental studies

INTRODUCTION

We conducted a systematic review of the experimental literature on the impact of tobacco-pack pictorial warning labels (PWLs) on youth and young adults.

METHODS

We systematically searched computerized databases and the reference lists of relevant articles. We included studies that used an experimental protocol to assess PWLs. Studies had to report findings for youth or young adult samples (aged <30 years). Thirty-one studies met the inclusion criteria, with a total sample size of 27506. Two coders independently coded all study characteristics and outcomes.

RESULTS

Twenty-eight studies experimentally evaluated PWLs for cigarette packs while three studies evaluated PWLs for smokeless tobacco packs. Generally, PWLs led to higher attention, stronger cognitive and affective reactions, more negative pack attitudes and smoking attitudes, and increased intentions not to use tobacco products compared to text warnings. PWLs were perceived to be more effective than text warnings for both cigarette packs and smokeless tobacco packs.

CONCLUSIONS

The systematic review showed that PWLs on tobacco products are effective across a wide range of tobacco-related outcomes among young people. Gaps in the literature include a lack of research on tobacco initiation and cessation and a dearth of literature on non-cigarette tobacco products.

Responses to cigarette health warning labels, harm perceptions and knowledge in a national sample of pregnant and non-pregnant women of reproductive age

INTRODUCTION

Little is known about the effectiveness of cigarette health warning labels (HWLs) among U.S. pregnant and non-pregnant women of reproductive age. Our intent was to examine HWL responses by pregnancy status and their associations with knowledge and perceived harm.

METHODS

We conducted cross-sectional analyses of first (2013-2014) and second (2014-2015) Population Assessment of Tobacco and Health waves. The sample (N = 19,095) was representative of U.S. women of reproductive age (18-45 years). We examined three HWL responses (seeing HWLs, forgoing cigarettes because of HWLs, likely-to-quit because of HWLs), perceived harm from smoking, and knowledge of health effects to fetuses and others. Weighted logistic regression compared HWL responses by pregnancy status and their associations with perceived harm and knowledge, adjusting for demographics and tobacco use. Results were presented as marginal predicted probabilities.

RESULTS

Pregnant smokers were less likely than never-pregnant smokers to report likelihood of quitting (57% vs 67%, p = 0.020). Forgoing cigarettes and likely-to-quit due to HWLs-but not seeing HWLs-were positively associated with perceived harm and knowledge. Pregnant smokers were less likely to have knowledge of fetal harm (83%) than ever-pregnant (91%, p = 0.006) and never-pregnant (92%, p = 0.003) smokers. However, pregnant smokers who reported likelihood of quitting were much more likely to have knowledge of fetal harm than those who did not (93% vs. 67%, p = 0.028).

CONCLUSIONS

Implementation of HWLs that elicit stronger reactions-such as pictorial HWLs-and increase knowledge of fetal risks is one action to help reduce tobacco use in pregnant and non-pregnant U.S. women of reproductive age.

Smoking ban and health at birth: Evidence from Hungary

In 2012, smoking restrictions were extended to hospitality venues in Hungary. Women working in bars and restaurants were primarily affected by the intervention. In this research, we analyze the effect of this smoking ban on the outcomes of their pregnancies. Using individual live birth, fetal loss, and infant mortality registry data, we examine the probability of live birth, indicators of health at birth, and the probability of death in the first year of life. We apply a difference-in-differences framework and show that the smoking ban has improved health at birth. We observed birth weight to increase by 56 g (95% CI: 4.2 to 106.8) and gestation length by 0.19 weeks (95% CI: 0.02 to 0.36). Due to the ban, the probability of being born with very low and low birth weight has decreased by 1.2 and 2.2 percentage points, respectively (95% CI: -0.2 to -2.2 and 0.06 to -4.4), and we see a 0.9 percentage points reduction in the chance of being born very preterm (95% CI: -0.03 to -1.9). We also observe a decrease in the probability of being born with a low Ponderal index (decrease of 4.1 percentage points, 95% CI: -0.7 to -7.5). Performing a series of robustness and placebo tests, we provide evidence that supports the causal interpretation of our results. We also show that the ban was more beneficial for newborns of parents with low educational attainment and at the bottom of the fetal health endowment distribution.

Impact of plain packaging of cigarettes on the risk perception of Uruguayan smokers: an experimental study

BACKGROUND

Uruguay, a South American country of 3.4 million inhabitants that has already banned tobacco advertising, prohibited such terms as light, mild and low-tar and required graphic warnings covering 80% of cigarette packs, is considering the imposition of plain, standardised packaging.

METHODS

We conducted an experimental choice-based conjoint analysis of the impact of alternative cigarette package designs on the risk perceptions of 180 adult current Uruguayan smokers. We compared plain packaging, with a standardised brand description and the dark brown background colour required on Australian cigarette packages, to two controls: the current package design with distinctive brand elements and colours; and a modified package design, with distinctive brand elements and the dark brown background colour. Graphic warnings were also varied.

RESULTS

Plain packaging significantly reduced the probability of perceiving the stimulus cigarettes as less harmful in comparison to the current package design (OR 0.398, 95% CI 0.333 to 0.476, p<0.001) and the modified package design (OR 0.729, 95% CI 0.626 to 0.849, p<0.001).

CONCLUSIONS

Plain packaging enhanced the perceived risk of cigarette products even in a highly regulated setting such as Uruguay. Both the elimination of distinctive brand elements and the use of Australia's dark brown background colour contributed to the observed effect.

Tobacco policy reform and population-wide antismoking activities in Australia: the impact on smoking during pregnancy

Introduction

This study examined the impact of antismoking activities targeting the general population and an advertising campaign targeting smoking during pregnancy on the prevalence of smoking during pregnancy in New South Wales (NSW), Australia.

Methods

Monthly prevalence of smoking during pregnancy was calculated using linked health records for all pregnancies resulting in a birth (800 619) in NSW from 2003 to 2011. Segmented regression of interrupted time series data assessed the effects of the extension of the ban on smoking in enclosed public places to include licensed premises (evaluated in combination with the mandating of graphic warnings on cigarette packs), television advertisements targeting smoking in the general population, print and online magazine advertisements targeting smoking during pregnancy and increased tobacco tax. Analyses were conducted for all pregnancies, and for the population stratified by maternal age, parity and socioeconomic status. Further analyses adjusted for the effect of the Baby Bonus maternity payment.

Results

Prevalence of smoking during pregnancy decreased from 2003 to 2011 overall (0.39% per month), and for all strata examined. For pregnancies overall, none of the evaluated initiatives was associated with a change in the trend of smoking during pregnancy. Significant changes associated with increased tobacco tax and the extension of the smoking ban (in combination with graphic warnings) were found in some strata.

Conclusions

The declining prevalence of smoking during pregnancy between 2003 and 2011, while encouraging, does not appear to be directly related to general population antismoking activities or a pregnancy-specific campaign undertaken in this period.

Health shocks and their long-lasting impact on health behaviors: Evidence from the 2009 H1N1 pandemic in Mexico

Worldwide, the leading causes of death could be avoided with health behaviors that are low-cost but also difficult to adopt. We show that exogenous health shocks could facilitate the adoption of these behaviors and provide long-lasting effects on health outcomes. Specifically, we exploit the spatial and temporal variation of the 2009 H1N1 influenza pandemic in Mexico and show that areas with a higher incidence of H1N1 experienced larger reductions in diarrhea-related cases among young children. These reductions continue even three years after the shock ended. Health improvements and evidence of information seeking via Google searches were consistent with changes in hand washing behaviors. Several robustness checks validate our findings and mechanism.

Effects of posted point-of-sale warnings on alcohol consumption during pregnancy and on birth outcomes

In 23 states and Washington D.C., alcohol retailers are required by law to post alcohol warning signs (AWS) that warn against the risks of drinking during pregnancy. Using the variation in the adoption of these laws across states and within states over time, I find a statistically significant reduction in prenatal alcohol use associated with AWS. I then use this plausibly exogenous change in drinking behavior to establish a causal link between prenatal alcohol exposure and birth outcomes. I find that AWS laws are associated with decreases in the odds of very low birth weight and very pre-term birth.

Smoke-free legislation and child health

In this paper, we aim to present an overview of the scientific literature on the link between smoke-free legislation and early-life health outcomes. Exposure to second-hand smoke is responsible for an estimated 166 ,000 child deaths each year worldwide. To protect people from tobacco smoke, the World Health Organization recommends the implementation of comprehensive smoke-free legislation that prohibits smoking in all public indoor spaces, including workplaces, bars and restaurants. The implementation of such legislation has been found to reduce tobacco smoke exposure, encourage people to quit smoking and improve adult health outcomes. There is an increasing body of evidence that shows that children also experience health benefits after implementation of smoke-free legislation. In addition to protecting children from tobacco smoke in public, the link between smoke-free legislation and improved child health is likely to be mediated via a decline in smoking during pregnancy and reduced exposure in the home environment. Recent studies have found that the implementation of smoke-free legislation is associated with a substantial decrease in the number of perinatal deaths, preterm births and hospital attendance for respiratory tract infections and asthma in children, although such benefits are not found in each study. With over 80% of the world’s population currently unprotected by comprehensive smoke-free laws, protecting (unborn) children from the adverse impact of tobacco smoking and SHS exposure holds great potential to benefit public health and should therefore be a key priority for policymakers and health workers alike.

The use of legal, illegal and roll-your-own cigarettes to increasing tobacco excise taxes and comprehensive tobacco control policies: findings from the ITC Uruguay Survey

BACKGROUND

Little research has been done to examine whether smokers switch to illegal or roll-your-own (RYO) cigarettes in response to a change in their relative price.

OBJECTIVE

This paper explores how relative prices between three cigarette forms (manufactured legal, manufactured illegal and RYO cigarettes) are associated with the choice of one form over another after controlling for covariates, including sociodemographic characteristics, smokers' exposure to antismoking messaging, health warning labels and tobacco marketing.

METHODS

Generalised estimating equations were employed to analyse the association between the price ratio of two different cigarette forms and the usage of one form over the other.

FINDINGS

A 10% increase in the relative price ratio of legal to RYO cigarettes is associated with a 4.6% increase in the probability of consuming RYO cigarettes over manufactured legal cigarettes (p≤0.05). In addition, more exposure to antismoking messaging is associated with a lower odds of choosing RYO cigarettes over manufactured legal cigarettes (p≤0.05). Non-significant associations exist between the manufactured illegal to legal cigarette price ratios and choosing manufactured illegal cigarettes, suggesting that smokers do not switch to manufactured illegal cigarettes as prices of legal ones increase. However, these non-significant findings may be due to lack of variation in the price ratio measures. To improve the effectiveness of increased taxes and prices in reducing smoking, policymakers need to narrow price variability in the tobacco market. Moreover, increasing antismoking messaging reduces tax avoidance in the form of switching to cheaper RYO cigarettes in Uruguay.