Abstract
BackgroundAlmost 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.MethodsTo 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.FindingsNeonatal and infant mortality decreased by 2.9% and 2.8%/year respectively following smoke-free legislation, with an estimated 7463 infant deaths (including 4623 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.InterpretationExpanding 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.FundingNetherlands Lung Foundation, HDRUK, Asthma UK center for Applied Research and NIHR Global Respiratory Health Unit (RESPIRE).
Highlights
Tobacco smoke exposure during perinatal and early life increases the risk of stillbirth, preterm birth, low weight birth, and neonatal and infant death [1À3]
We found that the child health benefits of smoke-free legislation in Thailand were comparable to those found in highincome countries
The evidence on the early-life health impact of smokefree legislation is almost entirely derived from evaluations in highincome countries (HICs) [7,9]. These findings may not be generalized to low- and middle-income countries (LMICs) for a number of reasons À 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 [10À12] pregnancy outcomes are generally poorer in LMICs than in HICs due to reduced antenatal care capacities [13]
Summary
Tobacco smoke exposure during perinatal and early life increases the risk of stillbirth, preterm birth, low weight birth, and neonatal and infant death [1À3]. The evidence on the early-life health impact of smokefree legislation is almost entirely derived from evaluations in highincome countries (HICs) [7,9] These findings may not be generalized to low- and middle-income countries (LMICs) for a number of reasons À 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 [10À12] pregnancy outcomes are generally poorer in LMICs than in HICs due to reduced antenatal care capacities [13]. The advantage of this method, when compared to other quasi-experimental methods, is that it provides a better counterfactual scenario (i.e. it recreates better the pre-legislation trends in Thailand), allowing less biased estimation [25À27]
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