Health outcomes of smoking during pregnancy and the postpartum period: an umbrella review

BACKGROUND: Smoking during pregnancy (SDP) and the postpartum period has serious health outcomes for the mother and infant. Although some systematic reviews have shown the impact of maternal SDP on particular conditions, a systematic review examining the overall health outcomes has not been published. Hence, this paper aimed to conduct an umbrella review on this issue. METHODS: A systematic review of systematic reviews (umbrella review) was conducted according to a protocol submitted to PROSPERO ( CRD42018086350 ). CINAHL, EMBASE, MEDLINE, PsycINFO, Web of Science, CRD Database and HMIC databases were searched to include all studies published in English by 31 December 2017, except those focusing exclusively on low-income countries. Two researchers conducted the study selection and quality assessment independently. RESULTS: The review included 64 studies analysing the relationship between maternal SDP and 46 health conditions. The highest increase in risks was found for sudden infant death syndrome, asthma, stillbirth, low birth weight and obesity amongst infants. The impact of SDP was associated with the number of cigarettes consumed. According to the causal link analysis, five mother-related and ten infant-related conditions had a causal link with SDP. In addition, some studies reported protective impacts of SDP on pre-eclampsia, hyperemesis gravidarum and skin defects on infants. The review identified important gaps in the literature regarding the dose-response association, exposure window, postnatal smoking. CONCLUSIONS: The review shows that maternal SDP is not only associated with short-term health conditions (e.g. preterm birth, oral clefts) but also some which can have life-long detrimental impacts (e.g. obesity, intellectual impairment). IMPLICATIONS: This umbrella review provides a comprehensive analysis of the overall health impacts of SDP. The study findings indicate that while estimating health and cost outcomes of SDP, long-term health impacts should be considered as well as short-term effects since studies not including the long-term outcomes would underestimate the magnitude of the issue. Also, interventions for pregnant women who smoke should consider the impact of reducing smoking due to health benefits on mothers and infants, and not solely cessation

Potential for health economics to influence policies on tobacco use during pregnancy in low-income and middle-income countries:a qualitative case study

INTRODUCTION: Tobacco control during pregnancy is a policy priority in high-income countries (HICs) because of the significant health and inequality consequences. However, little evidence exists on interventions to reduce tobacco use in low-income and middle-income countries (LMICs), especially for pregnant women. This study aimed to assess how health economics evidence, which is mainly produced in HICs, could be adopted for tobacco cessation policies for pregnant women in LMICs. METHODS: A qualitative case study was conducted in an international public health organisation. The organisation was chosen due to its capacity to influence health policies around the world. Tobacco control experts working in the organisation were identified through purposeful sampling and snowballing. Semistructured interviews were conducted with 18 informants with relevant experience of countries from all of the regions covered by the organisation. Data were analysed using the framework method. RESULTS: In practice, tobacco cessation during pregnancy was not viewed as a priority in LMICs despite international recognition of the issue. In LMICs, factors including the recorded country-specific prevalence of tobacco use during pregnancy, availability of healthcare resources and the characteristics of potential interventions all affected the use of health economics evidence for policy making. CONCLUSION: The scale of tobacco use among pregnant women might be greater than reported in LMICs. Health economics evidence produced in HICs has the potential to inform health policies in LMICs around tobacco cessation interventions if the country-specific circumstances are addressed. Economic evaluations of cessation interventions integrated into antenatal care with a household perspective would be especially relevant in LMICs

Towards optimum smoking cessation interventions during pregnancy: a household model to explore cost‐effectiveness

BACKGROUND AND AIMS: Previous economic evaluations of smoking cessation interventions for pregnant women are limited to single components, which do not in isolation offer sufficient potential impact to address smoking cessation targets. To inform the development of more appropriate complex interventions, we (1) describe the development of the Economics of Smoking in Pregnancy: Household (ESIP.H) model for estimating the life‐time cost‐effectiveness of smoking cessation interventions aimed at pregnant women and (2) use a hypothetical case study to demonstrate how ESIP.H can be used to identify the characteristics of optimum smoking cessation interventions. METHODS: The hypothetical intervention was based on current evidence relating to component elements, including financial incentives, partner smoking, intensive behaviour change support, cigarettes consumption and duration of support to 12 months post‐partum. ESIP.H was developed to assess the life‐time health and cost impacts of multi‐component interventions compared with standard National Health Service (NHS) care in England. ESIP.H considers cigarette consumption, partner smoking and some health conditions (e.g. obesity) that were not included in previous models. The Markov model's parameters were estimated based on published literature, expert judgement and evidence‐based assumptions. The hypothetical intervention was evaluated from an NHS perspective. RESULTS: The hypothetical intervention was associated with an incremental gain in quitters (mother and partner) at 12 months postpartum of 249 [95% confidence interval (CI) = 195–304] per 1000 pregnant smokers. Over the long‐term, it had an incremental negative cost of £193 (CI = –£779 to 344) and it improved health, with a 0.50 (CI = 0.36–0.69) increase in quality‐adjusted life years (QALYs) for mothers, partners and offspring, with a 100% probability of being cost‐effective. CONCLUSIONS: The Economics of Smoking in Pregnancy: Household model for estimating cost‐effectiveness of smoking cessation interventions aimed at pregnant women found that a hypothetical smoking cessation intervention would greatly extend reach, reduce smoking and be cost‐effective

Economic evaluation of smoking cessation interventions for pregnant women

Smoking during pregnancy (SDP) is a significant health problem, associated with high healthcare costs and health inequalities. Current SDP interventions are typically cost-effective, but their uptake, content and outcomes are very limited. This thesis aimed to produce evidence to identify the characteristics of ‘optimum’ SDP interventions, relating to aims (achieving smoke-free households or reducing smoking in the pregnant woman), content (higher financial incentives and more intense behavioural support) and longer duration. A Markov-based economic model was developed, which extended an existing model by incorporating partners’ smoking and the number of cigarettes consumed. A systematic umbrella review informed inclusion of additional health conditions. Three hypothetical interventions were designed based on available evidence, and cost-utility analysis was undertaken to assess their outcomes, healthcare costs and long-term cost-effectiveness compared to standard NHS care. Additionally, a qualitative study in an international public health organisation explored the applicability of high-income country-based economic evidence on SDP interventions in low and middle-income countries (LMICs). The economic modelling found that the hypothetical cessation interventions would greatly extend reach, reduce smoking, address inequalities, and be cost-effective. Piloting of SDP interventions based on this research would be warranted by UK policy-makers, and the findings have potential applicability to LMICs settings

How is the Societal Perspective Defined in Health Technology Assessment? Guidelines from Around the Globe

Some researchers have argued that the aim of an economic evaluation should be to offer guidance on resource allocation based on public interest from a societal perspective. The application of a societal perspective in health technology assessment (HTA), while common in many published studies, is not mandated in most countries, and there is limited discussion on what the societal perspective should encompass. This study aimed to systematically compare and contrast the HTA guidelines in different countries. HTA methods guidelines were identified through international HTA networks, such as the Professional Society for Health Economics and Outcomes Research (ISPOR) and Guide to Economic Analysis Research (GEAR). The respective HTA agencies were grouped into two categories: well-established and newly developed, based on the establishment date. Data extracted from the guidelines summarised the methodological details in the reference cases, including specifics on the societal perspective. The database search yielded 46 guidelines, and 65% explicitly considered the societal perspective. The maturity of these agencies is reflected in their attitudes towards the societal perspective; the societal perspective is defined in 73% of the guidelines of well-established agencies and only 56% of those of newly developed agencies. The guidelines from multipayer healthcare systems are more likely to consider the societal perspective. Although most guidelines from the well-established agencies recommend the inclusion of a societal perspective, the types of costs and consequences that should be included and the recommended approaches to valuing them are variable. The direct costs to family and carers were included in 73% of the societal perspective definitions, while non-health outcomes were considered in only 40%. Most HTA guidelines lack clear guidance on what to include under specific perspectives. Considering the recent advancements in economic evaluation methods, it is timely to rethink the role of the societal perspective in HTA guidelines and adopt a more comprehensive perspective to include all costs and consequences of healthcare services

Health outcomes of maternal smoking during pregnancy and postpartum period for the mother and infant: protocol for an umbrella review

Abstract Background Internationally, tobacco smoking is a leading cause of mortality, morbidity and health inequality. In England, despite increasing awareness about importance of public health interventions to reduce smoking, about 10% of pregnant women are known to be smokers at the time of delivery. There are many systematic reviews investigating the impact of maternal smoking during pregnancy on particular health conditions. Hence, this overview of systematic reviews, which aims to include all health conditions for mother and infant caused by smoking during pregnancy, is timely. Methods CINAHL, EMBASE, MEDLINE, PsycINFO, Web of Science, CRD Database (includes DARE, NHSEED and HTA) and HMIC databases will be searched for systematic reviews investigating the effects of smoking during pregnancy. Only reviews written in English and published by 31/12/17 will be included. Studies focussed on low-income countries will be excluded. Study selection and quality assessment will be completed by two reviewers independently. To assess the quality of included studies, the Centre for Reviews and Dissemination checklist for systematic reviews will be utilised. Discussion Existing systematic reviews focus on the impact of smoking during pregnancy on a specific health condition. This review aims to analyse current evidence on the overall health outcomes associated with smoking whilst pregnant by providing an overview of evidence from systematic reviews. Systematic review registration PROSPERO CRD42018086350

Towards optimum smoking cessation interventions during pregnancy: a household model to explore cost-effectiveness.

BACKGROUND AND AIMS: Previous economic evaluations of smoking cessation interventions for pregnant women are limited to single components, which do not in isolation offer sufficient potential impact to address smoking cessation targets. To inform the development of more appropriate complex interventions, we (1) describe the development of the Economics of Smoking in Pregnancy: Household (ESIP.H) model for estimating the life-time cost-effectiveness of smoking cessation interventions aimed at pregnant women and (2) use a hypothetical case study to demonstrate how ESIP.H can be used to identify the characteristics of optimum smoking cessation interventions. METHODS: The hypothetical intervention was based on current evidence relating to component elements, including financial incentives, partner smoking, intensive behaviour change support, cigarettes consumption and duration of support to 12 months post-partum. ESIP.H was developed to assess the life-time health and cost impacts of multi-component interventions compared with standard National Health Service (NHS) care in England. ESIP.H considers cigarette consumption, partner smoking and some health conditions (e.g. obesity) that were not included in previous models. The Markov model's parameters were estimated based on published literature, expert judgement and evidence-based assumptions. The hypothetical intervention was evaluated from an NHS perspective. RESULTS: The hypothetical intervention was associated with an incremental gain in quitters (mother and partner) at 12 months postpartum of 249 per 1000 pregnant smokers. Over the long-term, it had an incremental negative cost of £193 and it improved health, with a 0.50 increase in quality-adjusted life years (QALYs) for mothers, partners and offspring, with a 100% probability of being cost-effective. CONCLUSIONS: The Economics of Smoking in Pregnancy: Household model for estimating cost-effectiveness of smoking cessation interventions aimed at pregnant women found that a hypothetical smoking cessation intervention would greatly extend reach, reduce smoking and be cost-effective

Economic evaluations of tobacco control interventions in low‐ and middle‐income countries: a systematic review

Background and Aims: Tobacco consumption and its associated adverse outcomes remain major public health issues, particularly in low- and middle-income countries. This systematic review aimed to identify and critically assess full economic evaluations for tobacco control interventions in low- and middle-income countries. Methods: Electronic databases, including EMBASE, MEDLINE and PsycINFO and the grey literature, were searched using terms such as ‘tobacco’, ‘economic evaluation’ and ‘smoking’ from 1994 to 2020. Study quality was assessed using the Consensus Health Economic Criteria and the Philips checklist. Studies were included which were full economic evaluations of tobacco control interventions in low- and middle-income settings. Reviews, commentaries, conference proceedings and abstracts were excluded. Study selection and quality assessment were conducted by two reviewers independently. A narrative synthesis was conducted to synthesize the findings of the studies. Results: This review identified 20 studies for inclusion. The studies evaluated a wide range of interventions, including tax increase, nicotine replacement therapy (nicotine patch/gum) and financial incentives. Overall, 12 interventions were reported to be cost-effective, especially tax increases for tobacco consumption and cessation counselling. There were considerable limitations regarding data sources (e.g. using cost data from other countries or assumptions due to the lack of local data) and the model structure; sensitivity analyses were inadequately described in many studies; and there were issues around the transferability of results to other settings. Additionally, the affordability of the interventions was only discussed in two studies. Conclusions: There are few high-quality studies of the cost-effectiveness of tobacco use control interventions in low- and middle-income countries. The methodological limitations of the existing literatures could affect the generalizability of the findings

Temporal trends in associations between severe mental illness and risk of cardiovascular disease:A systematic review and meta-analysis

BACKGROUND: Severe mental illness (SMI; schizophrenia, bipolar disorders (BDs), and other nonorganic psychoses) is associated with increased risk of cardiovascular disease (CVD) and CVD-related mortality. To date, no systematic review has investigated changes in population level CVD-related mortality over calendar time. It is unclear if this relationship has changed over time in higher-income countries with changing treatments. METHODS AND FINDINGS: To address this gap, a systematic review was conducted, to assess the association between SMI and CVD including temporal change. Seven databases were searched (last: November 30, 2021) for cohort or case-control studies lasting ≥1 year, comparing frequency of CVD mortality or incidence in high-income countries between people with versus without SMI. No language restrictions were applied. Random effects meta-analyses were conducted to compute pooled hazard ratios (HRs) and rate ratios, pooled standardised mortality ratios (SMRs), pooled odds ratios (ORs), and pooled risk ratios (RRs) of CVD in those with versus without SMI. Temporal trends were explored by decade. Subgroup analyses by age, sex, setting, world region, and study quality (Newcastle-Ottawa scale (NOS) score) were conducted. The narrative synthesis included 108 studies, and the quantitative synthesis 59 mortality studies (with (≥1,841,356 cases and 29,321,409 controls) and 28 incidence studies (≥401,909 cases and 14,372,146 controls). The risk of CVD-related mortality for people with SMI was higher than controls across most comparisons, except for total CVD-related mortality for BD and cerebrovascular accident (CVA) for mixed SMI. Estimated risks were larger for schizophrenia than BD. Pooled results ranged from SMR = 1.55 (95% confidence interval (CI): 1.33 to 1.81, p < 0.001), for CVA in people with BD to HR/rate ratio = 2.40 (95% CI: 2.25 to 2.55, p < 0.001) for CVA in schizophrenia. For schizophrenia and BD, SMRs and pooled HRs/rate ratios for CHD and CVD mortality were larger in studies with outcomes occurring during the 1990s and 2000s than earlier decades (1980s: SMR = 1.14, 95% CI: 0.57 to 2.30, p = 0.71; 2000s: SMR = 2.59, 95% CI: 1.93 to 3.47, p < 0.001 for schizophrenia and CHD) and in studies including people with younger age. The incidence of CVA, CVD events, and heart failure in SMI was higher than controls. Estimated risks for schizophrenia ranged from HR/rate ratio 1.25 (95% CI: 1.04 to 1.51, p = 0.016) for total CVD events to rate ratio 3.82 (95% CI: 3.1 to 4.71, p < 0.001) for heart failure. Incidence of CHD was higher in BD versus controls. However, for schizophrenia, CHD was elevated in higher-quality studies only. The HR/rate ratios for CVA and CHD were larger in studies with outcomes occurring after the 1990s. Study limitations include the high risk of bias of some studies as they drew a comparison cohort from general population rates and the fact that it was difficult to exclude studies that had overlapping populations, although attempts were made to minimise this. CONCLUSIONS: In this study, we found that SMI was associated with an approximate doubling in the rate ratio of CVD-related mortality, particularly since the 1990s, and in younger groups. SMI was also associated with increased incidence of CVA and CHD relative to control participants since the 1990s. More research is needed to clarify the association between SMI and CHD and ways to mitigate this risk

Information Asymmetry in Hospitals: Evidence of the Lack of Cost Awareness in Clinicians

Background: Information asymmetries and the agency relationship are two defining features of the healthcare system. These market failures are often used as a rationale for government intervention. Many countries have government financing and provision of healthcare in order to correct for this, while health technology agencies also exist to improve efficiency. However, informational asymmetries and the resulting principal-agent problem still persist, and one example is the lack of cost awareness amongst clinicians. This study explores the cost awareness of clinicians across different settings. / Methods: We targeted four clinical cohorts: medical students, Senior House Officers/Interns, Mid-grade Senior Registrar/Residents, and Consultant/Attending Physicians, in six hospitals in the United Kingdom, the United States, Australia, New Zealand and Spain. The survey asked respondents to report the cost (as they recalled) of different types of scans, visits, medications and tests. Our analysis focused on the differential between the perceived/recalled cost and the actual cost. We explored variation across speciality, country and other potential confounders. Cost-awareness levels were estimated based on the cost estimates within 25% of the actual cost. / Results: We received 705 complete responses from six sites across five countries. Our analysis found that respondents often overestimated the cost of common tests while underestimating high-cost tests. The mean cost-awareness levels varied between 4 and 23% for different items. Respondents acknowledged that they did not feel they had received adequate training in cost awareness. / Discussion: The current financial climate means that cost awareness and the appropriate use of scarce healthcare resources is more paramount than perhaps ever before. Much of the focus of health economics research is on high-cost innovative technologies, yet there is considerable waste in the system with respect to overtreatment and overdiagnosis. Common reasons put forward for this include defensive medicine, poor education, clinical uncertainty and the institution of protocols. / Conclusion: Given the role of clinicians in the healthcare system, as agents both for patients and for providers, more needs to be done to remove informational asymmetries and improve clinician cost awareness