Smoke-free legislation and active smoking, second hand smoke exposure and health outcomes in low- and middle-income countries.

Background: Exposure to tobacco smoke imposes a heavy morbidity and mortality burden and exacerbates health inequalities. Whilst the health and economic benefits of smoke-free legislation (SFL) are evident in high income countries (HICs), there is a lack of evidence from low- and middle-income countries (LMICs) where implementation and monitoring mechanisms are generally weak. Objectives: To examine whether the health benefits of SFL identified in HICs are likely to accrue in LMICs and whether any benefits are evenly distributed between socioeconomic status (SES) groups. Methods: 1) A systematic review was undertaken to examine the impact of SFL on socioeconomic inequalities in tobacco-related health outcomes in adults 2) Secondary analyses of the Global Adult Tobacco Survey (GATS) data from 15 LMICs was undertaken to examine inequalities in second hand smoke (SHS) exposure at work and at home 3) Quasi-experimental difference-in-differences study design was used to examine whether the National Tobacco Control Programme (NTCP) in India was associated with reductions in active smoking. Results: 1) Evidence from LMICs examining the health impacts of SFL was sparse. Comprehensive SFL was associated with pro-equity impacts in smoking associated health outcomes in HICs 2) In LMICs, exposure to SHS at workplaces and at homes was higher among the low SES groups. Being employed in a smoke-free workplace in LMICs was associated with reduced exposure to SHS in the home 3) There was no compelling evidence that NTCP reduced bidi and cigarette consumption over and above the general reduction that occurred in all districts in India. Policy implications: Poor implementation of SFL in LMICs is associated with substantial forgone health benefits, especially in the low SES groups. Strengthening tobacco control is key to improve health outcomes and reduce inequalities in LMICs and attainment of the Sustainable Development Goals for Health

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

Impact of smoke-free legislation on perinatal and infant mortality:a national quasi-experimental study

Smoke-free legislation is associated with improved early-life outcomes; however its impact on perinatal survival is unclear. We linked individual-level data with death certificates for all registered singletons births in England (1995-2011). We used interrupted time series logistic regression analysis to study changes in key adverse perinatal events following the July 2007 national, comprehensive smoke-free legislation. We studied 52,163 stillbirths and 10,238,950 live-births. Smoke-free legislation was associated with an immediate 7.8% (95%CI 3.5-11.8; p < 0.001) reduction in stillbirth, a 3.9% (95%CI 2.6-5.1; p < 0.001) reduction in low birth weight, and a 7.6% (95%CI 3.4-11.7; p = 0.001) reduction in neonatal mortality. No significant impact on SIDS was observed. Using a counterfactual scenario, we estimated that in the first four years following smoke-free legislation, 991 stillbirths, 5,470 cases of low birth weight, and 430 neonatal deaths were prevented. In conclusion, smoke-free legislation in England was associated with clinically important reductions in severe adverse perinatal outcomes

Plain packaging of tobacco products: the logical next step for tobacco control policy in India

India implemented larger 85% pictorial health warnings on all tobacco products from 1 April 2016. However, to remove the last bit of glamour and attraction from the tobacco packs, it must now embrace plain packaging. Plain packaging prevents tobacco packs from carrying the tobacco industry brand imagery as mobile billboards. Postimplementation of larger 85% pictorial health warnings on all tobacco products, this analysis was undertaken to assess the feasibility of plain packaging as the next logical tobacco control policy measure in India. As part of this analysis, the research team reviewed the available literature on legal and policy challenges to plain packaging as a tobacco control policy initiative for India. Literature from 2010 to 2016 in English language was reviewed, which reveals that, India has taken several preparatory steps implemented by other countries like Australia and the UK that have introduced plain packaging, for example, stronger smoke-free laws, ban on tobacco advertising, promotion and sponsorship, increase in taxes and a report from civil society task force on plain packaging. The trade and investment agreements signed by India are also within the international trade norms relating to public health. A Private Member's Bill on plain packaging is also pending in the Parliament of India. Other potential challenges against such policy decision, for example, freedom of trade, right to property, violation of competition law and other laws including consumer protection laws, were found unsubstantiated by the research team. Plain packaging is the next logical step for tobacco control policy in India

Impact of school policies on non-communicable disease risk factors - a systematic review

BACKGROUND: Globally, non-communicable diseases (NCDs) are identified as one of the leading causes of mortality. NCDs have several modifiable risk factors including unhealthy diet, physical inactivity, tobacco use and alcohol abuse. Schools provide ideal settings for health promotion, but the effectiveness of school policies in the reduction of risk factors for NCD is not clear. This study reviewed the literature on the impact of school policies on major NCD risk factors. METHODS: A systematic review was conducted to identify, collate and synthesize evidence on the effectiveness of school policies on reduction of NCD risk factors. A search strategy was developed to identify the relevant studies on effectiveness of NCD policies in schools for children between the age of 6 to 18 years in Ovid Medline, EMBASE, and Web of Science. Data extraction was conducted using pre-piloted forms. Studies included in the review were assessed for methodological quality using the Effective Public Health Practice Project (EPHPP) quality assessment tool. A narrative synthesis according to the types of outcomes was conducted to present the evidence on the effectiveness of school policies. RESULTS: Overall, 27 out of 2633 identified studies were included in the review. School policies were comparatively more effective in reducing unhealthy diet, tobacco use, physical inactivity and inflammatory biomarkers as opposed to anthropometric measures, overweight/obesity, and alcohol use. In total, for 103 outcomes independently evaluated within these studies, 48 outcomes (46%) had significant desirable changes when exposed to the school policies. Based on the quality assessment, 18 studies were categorized as weak, six as moderate and three as having strong methodological quality. CONCLUSION: Mixed findings were observed concerning effectiveness of school policies in reducing NCD risk factors. The findings demonstrate that schools can be a good setting for initiating positive changes in reducing NCD risk factors, but more research is required with long-term follow up to study the sustainability of such changes

Adolescent and adult perceptions of the effects of larger size graphic health warnings on conventional and plain tobacco packs in India: A community-based cross-sectional study

INTRODUCTION: We studied adolescent and adult perceptions of the effects of larger size, 85% versus 40%, Graphic Health Warnings (GHWs) on conventional and plain tobacco packs, in India. METHODS: A cross-sectional survey was conducted with 2121 participants (aged ≥13 years), during the period 2015-16, in Delhi and Telangana, India. Four categories of GHWs on tobacco packs were shown: A - 40% existing (April 2013-April 2016), B - 40% new (April 2016-present), C - 85% new, and D - plain packs (85% new). Regression models tested percentage differences in choice of categories for eight outcomes, adjusted for gender, area of residence, socioeconomic status, age, and tobacco use. RESULTS: Of the total 2121 participants, 1120 were from Delhi, 1001 from Telangana, 50% were males, 62% were urban residents, 12% were adolescents, and 72% had never used tobacco. Among packs shown, the majority of participants perceived the 85% size GHWs more effective than the 40% size GHWs across all outcomes. The perceived increase in noticeability of GHWs was 45% for category C (p<0.05) and 43.5% for category D (p<0.05) versus category B. In Delhi, participants perceived plain packs to be most effective in motivating quitting, preventing initiation and conveying the health message. In Telangana, adolescents believed GHWs on plain packs were most noticeable, most effective for quitting and preventing initiation. CONCLUSIONS: The larger size 85% GHWs were perceived to be more effective in increasing noticeability of warnings, motivating cessation, preventing initiation, and conveying the intended health message. Support for plain packaging was higher in Delhi and among adolescents in Telangana