Cigarette taxation and neonatal and infant mortality: a longitudinal analysis of 159 countries

Previous studies on the associations between cigarette taxes and infant survival have all been in high-income countries and did not examine the relative benefits of different taxation levels and structures. We evaluated longitudinal associations of cigarette taxes with neonatal and infant mortality globally. We applied country-level panel regressions using 2008–2018 annual mortality and biennial WHO tobacco taxation data. Complete data was available for 159 countries. Outcomes were neonatal and infant mortality. We conducted analyses by type of taxes (i.e. specific cigarette taxes, ad valorem taxes, and other taxes, import duties and VAT) and the income group classification of countries. Covariates included scores for other WHO recommended tobacco control policies, socioeconomic, health-care, and air quality measures. Secondary analyses investigated the associations between cigarette tax and cigarette consumption. We found that a 10 percentage-point increase in total cigarette tax as a percentage of the retail price was associated with a 2.6% (95% Confidence Interval [CI]: 1.9% to 3.2%) decrease in neonatal mortality and a 1.9% (95% CI: 1.3% to 2.6%) decrease in infant mortality globally. Estimates were similar for both excise and ad valorem taxes. We estimated that 231,220 (95% CI: 152,658 to 307,655) infant deaths could have been averted in 2018 if all countries had total cigarette tax at least 75%. 99.2% of these averted deaths would have been in low- and middle-income countries (LMICs). The secondary analysis supported causal interpretation of results by finding that a 10 percentage-point increase in taxes was associated with a reduction of 94.6 (95% CI: 32.7 to 156.5) in annual cigarette consumption per capita. Although causal inference is precarious due to the quasi-experimental design, we used a robust analytical approach and focused on within-country changes. Limitations include an inability to include data on roll-your-own tobacco, other forms of tobacco use, and reliance on taxation data only for the cigarette brands most sold in each country. In line with limited existing evidence conducted in HICs, we found that raising taxes on tobacco was associated with a reduction in neonatal and infant mortality globally. Implementing recommended levels of taxation in LMICs should be a priority since this is where the lowest levels of taxation and the largest potential infant mortality benefits exis

Effect of comprehensive smoke-free legislation on neonatal mortality and infant mortality across 106 middle-income countries: a synthetic control study

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. Funding Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation, Netherlands Thrombosis Foundation, Health Data Research UK