Smoke-free legislation and neonatal and infant mortality in Brazil: longitudinal quasi-experimental study

Thomas Hone, Andre Salem Szklo, Filippos T. Filippidis, Anthony A. Laverty, Isabela Sattamini, Jasper Been, Cristiane Vianna, Mirian Souza, Liz Maria de Almeida, Christopher Millett

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ObjectiveTo examine the associations of partial and comprehensive smoke-free legislation with neonatal and infant mortality in Brazil using a quasi-experimental study design.DesignMonthly longitudinal (panel) ecological study from January 2000 to December 2016.SettingAll Brazilian municipalities (n=5565).ParticipantsInfant populations.InterventionSmoke-free legislation in effect in each municipality and month. Legislation was encoded as basic (allowing smoking areas), partial (segregated smoking rooms) or comprehensive (no smoking in public buildings). Associations were quantified by immediate step and longer term slope/trend changes in outcomes.Statistical analysesMunicipal-level linear fixed-effects regression models.Main outcomes measuresInfant and neonatal mortality.ResultsImplementation of partial smoke-free legislation was associated with a -3.3 % (95% CI -6.2% to -0.4%) step reduction in the municipal infant mortality rate, but no step change in neonatal mortality. Comprehensive smoke-free legislation implementation was associated with -5.2 % (95% CI -8.3% to -2.1%) and -3.4 % (95% CI -6.7% to -0.1%) step reductions in infant and neonatal mortality, respectively, and a -0.36 (95% CI -0.66 to-0.06) annual decline in the infant mortality rate. We estimated that had all smoke-free legislation introduced since 2004 been comprehensive, an additional 10 091 infant deaths (95% CI 1196 to 21 761) could have been averted.ConclusionsStrengthening smoke-free legislation in Brazil is associated with improvements in infant health outcomes-particularly under comprehensive legislation. Governments should accelerate implementation of comprehensive smoke-free legislation to protect infant health and achieve the United Nation's Sustainable Development Goal three.
Original languageEnglish
Pages (from-to)312-319
Number of pages8
JournalTobacco Control
Issue number3
Publication statusPublished - May 2020

Research programs

  • EMC MGC-02-52-01-A
  • EMC MM-03-54-04-A
  • EMC NIHES-02-65-02


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