Faber Timor, Kumar Arun, Mackenbach Johan P, Millett Christopher, Basu Sanjay, Sheikh Aziz, Been Jasper V
Division of Neonatology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, Netherlands.
Department of Paediatrics, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, Netherlands.
Lancet Public Health. 2017 Sep 5;2(9):e420-e437. doi: 10.1016/S2468-2667(17)30144-5. eCollection 2017 Sep.
Tobacco smoking and smoke exposure during pregnancy and childhood cause considerable childhood morbidity and mortality. We did a systematic review and meta-analysis to investigate whether implementation of WHO's recommended tobacco control policies (MPOWER) was of benefit to perinatal and child health.
We searched 19 electronic databases, hand-searched references and citations, and consulted experts to identify studies assessing the association between implementation of MPOWER policies and child health. We did not apply any language restrictions, and searched the full time period available for each database, up to June 22, 2017. Our primary outcomes of interest were perinatal mortality, preterm birth, hospital attendance for asthma exacerbations, and hospital attendance for respiratory tract infections. Where possible and appropriate, we combined data from different studies in random-effects meta-analyses. This study is registered with PROSPERO, number CRD42015023448.
We identified 41 eligible studies (24 from North America, 16 from Europe, and one from China) that assessed combinations of the following MPOWER policies: smoke-free legislation (n=35), tobacco taxation (n=11), and smoking cessation services (n=3). Risk of bias was low in 23 studies, moderate in 16, and high in two. Implementation of smoke-free legislation was associated with reductions in rates of preterm birth (-3·77% [95% CI -6·37 to -1·16]; ten studies, 27 530 183 individuals), rates of hospital attendance for asthma exacerbations (-9·83% [-16·62 to -3·04]; five studies, 684 826 events), and rates of hospital attendance for all respiratory tract infections (-3·45% [-4·64 to -2·25]; two studies, 1 681 020 events) and for lower respiratory tract infections (-18·48% [-32·79 to -4·17]; three studies, 887 414 events). Associations appeared to be stronger when comprehensive smoke-free laws were implemented than when partial smoke-free laws were implemented. Among two studies assessing the association between smoke-free legislation and perinatal mortality, one showed significant reductions in stillbirth and neonatal mortality but did not report the overall effect on perinatal mortality, while the other showed no change in perinatal mortality. Meta-analysis of studies on other MPOWER policies was not possible; all four studies on increasing tobacco taxation and one of two on offering disadvantaged pregnant women help to quit smoking that reported on our primary outcomes had positive findings. Assessment of publication bias was only possible for studies assessing the association between smoke-free legislation and preterm birth, showing some degree of bias.
Smoke-free legislation is associated with substantial benefits to child health. The majority of studies on other MPOWER policies also indicated a positive effect. These findings provide strong support for implementation of such policies comprehensively across the world.
Chief Scientist Office Scotland, Farr Institute, Netherlands Lung Foundation, Erasmus MC.
孕期和儿童期吸烟及接触烟雾会导致儿童出现相当高的发病率和死亡率。我们进行了一项系统综述和荟萃分析，以调查世界卫生组织推荐的烟草控制政策（MPOWER）的实施是否对围产期和儿童健康有益。
我们检索了19个电子数据库，手工检索参考文献和引文，并咨询专家以识别评估MPOWER政策实施与儿童健康之间关联的研究。我们未设置任何语言限制，并检索了每个数据库截至2017年6月22日的全部可用时间段。我们感兴趣的主要结局是围产期死亡率、早产、因哮喘加重而住院、因呼吸道感染而住院。在可能且合适的情况下，我们将不同研究的数据合并进行随机效应荟萃分析。本研究已在国际前瞻性系统评价注册库（PROSPERO）注册，注册号为CRD42015023448。
我们确定了41项符合条件的研究（24项来自北美，16项来自欧洲，1项来自中国），这些研究评估了以下MPOWER政策的组合：无烟立法（n = 35）、烟草税（n = 11）和戒烟服务（n = 3）。23项研究的偏倚风险低，16项为中度，2项为高。实施无烟立法与早产率降低相关（-3.77% [95%CI -6.37至-1.16]；10项研究，27530183人）、因哮喘加重而住院率降低（-9.83% [-16.62至-3.04]；5项研究，684826例）、因所有呼吸道感染而住院率降低（-3.45% [-4.64至-2.25]；2项研究，1681020例）以及因下呼吸道感染而住院率降低（-18.48% [-32.79至-4.17]；3项研究，887414例）。实施全面无烟法律时的关联似乎比实施部分无烟法律时更强。在两项评估无烟立法与围产期死亡率之间关联的研究中，一项显示死产和新生儿死亡率显著降低，但未报告对围产期死亡率的总体影响，而另一项显示围产期死亡率无变化。对其他MPOWER政策的研究进行荟萃分析是不可能的；所有四项关于提高烟草税的研究以及两项关于为弱势孕妇提供戒烟帮助的研究中报告我们主要结局的一项有阳性结果。仅对评估无烟立法与早产之间关联的研究进行了发表偏倚评估，显示存在一定程度的偏倚。
无烟立法对儿童健康有显著益处。大多数关于其他MPOWER政策的研究也表明有积极效果。这些发现为在全球全面实施此类政策提供了有力支持。
苏格兰首席科学家办公室、法尔研究所、荷兰肺部基金会、伊拉斯姆斯医学中心。
