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Smoke-free legislation and neonatal and infant mortality in Brazil: longitudinal quasi-experimental study
  1. Thomas Hone1,
  2. Andre Salem Szklo2,
  3. Filippos T Filippidis1,
  4. Anthony A Laverty1,
  5. Isabela Sattamini3,
  6. Jasper V Been4,5,6,7,
  7. Cristiane Vianna8,
  8. Mirian Souza2,
  9. Liz Maria de Almeida2,
  10. Christopher Millett1,3
  1. 1 Department of Primary Care and Public Health, Imperial College London, London, UK
  2. 2 Population Research Division, National Cancer Institute/Ministry of Health Brazil, Rio de Janeiro, Brazil
  3. 3 Center for Epidemiological Research in Nutrition and Health, University of São Paulo, São Paulo, São Paulo, Brazil
  4. 4 Division of Neonatology, Department of Paediatrics, Erasmus MC - Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
  5. 5 Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
  6. 6 Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
  7. 7 Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, United Kingdom
  8. 8 Tobacco Control Deptartment - Latin America, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
  1. Correspondence to Dr Thomas Hone, Department of Primary Care and Public Health, Imperial College London SW7 2AZ, London, UK; thomas.hone12{at}


Objective To examine the associations of partial and comprehensive smoke-free legislation with neonatal and infant mortality in Brazil using a quasi-experimental study design.

Design Monthly longitudinal (panel) ecological study from January 2000 to December 2016.

Setting All Brazilian municipalities (n=5565).

Participants Infant populations.

Intervention Smoke-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 analyses Municipal-level linear fixed-effects regression models.

Main outcomes measures Infant and neonatal mortality.

Results Implementation 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.

Conclusions Strengthening 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.

  • low/middle income country
  • secondhand smoke
  • public policy
  • global health
  • smoking ban

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  • Contributors CM proposed the original research question which was subsequently developed with input from all authors. JVB and TH contributed to the study design and analytical approach. TH compiled the data with input from IS, JB, ASS and CV. TH carried out the data analysis and production of figures and tables with input from all authors. All authors contributed to the data interpretation. TH wrote the first draft of the manuscript which was revised and edited by all authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. Data are available upon reasonable request.