Abstract:

A previous application of the Brazil SimSmoke tobacco control policy simulation model was used to show the effect of policies implemented between 1989 and 2010 on smoking-attributable deaths (SADs). In this study, we updated and further validated the Brazil SimSmoke model to incorporate policies implemented since 2011 (e.g., a new tax structure with the purpose of increasing revenues/real prices). In addition, we extended the model to estimate smoking-attributable maternal and child health outcomes (MCHOs), such as placenta praevia, placental abruption, preterm birth, low birth weight, and sudden infant death syndrome, to show the role of tobacco control in achieving the Millennium Development Goals. Using data on population, births, smoking, policies, and prevalence of MCHOs, the model is used to assess the effect on both premature deaths and MCHOs of tobacco control policies implemented in Brazil in the last 25 years relative to a counterfactual of policies kept at 1989 levels. Smoking prevalence in Brazil has fallen by an additional 17% for males (16%-19%) and 19% for females (14%-24%) between 2011 and 2015. As a result of the policies implemented since 1989, 7.5 million (6.4-8.5) deaths among adults aged 18 years or older are projected to be averted by 2050. Current policies are also estimated to reduce a cumulative total of 0.9 million (0.4-2.4) adverse MCHOs by 2050. Our findings show the benefits of tobacco control in reducing both SADs and smoking-attributable MCHOs at population level. These benefits may be used to better inform policy makers in low and middle income countries about allocating resources towards tobacco control policies in this important area.

Keywords:
Smoking; Pregnant Women; Maternal and Child Health

Resumo:

Foi utilizada uma versão anterior do modelo SimSmoke, de simulação de políticas de controle do tabagismo, para mostrar o efeito das políticas implementadas entre 1989 e 2010 sobre a mortalidade atribuível ao tabagismo (MAT). O estudo atualiza e estende a validação do modelo SimSmoke para incorporar as políticas implementadas a partir de 2011 (p.ex.: uma nova estrutura tributária com o objetivo de aumentar os impostos e preços reais do produtos de tabaco). Estendemos o modelo também para estimar os danos à saúde materna e infantil atribuíveis ao tabagismo, como placenta prévia, descolamento prematuro da placenta, prematuridade, baixo peso ao nascer e síndrome da morte súbita infantil, para demonstrar o papel do controle do tabagismo no cumprimento dos Objetivos do Milênio. O modelo usa dados demográficos, de nascimentos, de tabagismo, de políticas e de prevalência de desfechos maternos e infantis para avaliar o efeito das políticas de controle do tabagismo dos últimos 25 anos sobre mortes prematuras e danos à saúde materna e infantil, comparado a um cenário contrafatual de manutenção das políticas nos níveis de 1989. Entre 2011 e 2015, a prevalência do tabagismo no Brasil caiu em mais 17% entre homens (16%-19%) e 19% em mulheres (14%-24%). Como resultado das políticas lançadas desde 1989, estima-se que até 2050 serão evitadas 7,5 milhões (6,4-8,5 milhões) de mortes entre adultos com 18 anos ou mais. Estima-se também que as políticas atuais reduzirão um total acumulado de 0,9 milhão (0,4-2,4 milhões) de desfechos adversos de saúde materna e infantil até 2050. Nossos achados demonstram os benefícios do controle do tabagismo na redução da MAT e de danos à saúde materna e infantil atribuíveis ao tabagismo em nível populacional. Esses benefícios podem ser utilizados para informar os gestores nos países de renda baixa e média sobre a alocação de recursos para as políticas de controle do tabagismo.

Palavras-chave:
Hábito de Fumar; Gestantes; Saúde Materno-infantil

Resumen:

Se utilizó una versión anterior del modelo SimSmoke, de simulación de políticas de control del tabaquismo, para mostrar el efecto de las políticas implementadas entre 1989 y 2010 sobre la mortalidad atribuible al tabaquismo (MAT). El estudio actualiza y extiende la validación del modelo SimSmoke para incorporar las políticas implementadas a partir de 2011 (p. ej., una nueva estructura tributaria con el objetivo de aumentar los impuestos y precios reales de productos de tabaco). Extendemos el modelo también para estimar los daños a la salud materna e infantil atribuibles al tabaquismo, como placenta previa, desprendimiento prematuro de la placenta, prematuridad, bajo peso al nacer y síndrome de muerte súbita infantil, para demonstrar el papel del control del tabaquismo en el cumplimiento de los Objetivos del Milenio. El modelo usa datos demográficos, de nacimientos, de tabaquismo, de políticas y de prevalencia de desenlaces maternos e infantiles para evaluar el efecto de las políticas de control del tabaquismo de los últimos 25 años sobre muertes prematuras y daños a la salud materna e infantil, comparado con un escenario contrafáctico de mantenimiento de las políticas a los niveles de 1989. Entre 2011 y 2015, la prevalencia del tabaquismo en Brasil disminuyó en más de un 17% entre hombres (16%-19%) y 19% en mujeres (14%-24%). Como resultado de las políticas lanzadas desde 1989, se estima que hasta 2050 se evitarán 7,5 millones (6,4-8,5 millones) de muertes entre adultos con 18 años o más. Se estima también que las políticas actuales reducirán un total acumulado de 0,9 millones (0,4-2,4 millones) de desenlaces adversos de salud materna e infantil hasta 2050. Nuestros hallazgos demuestran los beneficios del control del tabaquismo en la reducción de MAT y de los daños a la salud materna e infantil, atribuibles al tabaquismo en nivel poblacional. Esos beneficios pueden ser utilizados para informar a los gestores en los países de renta baja y media sobre la asignación de recursos para las políticas de control del tabaquismo.

Palabras-clave:
Hábito de Fumar; Mujeres Embarazadas; Salud Materno-infantil

Introduction

Brazil has experienced a large decline in smoking prevalence in the last 25 years ¹1. Levy DT, de Almeida L, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med 2012; 9:e1001336.^,22. Monteiro C, Cavalcante T, Moura E, Claro RM, Szwarcwald CL. Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989-2003). Bull World Health Organ 2007; 85:527-34.^,33. Szklo AS, Almeida LM, Figueiredo VC, Autran M, Malta D, Caixeta R, et al. A snapshot of the striking decrease in cigarette smoking prevalence in Brazil between 1989 and 2008. Prev Med 2012; 54:162-7.^,44. Szklo A, Souza MC, Szklo M, de Almeida LM. Smokers in Brazil: who are they? Tob Control 2016; 25:564-70.. A previously developed SimSmoke simulation model by Levy et al. ¹1. Levy DT, de Almeida L, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med 2012; 9:e1001336. estimated nearly a 50% decline in Brazil’s smoking prevalence among adults aged 18 years or older, due to the implementation of interventions recommended by the World Health Organization Framework Convention on Tobacco Control (WHO-FCTC) between 1989 and 2010 ⁵5. World Health Organization. WHO framework convention on tobacco control. http://www.who.int/fctc/text_download/en/index.html (accessed on 30/Nov/2016).
http://www.who.int/fctc/text_download/en... . Since 2011, several states, covering 50% of the population, implemented 100% smoke-free air restrictions, followed by a federal law in 2014 ⁶6. Brasil. Decreto nº 8.262, de 31 de maio de 2014. Altera o Decreto nº 2.018, de 1º de outubro de 1996, que regulamenta a Lei nº 9.294, de 15 de julho de 1996. Diário Oficial da União 2014; 2 jun.^,77. Aliança de Controle do Tabagismo. Mapa de ambientes livres do tabaco no Brasil. http://www.actbr.org.br/biblioteca/mapa (accessed on 03/Mar/2017).
http://www.actbr.org.br/biblioteca/mapa... . Moreover, in 2012, a new tax structure went into effect to further increase cigarette tax revenues, which led to an increase of 23% in inflation-adjusted prices between 2012 and 2014 ⁸8. Ministério da Fazenda. Tributação IPI Cigarros. MP 540/2011; Decreto 7.555/2011. http://www.fazenda.gov.br/divulgacao/noticias/2011/agosto/Tributacao_IPI_Cigarros_MP_e_DECRETO_Imprensa.pdf (accessed on 30/Nov/2016).
http://www.fazenda.gov.br/divulgacao/not... ^,99. Iglesias RM, Szklo AS, Souza MC, Almeida LM. Estimating the size of illicit tobacco consumption in Brazil: findings from the global adult tobacco survey. Tob Control 2017; 26:53-9..

Tobacco control is not only vital for reducing smoking prevalence and, as consequence, smoking-attributable deaths among adults, but it also contributes towards the attainment of the Millennium Development Goals proposed by the United Nations’ Secretary-General in 2000, in particular goal #4 (reducing child mortality) ¹⁰10. Esson KM, Leeder SR. The Millennium development goals and tobacco control: an opportunity for global partnership. http://www.who.int/tobacco/publications/mdg_final_for_web.pdf (accessed on 30/Nov/2016).
http://www.who.int/tobacco/publications/... ^,1111. United Nations. United Nations Millennium Declaration. http://www.un.org/millennium/declaration/ares552e.pdf (accessed on 30/Nov/2016).
http://www.un.org/millennium/declaration... . Indeed, studies have found a causal relationship between prenatal smoking and adverse maternal and child health outcomes (MCHOs), such as placenta praevia, placental abruption, preterm birth, low birth weight, and sudden infant death syndrome ¹²12. Shah NR, Bracken MB. A systematic review and meta-analysis of prospective studies on the association between maternal cigarette smoking and preterm delivery. Am J Obstet Gynecol 2000; 182:465-72.^,1313. DiFranza JR, Lew RA. Effect of maternal cigarette smoking on pregnancy complications and Sudden Infant Death Syndrome. J Fam Pract 1995; 40:385-94.^,1414. U.S. Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A report of the Surgeon General. Atlanta: Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2014.. Although prenatal smoking is a particular concern in low and middle income nations ¹⁵15. Oncken CA, Dietz PM, Tong VT, Belizán JM, Tolosa JE, Berghella V, et al. Prenatal tobacco prevention and cessation interventions for women in low- and middle-income countries. Acta Obstet Gynecol Scand 2010; 89:442-53., the impact of prenatal smoking and the potential role of tobacco control policies in improving child health have received little attention ¹⁴14. U.S. Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A report of the Surgeon General. Atlanta: Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2014.^,1616. U.S. Department of Health and Human Services. The economics of tobacco and tobacco control. National Cancer Institute Tobacco Control Monograph, 21. NIH Publication No. 16-CA-8029A. http://cancercontrol.cancer.gov/brp/tcrb/monographs/21/index.html (accessed on 08/Mar/2017).
http://cancercontrol.cancer.gov/brp/tcrb... .

With strong tobacco control policies and a comprehensive surveillance network for MCHOs based on three health information systems - Information System on Live Births (SINASC), Mortality Information System (SIM), and Hospital Information System (SIH) ¹⁷17. Barros FC, Victora CG, Barros AJD, Santos IS, Albernaz E, Matijasevich A, et al. The challenge of reducing neonatal mortality in middle-income countries: findings from three Brazilian birth cohorts in 1982, 1993, and 2004. Lancet 2005; 365:847-54.^,1818. Lima CRA, Escamilla JA, Morais Neto OL, Queiroz VP. Successful Brazilian experiences in the field of health information. Final report. https://www.measureevaluation.org/our-work/health-information-systems/health-information-system-strengthening-in-lac-region-2005-2010/his-brazil-english-august2007.pdf/view (accessed on 08/Mar/2017).
https://www.measureevaluation.org/our-wo... -, Brazil is well-suited to evaluate the effect of implementing tobacco control policies on smoking-attributable adverse MCHOs. We updated the Brazil SimSmoke to incorporate the role of new policies and extended it to assess the overall impact of tobacco policies on the reduction of cigarette smoking by pregnant women and, as a consequence, on MCHOs. To our knowledge, our study represents the first one that considers the effect of tobacco control policies on MCHOs for low and middle income countries, including Brazil. A large scale survey in 2013 also made it possible to further validate the model ⁴4. Szklo A, Souza MC, Szklo M, de Almeida LM. Smokers in Brazil: who are they? Tob Control 2016; 25:564-70.^,1919. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013. Percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, Grandes Regiões e Unidades da Federação. http://www.ibge.gov.br/home/estatistica/populacao/pns/2013/default.shtm (accessed on 30/Nov/2016).
http://www.ibge.gov.br/home/estatistica/... .

Methods

Basic model and update in 2015

Brazil SimSmoke estimated the effect of Brazil’s tobacco control policies on smoking prevalence and smoking-attributable deaths (SADs) among adults aged 18 years or older between 1989 and 2010 ¹1. Levy DT, de Almeida L, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med 2012; 9:e1001336.. A discrete-time, first-order Markov process was employed to project population growth by births and deaths, and smoking prevalence by smoking initiation, cessation, and relapse rates. Changes in tobacco control policies shifted smoking prevalence through initiation and cessation. SADs were calculated using relative risks, smoking prevalence, and death rates. Projected smoking prevalence rates were validated using data from the Brazilian module of the 2003 World Health Survey (WHS) ²2. Monteiro C, Cavalcante T, Moura E, Claro RM, Szwarcwald CL. Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989-2003). Bull World Health Organ 2007; 85:527-34. and from the 2008 Brazilian Global Adult Tobacco Survey (GATS) ²⁰20. Instituto Nacional de Câncer. Global adult tobacco survey: Brazil report. http://www.who.int/tobacco/surveillance/en_tfi_gats_2010_brazil.pdf (accessed on 30/Nov/2016).
http://www.who.int/tobacco/surveillance/... .

Since 2011, stricter smoke-free air laws were implemented and cigarettes taxes were increased ⁶6. Brasil. Decreto nº 8.262, de 31 de maio de 2014. Altera o Decreto nº 2.018, de 1º de outubro de 1996, que regulamenta a Lei nº 9.294, de 15 de julho de 1996. Diário Oficial da União 2014; 2 jun.^,77. Aliança de Controle do Tabagismo. Mapa de ambientes livres do tabaco no Brasil. http://www.actbr.org.br/biblioteca/mapa (accessed on 03/Mar/2017).
http://www.actbr.org.br/biblioteca/mapa... ^,88. Ministério da Fazenda. Tributação IPI Cigarros. MP 540/2011; Decreto 7.555/2011. http://www.fazenda.gov.br/divulgacao/noticias/2011/agosto/Tributacao_IPI_Cigarros_MP_e_DECRETO_Imprensa.pdf (accessed on 30/Nov/2016).
http://www.fazenda.gov.br/divulgacao/not... ^,99. Iglesias RM, Szklo AS, Souza MC, Almeida LM. Estimating the size of illicit tobacco consumption in Brazil: findings from the global adult tobacco survey. Tob Control 2017; 26:53-9.. We incorporated those policies and validated the model using results from the 2013 Brazilian GATS, a large-scale population-wide survey ¹⁹19. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013. Percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, Grandes Regiões e Unidades da Federação. http://www.ibge.gov.br/home/estatistica/populacao/pns/2013/default.shtm (accessed on 30/Nov/2016).
http://www.ibge.gov.br/home/estatistica/... .

Extension of the model: incorporating smoking-attributable birth outcomes

Brazil SimSmoke was extended to estimate smoking-attributable MCHOs , including cases of low birth weight (LBW), preterm births (PTB), sudden infant death syndrome (SIDS), placenta praevia, and placental abruption. The number of smoking-attributable MCHOs is estimated as a product of the total number of cases for each outcome and the smoking-attributable fraction (SAF) for that outcome. The SAF is defined as:

SAF_o = p*[RR_o - 1] / [1 + p*(RR_o - 1)],

where p = active prenatal smoking prevalence and RR_o = relative risk of MCHO for active prenatal smokers compared to prenatal nonsmokers ²¹21. Lilienfeld A, Lilienfeld D. Foundations of epidemiology. New York: Oxford University Press; 1980.. Figure 1 shows the inputs, intermediate calculations, and outputs. Due to uncertainty in each of the three parameters, we conducted sensitivity analyses with credible upper and lower bounds.

To obtain the number of MCHOs, births by age and gender of the women of child-bearing potential were multiplied by the corresponding prevalence of MCHOs. Data on MCHOs from 2000 to 2013 were obtained from the SINASC, the SIM, and the SIH ¹⁷17. Barros FC, Victora CG, Barros AJD, Santos IS, Albernaz E, Matijasevich A, et al. The challenge of reducing neonatal mortality in middle-income countries: findings from three Brazilian birth cohorts in 1982, 1993, and 2004. Lancet 2005; 365:847-54.^,1818. Lima CRA, Escamilla JA, Morais Neto OL, Queiroz VP. Successful Brazilian experiences in the field of health information. Final report. https://www.measureevaluation.org/our-work/health-information-systems/health-information-system-strengthening-in-lac-region-2005-2010/his-brazil-english-august2007.pdf/view (accessed on 08/Mar/2017).
https://www.measureevaluation.org/our-wo... ^,2222. Jorge MH, Gotlieb SL, Soboll ML, de Almeida MF, Latorre MR. An information system on live births and the use of its data in epidemiology and health statistics. Rev Saúde Pública 1993; 27 Suppl:1-44., aggregated by ages 18-19, 20-29, 30-39, and 40-49. Because placenta praevia and placental abruption were included as one category since 2009, rates were combined in prior years. To avoid overlap, we excluded PTB from LBW cases. Since reliable data for adverse MCHOs were not available before 2000, we estimated trends in years prior to 2000 from the published literature on an outcome-by-outcome basis ²³23. Levy D, Jiang M, Szklo A, de Almeida LM, Autran M, Bloch M. Smoking and adverse maternal and child health outcomes in Brazil. Nicotine Tob Res 2013; 15:1797-804., yielding an increasing trend for PTB and a decreasing trend for SIDS between 1989 and 2000, but no trend for LBW and placenta praevia/placental abruption.

Our literature review ²³23. Levy D, Jiang M, Szklo A, de Almeida LM, Autran M, Bloch M. Smoking and adverse maternal and child health outcomes in Brazil. Nicotine Tob Res 2013; 15:1797-804. found that PTB tend to be underdiagnosed and underreported. However, their measurement improved in 2011, when gestational age began to be collected in exact weeks and not grouped into categories ²⁴24. Silveira MF, Matijasevich A, Horta BL, Bettiol H, Barbieri MA, Silva AA, et al. Prevalence of preterm birth according to birth weight group: a systematic review. Rev Saúde Pública 2013; 47:992-1003.. With rates 50% higher in 2011, but flat in prior years, we adjusted pre-2011 PTB estimates upward by 50%, which served as our lower bound. Since 2011 estimates were underestimated by at least 15% ²⁴24. Silveira MF, Matijasevich A, Horta BL, Bettiol H, Barbieri MA, Silva AA, et al. Prevalence of preterm birth according to birth weight group: a systematic review. Rev Saúde Pública 2013; 47:992-1003., we adjusted all years by an additional 15% as our midrange estimate and by 30% as our upper bound. We also adjusted SIDS estimates upward by 100% for midrange and by 200% for the upper bound ²³23. Levy D, Jiang M, Szklo A, de Almeida LM, Autran M, Bloch M. Smoking and adverse maternal and child health outcomes in Brazil. Nicotine Tob Res 2013; 15:1797-804.. Rates after 2013 for all MCHOs were assumed to remain at their 2013 levels (cf. Supplemental Table 1; http://www2.inca.gov.br/wps/wcm/connect/observatorio_controle_tabaco/site/home/biblioteca).

Our review ²³23. Levy D, Jiang M, Szklo A, de Almeida LM, Autran M, Bloch M. Smoking and adverse maternal and child health outcomes in Brazil. Nicotine Tob Res 2013; 15:1797-804. also indicated that the relative risks in Brazil were consistent with estimates for the United States, although at the low end in some cases. Consequently, the relative risks and the lower/upper bounds of smoking-attributable MCHOs for Brazil are based on US risks, which are based on reviews and recent studies with large samples for each outcome (cf. Supplemental Table 2; http://www2.inca.gov.br/wps/wcm/connect/observatorio_controle_tabaco/site/home/biblioteca) ¹⁴14. U.S. Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A report of the Surgeon General. Atlanta: Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2014.^,2323. Levy D, Jiang M, Szklo A, de Almeida LM, Autran M, Bloch M. Smoking and adverse maternal and child health outcomes in Brazil. Nicotine Tob Res 2013; 15:1797-804.^,2525. Levy D, Mohlman MK, Zhang Y. Estimating the potential impact of tobacco control policies on adverse maternal and child health outcomes in the United States using the SimSmoke tobacco control policy simulation model. Nicotine Tob Res 2016; 18:1240-9..

To estimate prenatal smoking prevalence, we assumed that the prevalence of smoking among pregnant women mirrors that of women of the same age in the general population, and that a fixed percentage of pregnant women who smoke quit during their pregnancy. Based on data from two earlier studies ²⁶26. Halal I, Victora C, Barros F. Determinantes do hábito de fumar e de seu abandono durante a gestação em localidade urbana na Região Sul do Brasil. Rev Saúde Pública 1993; 27:105-12.^,2727. Reis LG, da Silva CJ, Trindade A, Abrahão M, Silva VA. Women who smoke and stop during pregnancy: who are they? Rev Bras Saúde Matern Infant 2008; 8:217-21., and previous analyses ²³23. Levy D, Jiang M, Szklo A, de Almeida LM, Autran M, Bloch M. Smoking and adverse maternal and child health outcomes in Brazil. Nicotine Tob Res 2013; 15:1797-804., we estimate that 40% of women quit smoking during pregnancy. We also considered a lower bound where 30% quit at all ages, since the higher rate may reflect policies targeted at pregnant smokers implemented only after 2000 ³3. Szklo AS, Almeida LM, Figueiredo VC, Autran M, Malta D, Caixeta R, et al. A snapshot of the striking decrease in cigarette smoking prevalence in Brazil between 1989 and 2008. Prev Med 2012; 54:162-7.. Based on evidence from the 2013 Brazilian GATS ¹⁹19. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013. Percepção do estado de saúde, estilos de vida e doenças crônicas: Brasil, Grandes Regiões e Unidades da Federação. http://www.ibge.gov.br/home/estatistica/populacao/pns/2013/default.shtm (accessed on 30/Nov/2016).
http://www.ibge.gov.br/home/estatistica/... , we also estimated an upper bound where 50% of women smokers quit during pregnancy. These data were also used to distinguish prenatal smoking rates by age. Based on a study for Spain ²⁸28. Aranda Regules J, Mateos Vilchez P, González Villalba A, Sanchez F, Luna del Castillo JD. Validity of smoking measurements during pregnancy: specificity, sensitivity and cut-off points. Rev Esp Salud Pública 2008; 82:535-45., we assumed a 15% underreport of prenatal smoking, within the range of other countries ²⁹29. Gorber S, Schofield-Hurwitz S, Hardt J, Tremblay M. The accuracy of self-reported smoking: a systematic review of the relationship between self-reported and cotinine-assessed smoking status. Nicotine Tob Res 2009; 11:12-24..

The effect of policies

Policies are assumed to have the same effect sizes on prenatal smoking as on the female population, based on previous studies. For example, demand studies ³⁰30. Adams EK, Markowitz S, Kannan V, Dietz PM, Tong VT, Malarcher AM. Reducing prenatal smoking: the role of state policies. Am J Prev Med 2012; 43:34-40.^,3131. Gruber J, Koszegi B. Is addiction "rational": theory and practice. Q J Econ 2001; 116:1261-303.^,3232. Ringel JS, Evans WN. Cigarette taxes and smoking during pregnancy. Am J Public Health 2001; 91:1851-6.^,3333. Levy DE, Meara E. The effect of the 1998 Master Settlement Agreement on prenatal smoking. J Health Econ 2006; 25:276-94.^,3434. Hawkins SS, Baum CF. Impact of state cigarette taxes on disparities in maternal smoking during pregnancy. Am J Public Health 2014; 104:1464-70. have obtained prenatal prevalence price elasticities between -0.13 and -0.7, which are consistent with the elasticities used in SimSmoke, and a recent study ³⁴34. Hawkins SS, Baum CF. Impact of state cigarette taxes on disparities in maternal smoking during pregnancy. Am J Public Health 2014; 104:1464-70. found higher elasticities for those of low socioeconomic status. Studies have found that other tobacco control policies, including cessation treatment ³⁵35. Tong VT, Dietz PM, Rolle IV, Kennedy SM, Thomas W, England LJ. Clinical interventions to reduce secondhand smoke exposure among pregnant women: a systematic review. Tob Control 2015; 24:217-23.^,3636. Bombard JM, Farr SL, Dietz PM, Tong VT, Zhang L, Rabius V. Telephone smoking cessation quitline use among pregnant and non-pregnant women. Matern Child Health J 2013; 17:989-95., smoke-free air laws ²⁶26. Halal I, Victora C, Barros F. Determinantes do hábito de fumar e de seu abandono durante a gestação em localidade urbana na Região Sul do Brasil. Rev Saúde Pública 1993; 27:105-12., and media campaigns ³⁷37. Campion P, Owen L, McNeill A, McGuire C. Evaluation of a mass media campaign on smoking and pregnancy. Addiction 1994; 89:1245-54., are effective at reducing prenatal smoking.

To estimate the effect of the tobacco control policies implemented since 1989, all 2015 policies were set to their 1989 levels for all years. This counterfactual represents predicted smoking rates if there were no changes in tobacco control policies in Brazil, i.e., the long-term trend in the absence of policy change. For smoking prevalence, we considered the effect of all policies regarding the counterfactual rate in the same year. For SADs and each adverse MCHO, we calculated the net gain by subtracting the number of outcomes with policies implemented from the number of outcomes under the counterfactual in the same year.

Since tax policies have been found to be particularly effective in reducing initiation among young people and increasing cessation among underprivileged ones ³⁸38. International Agency for Research on Cancer. Effectiveness of tax and price policies for tobacco control. IARC Handbook of Cancer Prevention Volume 14. http://www.iarc.fr/en/publications/pdfs-online/prev/handbook14/handbook14-10.pdf (accessed on 30/Nov/2016).
http://www.iarc.fr/en/publications/pdfs-... , we assessed the independent effect of price increases. This point is particularly important for Brazil, because, between 1986 and 2015, the country had multiple tobacco excise tax policies, going from a single rate ad valorem system in the 1990s to a mixed system composed of two specific rates and one small ad valorem component since 2012 ³⁹39. Iglesias RJ, Jha P, Pinto M, da Costa e Silva VL, Godinho J. Tobacco control in Brazil. Washington DC: The International Bank for Reconstruction and Development/The World Bank; 2007.. It is worth noting that, between 2008 and 2014, consumer prices increased 146%, and much of this price expansion was possible due to an increase in the specific rate over the accumulated inflation rate in 2009 and the new tax structure implemented in 2012 ⁹9. Iglesias RM, Szklo AS, Souza MC, Almeida LM. Estimating the size of illicit tobacco consumption in Brazil: findings from the global adult tobacco survey. Tob Control 2017; 26:53-9.^,3939. Iglesias RJ, Jha P, Pinto M, da Costa e Silva VL, Godinho J. Tobacco control in Brazil. Washington DC: The International Bank for Reconstruction and Development/The World Bank; 2007..

Results

Validation and update of SimSmoke from 2011 to 2015

As shown in Table 1, SimSmoke predicted the overall relative decrease in smoking prevalence rates between 1989 and 2013 within 1% and 4% accuracy for males and females, respectively, but it was less accurate for the subperiod 2008-2013. The model made worse predictions for females by age group in the 2008-2013 subperiod, underpredicting the decline for the age groups 18-44 and 65+ and overpredicting the decline for women aged 45-64 years old.

In Table 2, Brazil SimSmoke uses the counterfactual of no policies implemented since 1989 to show the effect of policies implemented between 1989 and 2015, including stronger smoke-free air laws and higher cigarette taxes implemented in the last five years. In this counterfactual scenario, smoking prevalence is projected to have fallen from 43.3% to 31.3% among males and from 27.1% to 19.2% among females between 1989 and 2050. Compared to policies set to their 1989 levels, the policies implemented between 1989 and 2015 indicate a net 62% (56.9%-67.1%) and 66.7% (51.0%-78.7%) relative reduction in the smoking prevalence in Brazil by 2050 among males and females, respectively. If only the tax policy was implemented in Brazil since 1989, the net relative reduction in the smoking prevalence by 2050 would have been of 40.3% (32.0%-47.6%) for males and 40.6% (32.3%-47.9%) for females.

With current policies in place, cumulative smoking-attributable deaths are estimated at 594,017 (535,194-650,881) among men and 239,048 (160,549-321,842) among women by 2015 (Table 3). This number increases to 5.0 million (4.6-5.4) among men and 2.5 million (1.8-3.1) among women by 2050. Compared to the counterfactual of no policies, Brazil SimSmoke estimates a cumulative total of 7.5 million (6.4-8.5) fewer deaths (male and female) by 2050, as a result of the policies implemented between 1989 and 2050. Tax policy alone would have accounted for about 4.2 million (3.3-5.0) fewer deaths between 1989 and 2050 (male and female).

The relative differences from the implementation of the chosen policies are shown in Supplemental Table 3 (cf. http://www2.inca.gov.br/wps/wcm/connect/observatorio_controle_tabaco/site/home/biblioteca). By 2050, all policies will have reduced smoking-attributable deaths by 35.1% (32.1%-37.9%) in males and by 36.7% (26.7%-45.7%) in females. Also, tax policy alone will have reduced smoking-attributable deaths by 20.1% (15.8%-24.2%) in males and by 19.1% (15.0%-22.9%) in females.

Impact of tobacco policies on prenatal smoking prevalence and selected MCHOs

As shown in Table 4, the cumulative number of averted placenta praevia/placental abruption cases is estimated at 11,281 (3,538-22,336) by 2015 (net effect of policies implemented since 1989) and 28,564 (9,037-56,282) by 2050. A cumulative total of 172,683 (65,972-668,417) fewer PTB and 161,442 (98,323-244,379) fewer LBW babies were born by 2015, increasing to an estimated 446,410 (172,702-1,715,161) and 405,788 (249,368-604,880) fewer cases by 2050. For SIDS, a cumulative total of 706 (100-1,859) fewer deaths are estimated by 2015, increasing to 1,518 (215-3,979) fewer deaths by 2050. By 2050, tax policy alone will have reduced 19,431 (6,648-36,337) placenta praevia/placental abruption cases; 308,530 (127,854-1,132,921) PTB; 276,666 (183,522-398,030) LBW; and 1,052 (162-2,623) SIDS.

The relative differences from the implementation of the chosen policies are shown in Supplemental Table 4 (cf. http://www2.inca.gov.br/wps/wcm/connect/observatorio_controle_tabaco/site/home/biblioteca). By 2050, all policies will have reduced smoking-attributable placenta praevia/placental abruption cases by 41.4% (31.8%-48.7%), PTB by 43.6% (32.4%-50.7%), LBW by 39.1% (28.8%-47.7%), and SIDS by 33.0% (26.0%-39.0%). By 2050, tax policy alone will have reduced smoking-attributable placenta praevia/placental abruption cases by 28.1% (23.4%-31.4%); PTB by 30.1% (24.0%-33.5%); LBW by 26.7% (21.2%-31.4%); and SIDS by 22.8% (19.6%-25.7%).

Discussion

In previous study ¹1. Levy DT, de Almeida L, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med 2012; 9:e1001336., we showed that tobacco control policies were responsible for a 46% decrease in smoking prevalence between 1989 and 2010. Smoking prevalence in Brazil has fallen by almost 20% between 2011 and 2015. SimSmoke projected that 7.5 million deaths will be averted by 2050, including 500,000 cumulative deaths from policies implemented between 2011 and 2015 ¹1. Levy DT, de Almeida L, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med 2012; 9:e1001336.. This translates to a 46% reduction in smoking-attributable deaths between 2016 and 2050.

Brazil SimSmoke was also extended to consider the effect of prenatal smoking on smoking-attributable MCHOs. The model projected that 0.9 million (0.4-2.4) MCHOs will be averted by 2050. Brazil was chosen for this analysis because it had high rates of smoking at population level, but has witnessed marked reductions in smoking rates ¹1. Levy DT, de Almeida L, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med 2012; 9:e1001336.^,22. Monteiro C, Cavalcante T, Moura E, Claro RM, Szwarcwald CL. Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989-2003). Bull World Health Organ 2007; 85:527-34.^,33. Szklo AS, Almeida LM, Figueiredo VC, Autran M, Malta D, Caixeta R, et al. A snapshot of the striking decrease in cigarette smoking prevalence in Brazil between 1989 and 2008. Prev Med 2012; 54:162-7.^,44. Szklo A, Souza MC, Szklo M, de Almeida LM. Smokers in Brazil: who are they? Tob Control 2016; 25:564-70.. Our results indicate that, between 2016 and 2050, the already implemented policies will reduce the total number (net absolute reduction) of placental abruption/placenta praevia by 7.4%; PTB by 3.1%; LBW births by 8.3%; and SIDS by 9.2% (data not shown in a table).

Brazil has achieved the Millennium Development Goal of reducing under-five child mortality by two thirds between 1990 and 2015 ⁴⁰40. Instituto de Pesquisa Econômica Aplicada. Objetivos de Desenvolvimento do Milênio: relatório nacional de acompanhamento. http://www.pnud.org.br/Docs/5_RelatorioNacionalAcompanhamentoODM.pdf (accessed on 30/Nov/2016).
http://www.pnud.org.br/Docs/5_RelatorioN... . Our results indicate that tobacco control policies may have played a major role. The case for tobacco control becomes more compelling upon extending the analyses to consider the effects of second-hand smoke and/or other MCHOs, such as ectopic pregnancy and cleft palate ¹²12. Shah NR, Bracken MB. A systematic review and meta-analysis of prospective studies on the association between maternal cigarette smoking and preterm delivery. Am J Obstet Gynecol 2000; 182:465-72.. In addition, the costs of tobacco consumption pose a heavy burden on governments and society ¹⁰10. Esson KM, Leeder SR. The Millennium development goals and tobacco control: an opportunity for global partnership. http://www.who.int/tobacco/publications/mdg_final_for_web.pdf (accessed on 30/Nov/2016).
http://www.who.int/tobacco/publications/... . In 2011, smoking-attributable direct medical expenditures for cardiovascular, cancer, chronic obstructive pulmonary and perinatal diseases cost USD 15 billion in Brazil ⁴¹41. Pinto MT, Pichon-Riviere A, Bardach A. Estimativa da carga do tabagismo no Brasil: mortalidade, morbidade e custos. Cad Saúde Pública 2015; 31:1283-97.. Continuing to increase cigarette prices will increase tax revenues and reduce smoking prevalence, particularly among underprivileged people, thus saving funds for other health care challenges ³⁸38. International Agency for Research on Cancer. Effectiveness of tax and price policies for tobacco control. IARC Handbook of Cancer Prevention Volume 14. http://www.iarc.fr/en/publications/pdfs-online/prev/handbook14/handbook14-10.pdf (accessed on 30/Nov/2016).
http://www.iarc.fr/en/publications/pdfs-... .

Limitations

The previously validated model ¹1. Levy DT, de Almeida L, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med 2012; 9:e1001336. was updated in 2015 and made good predictions for the overall adult female and male smoking prevalence. The updated model made fewer good predictions for females by age group for the subperiod 2008-2013, which may reflect limitations in the model or in the data used to validate SimSmoke. Specifically, the model underpredicted the smoking rate reduction for those aged 18-44 yearsold, i.e., an age group closely linked to child-bearing potential. Consistent with the literature ¹1. Levy DT, de Almeida L, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med 2012; 9:e1001336., SimSmoke assigns a small effect size to the impact of warning labels on young people, who are often thought to ignore warnings. However, mass media campaigns and the new set of stronger health warnings related to both miscarriage and passive smoking exposure, implemented since 2009 ⁶6. Brasil. Decreto nº 8.262, de 31 de maio de 2014. Altera o Decreto nº 2.018, de 1º de outubro de 1996, que regulamenta a Lei nº 9.294, de 15 de julho de 1996. Diário Oficial da União 2014; 2 jun.^,77. Aliança de Controle do Tabagismo. Mapa de ambientes livres do tabaco no Brasil. http://www.actbr.org.br/biblioteca/mapa (accessed on 03/Mar/2017).
http://www.actbr.org.br/biblioteca/mapa... ^,88. Ministério da Fazenda. Tributação IPI Cigarros. MP 540/2011; Decreto 7.555/2011. http://www.fazenda.gov.br/divulgacao/noticias/2011/agosto/Tributacao_IPI_Cigarros_MP_e_DECRETO_Imprensa.pdf (accessed on 30/Nov/2016).
http://www.fazenda.gov.br/divulgacao/not... ^,99. Iglesias RM, Szklo AS, Souza MC, Almeida LM. Estimating the size of illicit tobacco consumption in Brazil: findings from the global adult tobacco survey. Tob Control 2017; 26:53-9.^,4242. Instituto Nacional de Câncer. Brazil: health warnings on tobacco products - 2009. http://www.tobaccolabels.ca/wp/wp-content/uploads/2013/12/Brazil-2008-Health-Warnings-on-Tobacco-Products-Report-English.pdf (accessed on 30/Nov/2016).
http://www.tobaccolabels.ca/wp/wp-conten... , may have produced greater effects than predicted. Price and tax policy may also have had greater effects on younger females than predicted by the model, due to their lower income than males ⁸8. Ministério da Fazenda. Tributação IPI Cigarros. MP 540/2011; Decreto 7.555/2011. http://www.fazenda.gov.br/divulgacao/noticias/2011/agosto/Tributacao_IPI_Cigarros_MP_e_DECRETO_Imprensa.pdf (accessed on 30/Nov/2016).
http://www.fazenda.gov.br/divulgacao/not... ^,99. Iglesias RM, Szklo AS, Souza MC, Almeida LM. Estimating the size of illicit tobacco consumption in Brazil: findings from the global adult tobacco survey. Tob Control 2017; 26:53-9.^,3838. International Agency for Research on Cancer. Effectiveness of tax and price policies for tobacco control. IARC Handbook of Cancer Prevention Volume 14. http://www.iarc.fr/en/publications/pdfs-online/prev/handbook14/handbook14-10.pdf (accessed on 30/Nov/2016).
http://www.iarc.fr/en/publications/pdfs-... ^,3939. Iglesias RJ, Jha P, Pinto M, da Costa e Silva VL, Godinho J. Tobacco control in Brazil. Washington DC: The International Bank for Reconstruction and Development/The World Bank; 2007.^,4040. Instituto de Pesquisa Econômica Aplicada. Objetivos de Desenvolvimento do Milênio: relatório nacional de acompanhamento. http://www.pnud.org.br/Docs/5_RelatorioNacionalAcompanhamentoODM.pdf (accessed on 30/Nov/2016).
http://www.pnud.org.br/Docs/5_RelatorioN... ^,4141. Pinto MT, Pichon-Riviere A, Bardach A. Estimativa da carga do tabagismo no Brasil: mortalidade, morbidade e custos. Cad Saúde Pública 2015; 31:1283-97.^,4242. Instituto Nacional de Câncer. Brazil: health warnings on tobacco products - 2009. http://www.tobaccolabels.ca/wp/wp-content/uploads/2013/12/Brazil-2008-Health-Warnings-on-Tobacco-Products-Report-English.pdf (accessed on 30/Nov/2016).
http://www.tobaccolabels.ca/wp/wp-conten... ^,4343. Instituto Brasileiro de Geografia e Estatística. National Household Sample Survey - 2012. http://www.ibge.gov.br/english/estatistica/populacao/trabalhoerendimento/pnad2012/default.shtm (accessed on 30/Nov/2016).
http://www.ibge.gov.br/english/estatisti... , thus suggesting that our estimates probably underestimated the decrease in smoking prevalence from implementing chosen policies among women of child-bearing potential and, as a consequence, probably underestimated the cumulative number of averted MCHOs.

The results of the model are based on the assumptions inherent to it, the policy effect sizes, and the data quality ¹1. Levy DT, de Almeida L, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med 2012; 9:e1001336.^,4444. Levy DT, Cummings KM, Hyland A. Increasing taxes as a strategy to reduce cigarette use and deaths: results of a simulation model. Prev Med 2000; 31:279-86.. Additional limitations are related to the estimates of the smoking-attributable MCHOs: (i) while the estimates of the relative risks of smoking for LBW babies, PTB, and SIDS for Brazil are generally consistent with estimates for the US ¹⁴14. U.S. Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A report of the Surgeon General. Atlanta: Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2014.^,2323. Levy D, Jiang M, Szklo A, de Almeida LM, Autran M, Bloch M. Smoking and adverse maternal and child health outcomes in Brazil. Nicotine Tob Res 2013; 15:1797-804., we found no Brazilian studies that considered placental abruption or placenta praevia; (ii) while smoking behaviors of Brazilian mothers appear to be similar to those of high income countries, Brazilian pregnant women may smoke fewer cigarettes and be less nicotine dependent ⁴4. Szklo A, Souza MC, Szklo M, de Almeida LM. Smokers in Brazil: who are they? Tob Control 2016; 25:564-70.^,1414. U.S. Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A report of the Surgeon General. Atlanta: Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2014., which may lower relative risks and the SAF measure used, thus suggesting that we may have overestimated the effect of policies on the cumulative number of averted MCHOs; (iii) in examining prenatal smoking over time, differences in smoking behaviors by socioeconomic status were not considered, which have become increasingly important in Brazil ¹1. Levy DT, de Almeida L, Szklo A. The Brazil SimSmoke policy simulation model: the effect of strong tobacco control policies on smoking prevalence and smoking-attributable deaths in a middle income nation. PLoS Med 2012; 9:e1001336.^,22. Monteiro C, Cavalcante T, Moura E, Claro RM, Szwarcwald CL. Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989-2003). Bull World Health Organ 2007; 85:527-34.^,33. Szklo AS, Almeida LM, Figueiredo VC, Autran M, Malta D, Caixeta R, et al. A snapshot of the striking decrease in cigarette smoking prevalence in Brazil between 1989 and 2008. Prev Med 2012; 54:162-7.^,44. Szklo A, Souza MC, Szklo M, de Almeida LM. Smokers in Brazil: who are they? Tob Control 2016; 25:564-70.; for instance, smoking prevalence is usually higher among less educated women (versus high educated), and they quit less during pregnancy ⁴4. Szklo A, Souza MC, Szklo M, de Almeida LM. Smokers in Brazil: who are they? Tob Control 2016; 25:564-70.^,4545. Kale PL, Fonseca SC, da Silva KS, da Rocha PM, Silva RG, Pires AC, et al. Smoking prevalence, reduction, and cessation during pregnancy and associated factors: a cross-sectional study in public maternities, Rio de Janeiro, Brazil. BMC Public Health 2015; 15:406.. As a consequence, although we also considered a lower quitting rate during pregnancy to increase the SAF measure used and to estimate the upper bounds for averted MCHOs, we still may have underestimated the number of averted MCHOs; (iv) although we could not consider the frequency of maternal smoking in successive pregnancies and its association with repetition of the selected MCHOs, smoking persistence may be an important risk factor to further increase the respective relative risks and, as a result, the cumulative number of averted outcomes ⁴⁶46. Sclowitz IK, Santos IS, Domingues MR, Matijasevich A, Barros AJD. Maternal smoking in successive pregnancies and recurrence of low birthweight: the 2004 Pelotas birth cohort study, Brazil. Cad Saúde Pública 2013; 29:123-30.; (v) although estimates of prenatal smoking prevalence were corrected for underreporting ²⁸28. Aranda Regules J, Mateos Vilchez P, González Villalba A, Sanchez F, Luna del Castillo JD. Validity of smoking measurements during pregnancy: specificity, sensitivity and cut-off points. Rev Esp Salud Pública 2008; 82:535-45., underreporting may also reduce the strength of the SAF measure used ²⁹29. Gorber S, Schofield-Hurwitz S, Hardt J, Tremblay M. The accuracy of self-reported smoking: a systematic review of the relationship between self-reported and cotinine-assessed smoking status. Nicotine Tob Res 2009; 11:12-24. and, therefore, underestimate the total number of averted MCHOs; (vi) wide variations in MCHOs exist by regions of Brazil, and they were not considered ²³23. Levy D, Jiang M, Szklo A, de Almeida LM, Autran M, Bloch M. Smoking and adverse maternal and child health outcomes in Brazil. Nicotine Tob Res 2013; 15:1797-804.^,2424. Silveira MF, Matijasevich A, Horta BL, Bettiol H, Barbieri MA, Silva AA, et al. Prevalence of preterm birth according to birth weight group: a systematic review. Rev Saúde Pública 2013; 47:992-1003.^,4747. Veloso HJ, da Silva AA, Bettiol H, Goldani MZ, Filho FL, Simões VM, et al. Low birth weight in São Luís, northeastern Brazil: trends and associated factors. BMC Pregnancy Childbirth 2014 ;14:155.; (vii) Brazil SimSmoke does not directly incorporate changes in policies that target pregnant smokers; (viii) we did not consider the fact that pregnancy interruptions - by either induction or caesarean section - have become much more frequent in Brazil in the last years ¹⁷17. Barros FC, Victora CG, Barros AJD, Santos IS, Albernaz E, Matijasevich A, et al. The challenge of reducing neonatal mortality in middle-income countries: findings from three Brazilian birth cohorts in 1982, 1993, and 2004. Lancet 2005; 365:847-54.^,4848. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013: ciclos de vida. Brasil e grandes regiões. http://biblioteca.ibge.gov.br/visualizacao/livros/liv94522.pdf (accessed on 03/Mar/2017).
http://biblioteca.ibge.gov.br/visualizac... ^,4949. Yang H, Kramer MS, Platt RW, Blondel B, Béart G, Morin I, et al. How does early ultrasound scan estimation of gestational age lead to higher rates of preterm birth? Am J Obstet Gynecol 2002; 186:433-7.. Although the relative risks of adverse MCHOs from Brazilian studies were within the range of the lower bounds of relative risks used to estimate smoking-attributable MCHOs for Brazil ²³23. Levy D, Jiang M, Szklo A, de Almeida LM, Autran M, Bloch M. Smoking and adverse maternal and child health outcomes in Brazil. Nicotine Tob Res 2013; 15:1797-804., Brazilian pregnant women who do not smoke may be increasingly at higher risk for MCHOs than those from high income countries, which may further lower respective relative risks, thus suggesting that we may have overestimated the effect of policies on MCHOs.

Conclusion

The WHO-FCTC is a clear translation of the goals expressed in the Millennium Declaration regarding maternal and child health ⁵5. World Health Organization. WHO framework convention on tobacco control. http://www.who.int/fctc/text_download/en/index.html (accessed on 30/Nov/2016).
http://www.who.int/fctc/text_download/en... ^,1010. Esson KM, Leeder SR. The Millennium development goals and tobacco control: an opportunity for global partnership. http://www.who.int/tobacco/publications/mdg_final_for_web.pdf (accessed on 30/Nov/2016).
http://www.who.int/tobacco/publications/... ^,1111. United Nations. United Nations Millennium Declaration. http://www.un.org/millennium/declaration/ares552e.pdf (accessed on 30/Nov/2016).
http://www.un.org/millennium/declaration... . Our findings show the benefits of tobacco control in reducing both SADs and smoking-attributable MCHOs at population level. Thus, our analysis may better inform policy makers in low and middle income countries (LMICs) about allocating resources toward tobacco control policies in this important area. The analyses of this study are applied to Brazil, but similar results may be expected in other LMICs with strong tobacco control policies.

Acknowledgments

Brazilian National Cancer Institute José Alencar Gomes da Silva (INCA), Brazilian National Research Council (CNPq), US National Cancer Institute (NCI), and Bloomberg Philanthropies.

References

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