Background Smoking during pregnancy (SDP) and the postpartum period has serious health outcomes for the mother and infant. Although some systematic reviews have shown the impact of maternal SDP on particular conditions, a systematic review examining the overall health outcomes has not been published. Hence, this paper aimed to conduct an umbrella review on this issue. Methods A systematic review of systematic reviews (umbrella review) was conducted according to a protocol submitted to PROSPERO (CRD42018086350). CINAHL, EMBASE, MEDLINE, PsycINFO, Web of Science, CRD Database and HMIC databases were searched to include all studies published in English by 31 December 2017, except those focusing exclusively on low-income countries. Two researchers conducted the study selection and quality assessment independently. Results The review included 64 studies analysing the relationship between maternal SDP and 46 health conditions. The highest increase in risks was found for sudden infant death syndrome, asthma, stillbirth, low birth weight and obesity amongst infants. The impact of SDP was associated with the number of cigarettes consumed. According to the causal link analysis, five mother-related and ten infant-related conditions had a causal link with SDP. In addition, some studies reported protective impacts of SDP on pre-eclampsia, hyperemesis gravidarum and skin defects on infants. The review identified important gaps in the literature regarding the dose-response association, exposure window, postnatal smoking. Conclusions The review shows that maternal SDP is not only associated with short-term health conditions (e.g. preterm birth, oral clefts) but also some which can have life-long detrimental impacts (e.g. obesity, intellectual impairment). Implications This umbrella review provides a comprehensive analysis of the overall health impacts of SDP. The study findings indicate that while estimating health and cost outcomes of SDP, long-term health impacts should be considered as well as short-term effects since studies not including the long-term outcomes would underestimate the magnitude of the issue. Also, interventions for pregnant women who smoke should consider the impact of reducing smoking due to health benefits on mothers and infants, and not solely cessation.

Background Severe mental illness (SMI; schizophrenia, bipolar disorders (BDs), and other nonorganic psychoses) is associated with increased risk of cardiovascular disease (CVD) and CVD-related mortality. To date, no systematic review has investigated changes in population level CVD-related mortality over calendar time. It is unclear if this relationship has changed over time in higher-income countries with changing treatments. Methods and findings To address this gap, a systematic review was conducted, to assess the association between SMI and CVD including temporal change. Seven databases were searched (last: November 30, 2021) for cohort or case–control studies lasting ≥1 year, comparing frequency of CVD mortality or incidence in high-income countries between people with versus without SMI. No language restrictions were applied. Random effects meta-analyses were conducted to compute pooled hazard ratios (HRs) and rate ratios, pooled standardised mortality ratios (SMRs), pooled odds ratios (ORs), and pooled risk ratios (RRs) of CVD in those with versus without SMI. Temporal trends were explored by decade. Subgroup analyses by age, sex, setting, world region, and study quality (Newcastle–Ottawa scale (NOS) score) were conducted. The narrative synthesis included 108 studies, and the quantitative synthesis 59 mortality studies (with (≥1,841,356 cases and 29,321,409 controls) and 28 incidence studies (≥401,909 cases and 14,372,146 controls). The risk of CVD-related mortality for people with SMI was higher than controls across most comparisons, except for total CVD-related mortality for BD and cerebrovascular accident (CVA) for mixed SMI. Estimated risks were larger for schizophrenia than BD. Pooled results ranged from SMR = 1.55 (95% confidence interval (CI): 1.33 to 1.81, p < 0.001), for CVA in people with BD to HR/rate ratio = 2.40 (95% CI: 2.25 to 2.55, p < 0.001) for CVA in schizophrenia. For schizophrenia and BD, SMRs and pooled HRs/rate ratios for CHD and CVD mortality were larger in studies with outcomes occurring during the 1990s and 2000s than earlier decades (1980s: SMR = 1.14, 95% CI: 0.57 to 2.30, p = 0.71; 2000s: SMR = 2.59, 95% CI: 1.93 to 3.47, p < 0.001 for schizophrenia and CHD) and in studies including people with younger age. The incidence of CVA, CVD events, and heart failure in SMI was higher than controls. Estimated risks for schizophrenia ranged from HR/rate ratio 1.25 (95% CI: 1.04 to 1.51, p = 0.016) for total CVD events to rate ratio 3.82 (95% CI: 3.1 to 4.71, p < 0.001) for heart failure. Incidence of CHD was higher in BD versus controls. However, for schizophrenia, CHD was elevated in higher-quality studies only. The HR/rate ratios for CVA and CHD were larger in studies with outcomes occurring after the 1990s. Study limitations include the high risk of bias of some studies as they drew a comparison cohort from general population rates and the fact that it was difficult to exclude studies that had overlapping populations, although attempts were made to minimise this. Conclusions In this study, we found that SMI was associated with an approximate doubling in the rate ratio of CVD-related mortality, particularly since the 1990s, and in younger groups. SMI was also associated with increased incidence of CVA and CHD relative to control participants since the 1990s. More research is needed to clarify the association between SMI and CHD and ways to mitigate this risk.

Some researchers have argued that the aim of an economic evaluation should be to offer guidance on resource allocation based on the interest of the public from a societal perspective. The application of a societal perspective in health technology assessment (HTA) while common in many published studies is not mandated in most countries, and there is limited discussion on what the societal perspective should encompass. This study aimed to systematically compare and contrast the HTA guidelines in different countries.HTA methods guidelines were identified through international HTA networks, such as ISPOR and GEAR. The respective HTA agencies were grouped into two categories: well-established and newly-developed, based on the establishment date. Data extracted from the guidelines summarised the methodological details in the reference cases, including specifics on the societal perspective. The database search yielded 46 guidelines, and 65% explicitly considered the societal perspective. The maturity of these agencies is reflected in their attitudes towards the societal perspective; the societal perspective is defined in 70% of the guidelines of well-established agencies and only 56% of those of newly-developed agencies. The guidelines from multi-payer healthcare systems are more likely to consider the societal perspective. Although most guidelines from the well-established agencies recommend the inclusion of a societal perspective, the types of costs and consequences that should be included and the recommended approaches to valuing them are variable. The direct costs to family and carers are included in 73% of the societal perspective definitions and non-health outcomes were considered in only 40%. Most HTA guidelines lack clear guidance on what to include under specific perspectives. Considering the recent advancements in economic evaluation methods, it is timely to re-think the role of the societal perspective in HTA guidelines and adopt a more comprehensive perspective to include all costs and consequences of healthcare services.

Background Information asymmetries and the agency relationship are two defining features of the healthcare system. These market failures are often used as a rationale for government intervention. Many countries have government financing and provision of healthcare in order to correct for this, while health technology agencies also exist to improve efficiency. However, informational asymmetries and the resulting principal-agent problem still persist, and one example is the lack of cost awareness amongst clinicians. This study explores the cost awareness of clinicians across different settings. Methods We targeted four clinical cohorts: medical students, Senior House Officers/Interns, Mid-grade Senior Registrar/Residents, and Consultant/Attending Physicians, in six hospitals in the United Kingdom, the United States, Australia, New Zealand and Spain. The survey asked respondents to report the cost (as they recalled) of different types of scans, visits, medications and tests. Our analysis focused on the differential between the perceived/recalled cost and the actual cost. We explored variation across speciality, country and other potential confounders. Cost-awareness levels were estimated based on the cost estimates within 25% of the actual cost. Results We received 705 complete responses from six sites across five countries. Our analysis found that respondents often overestimated the cost of common tests while underestimating high-cost tests. The mean cost-awareness levels varied between 4 and 23% for different items. Respondents acknowledged that they did not feel they had received adequate training in cost awareness. Discussion The current financial climate means that cost awareness and the appropriate use of scarce healthcare resources is more paramount than perhaps ever before. Much of the focus of health economics research is on high-cost innovative technologies, yet there is considerable waste in the system with respect to overtreatment and overdiagnosis. Common reasons put forward for this include defensive medicine, poor education, clinical uncertainty and the institution of protocols. Conclusion Given the role of clinicians in the healthcare system, as agents both for patients and for providers, more needs to be done to remove informational asymmetries and improve clinician cost awareness. Supplementary Information The online version contains supplementary material available at 10.1007/s40258-022-00736-x.

IntroductionTobacco control during pregnancy is a policy priority in high-income countries (HICs) because of the significant health and inequality consequences. However, little evidence exists on interventions to reduce tobacco use in low-income and middle-income countries (LMICs), especially for pregnant women. This study aimed to assess how health economics evidence, which is mainly produced in HICs, could be adopted for tobacco cessation policies for pregnant women in LMICs.MethodsA qualitative case study was conducted in an international public health organisation. The organisation was chosen due to its capacity to influence health policies around the world. Tobacco control experts working in the organisation were identified through purposeful sampling and snowballing. Semistructured interviews were conducted with 18 informants with relevant experience of countries from all of the regions covered by the organisation. Data were analysed using the framework method.ResultsIn practice, tobacco cessation during pregnancy was not viewed as a priority in LMICs despite international recognition of the issue. In LMICs, factors including the recorded country-specific prevalence of tobacco use during pregnancy, availability of healthcare resources and the characteristics of potential interventions all affected the use of health economics evidence for policy making.ConclusionThe scale of tobacco use among pregnant women might be greater than reported in LMICs. Health economics evidence produced in HICs has the potential to inform health policies in LMICs around tobacco cessation interventions if the country-specific circumstances are addressed. Economic evaluations of cessation interventions integrated into antenatal care with a household perspective would be especially relevant in LMICs.