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Diabet. Med. 27, 295–302 (2010) Aims Cigarette smoking is a well-known risk factor associated with diabetic nephropathy. The objective of this study was to further investigate the dose–response effect of tobacco exposure on proteinuria in males with Type 2 diabetes. Methods Five hundred and nine males with Type 2 diabetes were selected from a cohort participating in a glucose control study in Taiwan. Pack-years of cigarette smoking were calculated to define tobacco exposure. Proteinuria was identified if albumin-to-creatinine ratio was ≥ 30 mg/g in at least two of three consecutive urine tests. Logistic regression and trend tests were used to delineate the association between smoking status and proteinuria. Results Compared with non-smokers, those who had smoked 15–30 or more than 30 pack-years were respectively 2.78 (95% CI 1.34–5.76, P < 0.01) and 3.20 (95% CI 1.74–5.86, P < 0.001) times more likely to develop proteinuria. The dose–response effect of tobacco exposure on the development of proteinuria is highly significant in all subjects ( P = 0.001) and in subgroups with relatively short duration of diabetes mellitus ( P < 0.001), good blood pressure control ( P = 0.001) and those of young age ( P = 0.007). Conclusions The current study shows a clear dose–response effect of cigarette smoking on development of proteinuria in male Type 2 diabetic patients. These findings reinforce the urgent need to encourage diabetic patients to stop smoking regardless of age, duration of diabetes mellitus or status of blood pressure control. [ABSTRACT FROM AUTHOR]

Presents a report on the opening of cigarette market in Taiwan. Reason U.S. tobacco companies turned to Asia for new markets; Observation on the increase in betel quid consumption; Impact of market opening on betel quid consumption.

Objectives: To estimate smoking attributable mortality (SAM) in Taiwan for the years 2001 through 2020 under scenarios of reductions in smoking rates by 0%, 2%, 4%, and 10% per year. Method: The smoking attributable fraction (SM) was used to calculate SAM from the risk experience in following up a large cohort (86 580 people) in Taiwan. Smoking rates were based on the 2001 National Health Interview Survey and other national surveys. An average 10 year lag was assumed between smoking rates and subsequent mortality. Results: In 2001, 18 803 deaths, or 1 out of 4 deaths (27%), in middle aged men (35-69 years old) were attributable to smoking. SAM has been increasing and will continue to increase if smoking rates remain constant or even if reduced annually by 2%. SAM would begin to decrease only if rates were to be reduced by at least 4% a year. Conclusions: The projected SAM in this study illustrates the seriousness of smoking caused mortality. Current efforts in tobacco control would lead to a progressive increase in SAM, unless efforts were doubled and smoking rates reduced by more than 4% a year. The urgency in requiring stronger tobacco control programmes to attenuate the staggering death tolls is compelling. [ABSTRACT FROM AUTHOR]

Purpose: To examine smoking behaviours in Taiwan and compare those behaviours to those in the USA. Methods: Using the National Health Interview Survey (NHIS) of Taiwan (2001), a survey of over 20 000 participants, frequencies were calculated for smoking, ex-smoking, quantity smoked, and exposure to environ mental tobacco smoke (ETS). Breakdowns by age, sex, and socioeconomic status were also calculated. Results: The ratio of male to female smoking rates was 10.9 to 1 among adults (46.8%/4.3%), but 3.6 to 1 among underage teenagers (1 4.3%/4.0%). The proportion of underage to adult smokers was three times higher for girls than for boys. Smoking prevalence substantially increased during and after high school years, and peaked in those aged 30-39 years. Smoking rates of high school age adolescents increased more than threefold if they did not attend school or if they finished their education after high school. Low income and less educated smokers smoked at nearly twice the rate of high income and better educated smokers. The smoker/ex-smoker ratio was close to 7. Male daily smokers smoked on average 17 cigarettes/day, and females, 11. Half of the total population, especially infants and women of childbearing age, were exposed to ETS at home. Conclusions: Taiwan has particularly high male smoking prevalence and much lower female prevalence. The low female prevalence is likely to increase if the current sex ratio of smoking by underage youth continues. The low quit rate among males, the high ETS exposure of females and young children at home, and the sharp increase in smoking rates when students leave school, are of particular concern. These observations on smoking behaviour can provide valuable insights to assist policymakers and health educators in formulating strategies and allocating resources in tobacco control. [ABSTRACT FROM AUTHOR]

Objective: To develop a simulation model to predict the effects of tax policies on smoking prevalence rates and smoking attributable deaths. Methods: Using data from Taiwan, a simulation model is developed that projects population using birth and death rate data, future smoking rates using initiation, cessation and relapse data, and smoking attributable deaths using smoking prevalence and relative risk estimates. The model projects the number of smokers and smoking related deaths from a baseline year forward. The effects of taxes of different sizes, indexed and unindexed, and temporary versus sustained are modelled using elasticities based on published studies of demand. Results: The model predicts that sustained tax increases have the potential to substantially reduce the number of smokers and the number of premature deaths, with the effects growing over time. Indexing taxes to inflation stems erosion of the tax effect. In our model, when the tax increases by 10 times (NT$50) over the recent tax increase (NT$5) and taxes are indexed to inflation, the smoking prevalence rate falls by over 15% soon after the tax increase, and by about 30% in relative terms by the year 2040, resulting in 4500 lives saved per year. Conclusions: Tax rises have the ability to substantially affect smoking rates in Taiwan. These effects grow over time and lead to substantial savings in lives and health care costs. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of promotions on cigarette sales in Taiwan after the cigarette market opened to foreign companies, and to assess whether young smokers were targeted by these companies. Methods: Trends in cigarette sates, advertising expenditure, brand preference, and cigarette consumption were examined for the period following the 1987 opening of the cigarette market. Tobacco industry internal documents from Legacy Tobacco Documents Library of the University of California, San Francisco, were searched for corporate strategies on promoting youth consumption in Taiwan. Results: Between 1995 and 2000, the inflation adjusted advertising expenditures by all foreign firms increased fourfold. Much of the expenditure was spent on brand stretching the Mild Seven (Japan) and David off (Germany) brands in television advertising. By 2000, the market share of foreign cigarettes exceeded domestics by three to one among young smokers and the leading brand preferred by this segment shifted from the most popular domestic brand (Long Life) to a foreign brand (Mild Seven). Furthermore, there was a sudden increase of 16.4% in smoking rates among young adults (from 36.1 % to 42.0%) during the first five years after the market opened. This was also accompanied by increased per capita cigarette consumption and decreased age of smoking initiation. Industry documents confirmed the use of strategies targeted at the young. In particular, establishing new paint of sale (POS) retail stores or promotional activities at POS were found to be more effective than advertising in magazines. Conclusions: This study provides evidence that advertising increased with increased competition following the market opening, which, in turn, spurred cigarette sales and consumption. Foreign tobacco companies have deliberately targeted youth in Taiwan and succeeded in gaining three quarters of their cigarette purchases within a decade. Expanding youth consumption will incur excessive future health care costs borne by society. Foreign tobacco companies should be obligated to reimburse these expenses through higher tariffs on cigarettes. [ABSTRACT FROM AUTHOR]

Objective: To estimate productivity losses and financial costs to employers caused by cigarette smoking in the Taiwan workplace. Methods: The human capital approach was used to calculate lost productivity. Assuming the value of lost productivity was equal to the wage/salary rate and basing the calculations on smoking rate in the workforce, average days of absenteeism, average wage/salary rate, and increased risk and absenteeism among smokers obtained from earlier research, costs due to smoker absenteeism were estimated. Financial losses caused by passive smoking, smoking breaks, and occupational injuries were calculated. Results: Using a conservative estimate of excess absenteeism from work, male smokers took off an average of 4.36 sick days and male non-smokers took off an average of 3.30 sick days. Female smokers took off an average of 4.96 sick days and non-smoking females took off an average of 3.75 sick days. Excess absenteeism caused by employee smoking was estimated to cost US$178 million per annum for males and US$6 million for females at a total cost of US$184 million per annum. The time men and women spent taking smoking breaks amounted to nine days per year and six days per year, respectively, resulting in reduced output productivity losses of US$733 million. Increased sick leave costs due to passive smoking were approximately US$81 million. Potential costs incurred from occupational injuries among smoking employees were estimated to be US$34 million. Conclusions: Financial costs caused by increased absenteeism and reduced productivity from employees who smoke are significant in Taiwan. Based on conservative estimates, total costs attributed to smoking in the workforce were approximately US$1032 million. [ABSTRACT FROM AUTHOR]

Objective: To assess the mortality risks from injuries for smokers and ex-smokers and to quantify the mortality burden of smoking from injury in Taiwan. Methods: Smokers' (and ex-smokers') mortality risks from injuries were compared with that of non- smokers in a merged cohort from Taiwan. A total of 64 319 male subjects were followed up for 12-18 years. Relative risks (RR) (adjusted for age and alcohol use) and 95% confidence intervals (Cl) for cause specific injury deaths were calculated using the Cox proportional hazard model. Relative risks of injury mortality were also calculated to assess the presence of dose-response relations with daily smoking quantity. Results: Alcohol use adjusted relative mortality risks for all injuries (RR 1.69, 95% Cl 1.39 to 2.05) including those from motor vehicle accidents (RR 1.88, 95% Cl 1.44 to 2.45) and non-motor vehicle accidents (RR 1.48, 95% Cl 1.11 to 1.99) were significantly higher for smokers than non-smokers. Mortality was also increased for most subtypes of non-motor vehicle injuries including falls, fires, and job related injuries. Furthermore, these increases were dose dependent, with the heaviest smokers having the highest risk and the lightest smokers the lowest risk, and ex-smokers, no increase. In 2001, over one fifth (23%) of all male injury deaths in Taiwan was associated with smoking. Conclusion: This study demonstrated the significant association between fatal injuries and smoking. This relation adds further weight to smoking cessation campaigns. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of smoking disparities on health disparities, in terms of gap in life expectancy, in Taiwan cities and counties. Methods: Using she decomposition method of life expectancy, the contribution of each disease category to the life expectancy gap was quantitatively expressed as the number of years of life. The smoking attributable fraction (SAF) was calculated for each city and county based on their respective smoking prevalence and relative risk for each smoking related disease. The smoking attributable gap (SAG) in life expectancy between two sites is the sum of the difference in SAF between two sites for each smoking related disease multiplied by the number of years this disease contributed to the life expectancy gap. Results: Significant health and smoking disparities were present among the 23 cities and counties in Taiwan. These health disparities and smoking disparities were highly correlated (R2 = 0.3676). Generally, the health gap increased with increasing smoking disparity. The disparity in smoking prevalence and intensity among cities and counties in Taiwan was responsible for up to 19% of the health disparity. The health disparity is also highly correlated (R2 = 0.3745) with SAG in life expectancy. Conclusions: Reducing smoking is important to health, and reducing the smoking disparity is also important for reducing the health disparity observed in Taiwan. The larger the health disparity is, the more important the smoking attributable disparity could be. The reduction of smoking disparities could be a realistic and cost effective way toward reducing health disparities. [ABSTRACT FROM AUTHOR]

Objective: To describe the characteristics of betel quid chewers and to investigate the behavioral and mortality relations between betel quid chewing and cigarette smoking. Method: Prevalence and mortality risks of betel quid chewers by smoking status were calculated, based on the National Health Interview Survey in 2001 and community based cohort, respectively. Cox's proportional hazards model was used to adjust mortality risks for age, alcohol use, and education. Results: Almost all betel quids chewers were smokers, and most started chewing after smoking. Chewers were predominantly male, mostly in their 30s and 40s, more likely being among the lowest educational or income group, and residing in the eastern regions of Taiwan. On average, betel quid chewers who smoked consumed 18 pieces of betel quid a day, and smoked more cigarettes per day. Far more smokers (15% v 6.8%). The significantly increased mortality of betel quid users who also smoked, for all causes, all cancer, oral cancer, and cancer of the nasopharynx, lung and liver, was the result of the combined effects of chewing and smoking. Smokers who chewed betel quid nearly tripled their oral cancer risks from a relative risk of 2.1 to 5.9. Increasing the number of cigarettes smoked among betel quid chewers was associated with a synergistic effect, reflective of the significant interaction between the two. Conclusion: To a large extent, the serious health consequences suffered by betel quid chewers were the result of the combined effects of smoking and chewing. Betel quid chewing should not be considered as an isolated issue, but should be viewed conjointly with cigarette smoking. Reducing cigarette smoking serves as an important first step in reducing betel quid chewing, and incorporating betel quid control into tobacco control may provide a new paradigm to attenuate the explosive increase in betel quid use in Taiwan. [ABSTRACT FROM AUTHOR]

Objectives: To assess parental influence on smoking behaviour by high school students in an Asian culture and to compare the relative importance of parental and peer influence. Methods: A 5% nationally representative sample, including 44 976 high school students in 10th to 12th grade (aged 15-18 years) in Taiwan, were surveyed in 1995. Each completed a long self administered questionnaire. Parental influence was measured by examining both parental behaviour (smoking status) and altitudes (perceived "tender loving care" (TLC) by adolescents). Changes in smoking status were used to determine peer influence, defined as the increase in the likelihood of smoking from grade 10 to 12 in a steady state environment. Odds ratios (ORs) were calculated For parental and peer influence, using logistic regression. Results: Adolescents of smoking parents with low TLC had the highest smoking rates and those of non- smoking parents with high TLC had the lowest. The difference was more than twofold in boys and more than fourfold in girls. When either parental smoking status or TLC alone was considered, parental influence was similar to peer influence in boys, but larger than peer influence in girls. However, when smoking status and TLC were considered jointly, it became larger than peer influence for both groups (OR 2.8 vl.8 for boys and OR 3.9 v 1.3 for girls). Conclusion: When parental influence is taken as parental behaviour and attitude together, it plays a more important role than peer influence in smoking among high school students in Taiwan. This study, characterising such relationships among Asian populations For the first time, implies that future prevention programmes should direct more efforts toward the parental smoking and parent-child relationships, and not aim exclusively at adolescents in schools. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of the opening of the Taiwanese cigarette market on cigarette consumption, changes in market share, and the effects on tobacco control efforts. Methods: With the use of key word "Taiwan", the Legacy Tobacco Documents Library of the University of California, San Francisco, was searched for internal documents related to smuggling activities, promotion of light cigarettes, and market share analyses in Taiwan. Age adjusted smoking rates and cigarette and betel quid consumption before and after market opening were compared. Results: By 2000, the market share of imported cigarettes increased from less than 2% in 1986 to nearly 50%, and per capita cigarette consumption increased 15% following market opening. Because of the sharp increase in smuggling, with contraband cigarettes being as popular as legal imports, and the rapid proliferation of retail outlets, such as betel quid stalls, the market penetration by foreign tobacco companies was greater in Taiwan than among the other Super 301 Asian countries. Aggressive cigarette marketing strategies were associated with a 6% increase in adult male smoking prevalence, and with a 13% increase in the youth rate, within three years after market opening. The market opening also had an incidental effect on increasing the popularity of betel quid. Betel quid chewing has since become a major public health problem in Taiwan. Conclusion: The opening of the cigarette market in 1987 had a long lasting impact on Taiwan. It increased smoking prevalence and the market has become dominated by foreign companies. The seriousness of smuggling and its associated loss of revenue by the government, the extent of increased youth smoking and its associated future health care costs, and the increased use of betel quid and the associated doubling of oral cancer mortality rates each pose significant problems to Taiwan. However, the market opening galvanised anti-smoking sentiment and forced the government to initiate and intensify a series of tobacco control efforts. [ABSTRACT FROM AUTHOR]

Objective: To estimate the smoking attributable medical expenditures and productivity loss of people aged 35 and over in Taiwan in 2001 from a societal viewpoint. Methods: A prevalence based approach was used to estimate smoking attributable costs. Epidemiological parameters were obtained from two follow up studies and government statistics. Data on medical care utilisation and expenditure were extracted from the National Health Insurance claim data. Results: Total smoking attributable medical expenditures (SAEs) amounted to US$397.6 million, which accounted for 6.8% of the total medical expenditures for people aged 35 and over. Mean annual medical expenditures per smoker was US$70 more than that of each non-smoker. Smoking attributable years of potential life lost (YPLL) totalled to 217 761 years for males and 15 462 years for females, and the corresponding productivity loss was US$1371 million for males and US$18.7 million for females. Conclusion: Medical expenditures attributable to smoking accounted for 6.8% of the total medical expenditure of people aged 35 and over for the year 2001 in Taiwan. Corresponding YPLL and productivity loss also demand that actions be taken to fight cigarette smoking. [ABSTRACT FROM AUTHOR]

Background: While all-cause mortality is reportedly increased in preserved ratio impaired spirometry (PRISm), no remedial efforts have been suggested., Aim: To study the ability of physical activity (PA) on reducing the morality increased in PRISm patients., Design: We prospectively enrolled a cohort of Taiwanese adults from 1994 to 2018 in a health surveillance program., Methods: Mortality risks of those who were inactive were compared against those meeting the current recommendation of 150 min/week of PA. Cox proportional hazards models were used for hazard ratios and life table method was for estimating loss of life expectancy., Results: A total of 461 183 adults were enrolled. Among them, one-seventh of the cohort (65 832 or 14.3%) had PRISm, and 53.1% were inactive. Those who were inactive with PRISm had 28% increased mortality from all-cause, 45% from cardiovascular diseases (CVDs) and 67% from respiratory disease, with a 3-year reduction in life expectancy (males, 3.72 and females, 2.93). In PRISm patients who met the exercise recommendation, excess mortality was reduced by two-third, both all-cause (from 28% to 9%) and CVD (from 45% to 15%)., Conclusion: PRISm involves a large portion of general population (14.3%) and shortens life expectancy by 3 years. More than half of the subjects were physically inactive, and adherence to 150 min/week of PA was associated with a two-third reduction of excess mortality from all cause and from CVD. Recommending PA among those with PRISm might be highly beneficial, although exercise alone may not eliminate all risks associated with PRISm., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: To assess the magnitude of cigarette smuggling after the market opened in Taiwan., Methods: Review of tobacco industry documents for references to smuggling activities related to Taiwan and government statistics on seizure of smuggled cigarettes., Results: The market opening in 1987 led to an increase in smuggling. Contraband cigarettes became as available as legal ones, with only a small fraction (8%) being seized. Being specifically excluded from the market-opening, Japan entered the Taiwan market by setting up a Swiss plant as a legal cover for smuggling 10-20 times its legal quota of exports to Taiwan. Smuggling in Taiwan contributed to increased consumption of foreign brands, particularly by the young. Taiwan, not a member of the World Health Organization, was excluded from the East Asian 16-member "Project Crocodile", a regional anti-smuggling collaborative effort to implement the Framework Convention on Tobacco Control., Conclusions: Taiwan showed a sharp increase in smuggling after market liberalisation. Being excluded from the international community, Taiwan faces an uphill battle to fight smuggling alone. If Taiwan remained as its weakest link, global efforts to reduce tobacco use will be undermined, particularly for countries in the East Asian region.

This study examined mortality attributed to active and passive smoking in Taiwan for the years 1981 and 1990. It was estimated that 19,283 deaths, representing 19% of the total number of deaths in 1990 (almost one out of five deaths in Taiwan), were smoking related. On an average day, 53 people died as a result of cigarette smoking, including 13 deaths from passive smoking. More men died (14,140 deaths) from smoking-related causes than from all cancer deaths combined (13,161 deaths); 91% of lung cancer and 30% of all cancers were due to smoking. In comparison, the smoking attributable mortality was much less for women, with 5,143 deaths. In addition, almost 5,000 deaths can be attributed to passive smoking every year in Taiwan with more deaths from women than from men. The overall prevalence rates for cigarette smoking has changed little in the last 20 years; approximately 60% for men and 4% for women although a consistent increase of one million new smokers was added every decade. Among younger people, the rate increased substantially, while it dropped 10-15% among middle-aged and older persons. Smoking is the largest single source of health risk in Taiwan. It is crucial that strategies to prevent smoking initiation among young people be developed so that the most vulnerable group can receive immediate attention. Despite the recent aggressive smoking cessation campaign by the Department of Health, much work remains. In order to facilitate this work, it is therefore recommended that the government commit to a goal of smoke-free nation by the year 2010.

Mortality data of Taiwan for 1981 through 1986 were analyzed using three different statistics in order to assess the role of environmental and lifestyle factors in causing mortality variations. Infant mortality rates from different geographic regions generally correlated well with overall mortality from all ages, suggesting that there are many common risk factors affecting the entire age range of the population. The mortality rates of tobacco- and alcohol-related causes of death and cancers were much higher in males than females. A number of cancer sites, including the lung, the liver, the stomach, and the nasopharynx, showed more than twofold excesses in males. In contrast, females had a tenfold excess of genital cancer and a 33% higher rate of diabetes. With rapid industrialization, occupational hazards played an increasing role in the development of cancer and other causes of death. During the study period, fishermen showed increased risk for cancers of the stomach, the esophagus, and the liver, while construction workers had an increased risk for cancer of the esophagus. Peasants and soldiers had an elevated suicide mortality. Among apprentices, fatal injuries were high. Findings from this study are useful in setting priorities for health and safety programs and directing efforts such as health education programs and other preventive strategies against disease.

The mortality experience of Taiwan was examined for two time periods (1976 and 1983) to determine the magnitude and direction of change in age-adjusted mortality and to identify deviation from the expected progress by comparison with two industrialized nations, the USA and Japan. Between 1976 and 1983 the overall mortality showed an annual average of nearly 2% decrease, mostly contributed by the marked reduction in the number of young. Significant reductions were also observed for deaths from strokes, rheumatic heart disease, ill-defined conditions, cancer of the stomach, and infectious diseases such as tuberculosis. A disturbing increase in suicide as well as accidents primarily caused by motor vehicles was noted. In general, cancer increased, to an alarming degree for environmentally implicated cancers such as lung, pancreas, nasopharynx, brain and liver in men. When compared to that of the USA or Japan, the mortality experience of Taiwan showed the following increases: overall female mortality, accidental deaths, suicide among elderly women, deaths from strokes, ulcers, asthma, and liver, nasopharyngeal and cervical cancers. However, the overall cancer mortality rate was still much lower than that either in the USA or Japan. Despite marked reductions in infectious disease mortality, deaths from tuberculosis were nearly 40 times those of the USA. Although deaths from ill-defined conditions decreased by half during this study period, they were still high, particularly among elderly women (13% of all deaths and 22 times higher than the USA), which probably reflects inadequate medical services for women. The role of the Taiwanese government in the financing of health services was found to be far smaller than that of the USA or Japan. Expanding health care expenditure by the government is desirable if improvement in the maldistribution of medical services is to be achieved and the untoward health effects of rapid industrialization is to be reduced.