Reducing health disparity in Taiwan: quantifying the role of smoking

Smoking Paradox in Stroke Survivors?: Uncovering the Truth by Interpreting 2 Sets of Data

Background and Purpose- The observation that smokers with stroke could have better outcome than nonsmokers led to the term "smoking paradox." The controversy of such a complex claim has not been fully settled, even though different case mix was noted. Analyses were conducted on 2 independent data sets to evaluate and determine whether such a paradox truly exists. Methods- Taiwan Stroke Registry with 88 925 stroke cases, and MJ cohort with 541 047 adults participating in a medical screening program with 1630 stroke deaths developed during 15 years of follow-up (1994-2008). Primary outcome for stroke registry was functional independence at 3 months by modified Rankin Scale score ≤2, for individuals classified by National Institutes of Health Stroke Scale score at admission. For MJ cohort, mortality risk by smoking status or by stroke history was assessed by hazard ratio. Results- A >11-year age difference in stroke incidence was found between smokers and nonsmokers, with a median age of 60.2 years for current smokers and 71.6 years for nonsmokers. For smokers, favorable outcome in mortality and in functional assessment in 3 months with modified Rankin Scale score ≤2 stratified by the National Institutes of Health Stroke Scale score was present but disappeared when age and sex were matched. Smokers without stroke history had a ≈2-fold increase in stroke deaths (2.05 for ischemic stroke and 1.53 for hemorrhagic stroke) but smokers with stroke history, 7.83-fold increase, overshadowing smoking risk. Quitting smoking at earlier age reversed or improved outcome. Conclusions- "The more you smoke, the earlier you stroke, and the longer sufferings you have to cope." Smokers had 2-fold mortality from stroke but endured stroke disability 11 years longer. Quitting early reduced or reversed the harms.

Analysis of influential factors associated with the smoking behavior of aboriginal schoolchildren in remote Taiwanese mountainous areas

BACKGROUND

A disparity in smoking behavior exists between the general and minority populations residing in Taiwan's mountainous areas. This study analyzed individual and environmental factors associated with children's smoking behavior in these areas of Taiwan.

METHODS

In this school-based study, data on smoking behavior and related factors for mountain-dwelling students were obtained from the 2008 and 2009 Control of School-aged Children Smoking Study surveys. A representative sample (N = 1239) from 26 primary schools was included. The association among 3 groups (never-, former-, and current-smokers) and the potential variables were simultaneously examined using unordered polytomous logistic regression analysis.

RESULTS

Between 13% and 34% of ever-smokers reported that their first smoking experience was in third grade. More than 70% were found to have bought cigarettes and 87% reported that the tobacco retailers had sold them cigarettes. The significant factors for current-smokers were predisposing factors, ie, attitude toward smoking (adjusted odds ratio [AOR] = 1.21); reinforcing factors, ie, family smoked in front of me (AOR = 2.44), friends smoked in front of me (AOR = 16.24), and school staff smoked in front of me (AOR = 2.98); and enabling factors, ie, cigarette availability and accessibility (AOR = 2.16 and 2.42, respectively). A student's perceived punishment for smoking at school had a positive significant effect on the risk of being former-smokers (AOR = 1.57).

CONCLUSION

The findings provide a basis for school and community to design and implement effective anti-smoking programs for remote mountain-based students to further reduce youth smoking.

A study of smoking disparity and factors associated with children smoking behavior in the mountain and city schools in Taiwan

BACKGROUND

While higher smoking prevalences have been better described for adults and adolescents in the mountainous areas than in the plain area in Taiwan, no studies have previously examined whether this disparity begins with children in elementary schools. The purpose of this study was thus designed to explore clustering in smoking behavior among elementary school children attending mountain schools compared to those attending city schools.

METHODS

This study analyzed data obtained by a survey on smoking behavior collected during the School Smoking Survey Project performed in 13 elementary schools of Taoyuan County, Taiwan. Overall, 1585 third and fourth graders (mean age 8.9 years) participated in the study. A multilevel logistic regression analysis was performed to explore the effects of school location on individual smoking behavior among elementary school children while controlling for individual-level characteristics.

RESULTS

Overall, 34.9% of the elementary school students in the mountain schools reported having tried cigarette smoking compared to only 9.6% of students from city schools. Students attending mountain schools had a greater likelihood of reporting smoking than students attending city schools after controlling for individual-level characteristics (OR = 2.57, 95% CI = 1.10-5.99).

CONCLUSIONS

A significant individual clustering in smoking behavior was found among third- and fourth-grade children attending mountain schools. The new findings suggest that the adult geographic smoking disparity begins in elementary school. Interventions aimed at reducing smoking disparity in adults need to target elementary schools in high-risk locations.

All-cause mortality attributable to chronic kidney disease: a prospective cohort study based on 462 293 adults in Taiwan

BACKGROUND

Both end-stage renal disease and chronic kidney disease are increasing worldwide; however, the full effect of chronic kidney disease is unknown because mortality risks for all five stages are unavailable. We assessed prevalence and mortality risks for all stages of chronic kidney disease and quantified its attributable mortality in Taiwan.

METHODS

The cohort consisted of 462 293 individuals aged older than 20 years who participated in a standard medical screening programme since 1994. As of Dec 31, 2006, we identified 14 436 deaths. Chronic kidney disease was determined by glomerular filtration rate and urinary protein. We estimated national prevalence in Taiwan from the cohort by adjusting age and educational levels. Hazard ratios (HRs) were calculated with Cox proportionate hazards model. We calculated mortality attributable to chronic kidney disease for national population and for low socioeconomic status.

FINDINGS

The national prevalence of chronic kidney disease was 11.93% (95% CI 11.66-12.28), but only 3.54% (3.37-3.68) of participants in the cohort were aware of their disorder. Prevalence was substantially higher in the group with low socioeconomic status than in the high status group (19.87% [19.84-19.91] vs 7.33% [7.31-7.35]). 56 977 (12%) of cohort participants had chronic kidney disease; those with disease had 83% higher mortality for all cause (HR 1.83 [1.73-1.93]) and 100% higher for cardiovascular diseases (2.00 [1.78-2.25]), in a cohort that was observed for 13 years with median follow-up of 7.5 years (IQR 4.0-10.1). 10.3% (95% CI 9.57-11.03) of deaths in the entire population were attributable to chronic kidney disease, but 17.5% (16.27-18.67) of deaths in the low socioeconomic status population. 2350 (39%) deaths occurred before 65 years of age in those with chronic kidney disease. Regular users of Chinese herbal medicines had a 20% (odds ratio 1.20 [1.16-1.24]) increased risk of developing chronic kidney disease.

INTERPRETATION

The high prevalence of chronic kidney disease and its associated all-cause mortality, especially in people with low socioeconomic status, make reduction of this disorder a public-health priority. Promotion of its recognition through the general public knowing their glomerular filtration rate and testing their urine is crucial to reduce premature deaths from all causes and to attenuate this global epidemic.

A multilevel analysis of neighborhood and individual effects on individual smoking and drinking in Taiwan

Background

We assessed direct effects of neighborhood-level characteristics and interactive effects of neighborhood-level characteristics and individual socioeconomic position on adult smoking and drinking, after consideration of individual-level characteristics in Taiwan.

Methods

Data on individual sociodemographic characteristics, smoking, and drinking were obtained from Taiwan Social Change Survey conducted in 1990, 1995, and 2000. The overall response rate was 67%. A total of 5883 women and men aged over 20 living in 434 neighborhoods were interviewed. Participants' addresses were geocoded and linked with Taiwan census data for measuring neighborhood-level characteristics including neighborhood education, neighborhood concentration of elderly people, and neighborhood social disorganization. The data were analyzed with multilevel binomial regression models.

Results

Several interaction effects between neighborhood characteristics and individual socioeconomic status (SES) were found in multilevel analyses. Our results indicated that different neighborhood characteristics led to different interaction patterns. For example, neighborhood education had a positive effect on smoking for low SES women, in contrast to a negative effect on smoking for high SES women. This result supports the hypothesis of "relative deprivation," suggesting that poor people living in affluent neighborhoods suffer from relative deprivation and relative standing. On the other hand, neighborhood social disorganization has positive effects on drinking for low SES individuals, but not for high SES individuals. These interactive effects support the hypothesis of the double jeopardy theory, suggesting that living in neighborhoods with high social disorganization will intensify the effects of individual low SES.

Conclusion

The findings of this study show new evidence for the effects of neighborhood characteristics on individual smoking and drinking in Taiwan, suggesting that more studies are needed to understand neighborhood effects in Asian societies.