Uncovering the relation between betel quid chewing and cigarette smoking in Taiwan.

OBJECTIVE: To describe the characteristics of betel quid chewers and to investigate the behavioural 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 a 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 quid 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 use betel quid than non-smokers (27.5% v 2.5%), but ex-smokers quit betel quid more than smokers (15.1% 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.

Reducing health disparity in Taiwan: quantifying the role of smoking.

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 the 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.

Workplace smoking related absenteeism and productivity costs in Taiwan.

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 USD 178 million per annum for males and USD 6 million for females at a total cost of USD 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 USD 733 million. Increased sick leave costs due to passive smoking were approximately USD 81 million. Potential costs incurred from occupational injuries among smoking employees were estimated to be USD 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 USD 1032 million.

The impact of the cigarette market opening in Taiwan.

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.

Smoking behaviour in Taiwan, 2001.

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 environmental 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 (14.3%/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.

Mortality patterns among residents in Louisiana's industrial corridor, USA, 1970-99.

BACKGROUND: Because of the high concentration of oil refining and petrochemical facilities, the industrial area of the lower Mississippi River of South Louisiana has been termed the Industrial Corridor and has frequently been referred to as the "Cancer Corridor". AIMS: To quantitatively assess the "Cancer Corridor" controversy based on mortality data available in the public domain, and to identify potential contributing factors to the observed differences in mortality. METHODS: Age adjusted mortality rates were calculated for white and non-white males and females in the Industrial Corridor, Louisiana, and the United States for the time periods 1970-79, 1980-89, and 1990-99. RESULTS: All-cause mortality and all cancer combined for white males in the Industrial Corridor were significantly lower than the corresponding Louisiana population while Louisiana had significantly higher rates than the US population for all three time periods. Cancer of the lung was consistently higher in the Industrial Corridor region relative to national rates but lower than or similar to Louisiana. Non-respiratory disease and cerebrovascular disease mortality for white males in the Industrial Corridor were consistently lower than either Louisiana or the USA. However, mortality due to diabetes and heart disease, particularly during the 1990s, was significantly higher in the Industrial Corridor and Louisiana when compared to the USA. Similar mortality patterns were observed for white females. The mortality for non-white males and females in the Industrial Corridor was generally similar to the corresponding populations in Louisiana. There were no consistent patterns for all cancer mortality combined. Stomach cancer was increased among non-whites in both the Industrial Corridor and Louisiana when compared to the corresponding US data. Mortality from diabetes and heart disease among non-whites was significantly higher in the Industrial Corridor and Louisiana than in the USA. CONCLUSIONS: Mortality rates in the Industrial Corridor area were generally similar to or lower than the State of Louisiana, which were increased compared to the United States. Contrary to prior public perceptions, mortality due to cancer in the Industrial Corridor does not exceed that for the State of Louisiana.

An ergonomics program designed to reduce the incidence of upper extremity work related musculoskeletal disorders.

In 1992, the Johns Hopkins Hospital and University initiated a program aimed at the early diagnosis and treatment of potential upper extremity work related musculoskeletal disorders (UEWMSDs), ergonomic assessment and abatement of work areas where individuals with UEWMSDs are employed, as well as the identification and correction of areas throughout the hospital and university where UEWMSDs could possibly occur. The program resulted in an initial increase in the number and cost for the treatment of UEWMSDs. Subsequently, there was a significant decrease in the number of UEWMSDs reported and virtual elimination of the need to use surgical procedures to correct these conditions. This article suggests that a coordinated program of medical care, ergonomic assessment, and intervention can be efficacious in the primary, secondary, and tertiary prevention of UEWMSD.

Managed care for workers' compensation: three years of experience in an "employee choice" state.

Managed care techniques are becoming increasingly available to manage the medical indemnity losses associated with injuries paid for under the workers' compensation system. The authors describe 3 years' experience of identifying and abating workplace hazards and medically managing cases utilizing a preferred provider organization established solely for workers' compensation cases. In the model described, the occupational physician/nurse case-management team coordinates the entire process, from prevention of accidents to facilitated return to work. During the study period (1992 to 1995), per-capita losses were reduced by 23%, from $241 in fiscal year 1992 (the year before the managed care initiative), to $185 in fiscal year 1995. (Hereafter, each year referred to indicates that fiscal year.) In 1992, 22 lost-time cases per 1000 employees occurred, whereas the number of lost-time cases in the years 1993 to 1995 averaged 12 to 14 per 1000 employees. The rate of "medical only" cases dropped significantly from 155 per 1000 in 1992 to 96 per 1000 in 1995. The per-capita amount of monies spent on medical care decreased from $81 in 1992 to $63 in 1995. The most significant savings in medical costs related to claims associated with new occupational injuries, injuries that occurred during the fiscal year. In 1992, the per-capita loss on such cases was $23 and in 1995 it was $13, a 43% decrease. The number of temporary/total days dropped significantly from 163 per 100 employees in 1992 to 70 days in 1995. Concurrently, the per-capita loss for temporary total disability was reduced from $53 in 1992 to $26 in 1995. Per-capita administrative costs, as well as other indemnity losses (predominantly permanent partial disability), decreased only slightly over the study period ($58 to $54 and $60 to $51, respectively). We feel that these results indicate that environmental-risk management and medical-care management can be integrated to produce substantial savings. It also suggest that managed-care techniques, which are becoming more available to employers, can even be applied in status that do not have managed care legislation.

A comprehensive initiative to manage the incidence and cost of occupational injury and illness. Report of an outcomes analysis.

A comprehensive initiative utilizing an in-house preferred provider organization, medical case management, and application of ergonomic techniques was implemented in an effort to control the incidence and cost of workplace injuries. The program was evaluated utilizing OSHA 200 Logs to compare the incidence and lost time due to compensable injury and illnesses before and after beginning the program. After the introduction, there was a significant decrease in injuries and illnesses (53/1000 vs 27/1000, P<.01) and average days lost per event (10.4 vs 6.6 days, P<.01). A significant increase in restricted-duty days (.2 vs 1.5 days, P<.01) and an 18% reduction in medical and indemnity costs of the institution's workers' compensation expenditures were observed. This study demonstrates the initial effectiveness of an aggressive ergonomic and managed care approach to reducing the incidence, severity, and cost of occupationally related injury and illness. It also highlights the effectiveness of an outcomes analysis approach, using lost time as an end point, to measure the effectiveness of preventive and management strategies in the workers' compensation setting.

A cohort mortality study of two California refinery and petrochemical plants.

This study examined the 1973 to 1989 mortality experience of Shell's two California manufacturing locations' employees who worked more than 6 months before December 31, 1989 and pensioners who were alive as of January 1, 1973. Vital status of each employee as of December 31, 1989 was determined from various sources including company records, the National Death Index, and the Social Security Administration's Master Beneficiary Record file. The study included many long-term employees, with more than half (57%) of the total population working 20 years or longer. The total population exhibited 11% lower all causes mortality and 20% lower cancer mortality, as compared with the California general population. There were no significant excesses of any cause-specific mortality including cancer. Among total employees, mortality for several cancer sites showed a statistically nonsignificant increase, for example, cancer of the kidney (8 observed deaths and 6.02 expected), cancer of the bladder (11 observed deaths and 9.17 expected), and Hodgkin's disease (2 observed deaths and 1.01 expected). A review of these work histories revealed no predominant work area or job assignment. In contrast to the ecologic studies based on local county rates, lung cancer mortality in this study was significantly lower (Standardized Mortality ratio [SMR] = 0.73). In addition, statistically significant deficits in mortality were found for cirrhosis of the liver (SMR = 0.63) and all external causes of death (SMR = 0.74). This study also failed to show an increased mortality rate for cancers of the brain, stomach, and prostate--causes which have been reported to be elevated in other refinery and petrochemical employee studies.

Mortality experience in a rapidly developing economy in Taiwan: infant mortality, gender gap, and occupational risks.

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.

Health care utilization and costs for injury in a corporate setting.

This article presents the incidence and costs for non-work-related injuries among 15,408 employees and their families based on health insurance claims data analysis. The treatment of injuries accounted for 11.3% of the plan's total health care costs ($31 million) for the 1986 policy year. For adults, women had a higher incidence rate than men; but for children, males had a higher incidence rate than females. A disproportionately high share of claims and charges for adults were attributed to low back disorders. Hospital admissions, length of stay and hospital days per 1,000 persons were similar for males and females, but much higher for adults than for children. This article provides an example of the utility of health insurance claims data as a source of morbidity information for disease surveillance and epidemiologic research. The analysis of claims data can be seen as a prerequisite to the development of preventive programs aimed at reducing injury rates and health care costs for injuries in a corporate setting.

Mortality trend in a rapidly developing economy in Taiwan. Part II: Life expectancy and "potential years of life lost".

Taiwan has made remarkable economic progress in the last 30 years. The life expectancy of its population improved steadily during this period. A male child born in 1983 could look forward to 70.4 years of life and a female child to 75.3 years, gains of 17.5 years and 19.0 years, respectively, since 1950. The potential gains in life expectancy of the Taiwan population are also examined if the five leading causes of death are reduced or eliminated. In addition, this paper discusses the concept of potential productive years of life lost (PYLL), examines the leading causes of premature death and shows how this measure can be used to target prevention programs and health care planning.

PIP: Researchers analyzed 1983 vital statistics for Taiwan using the life table analysis and calculating the potential years of life lost (PYLL) to identify life shortening features of several major causes of death and examine the preventability of premature mortality. Life expectancy for males was 69.9 years whereas for females it was 75.1 years. these corresponding life expectancies for Japan were 73.8 years and 79.6 years and 71.7 years and 78.7 years for the US. Between 1950-1983, life expectancy at birth in Taiwan increased 17.5 years for males and 19 years for females. In 1983, the cumulative total of PYLL before age 70 for males was 737,205 compared to 353,780 years for females. Thus loss of productivity of males was 2 times that of females. Most of this loss was a result of accidents. In fact, they contributed to 37.2% of PYLL for males and 24.9% of PYLL for females. Even though accidents were also the leading cause for the most PYLL in Japan and the US (17.4% and 8.7% respectively in Japan and 25% for both sexes combined in the US), the magnitude was considerably lower than that of Taiwan. Further the type of accidents males were more likely to die from were motor vehicle accidents (18,8% vs. 18.4% for home and workplace accidents). On the other hand, women were more likely to die from home and workplace accidents(14% vs. 10%). The 2nd major cause for the most PYLL was all cancers, except liver cancer, (15.9% for males and 20.4% for females). The 3rd major cause for the most PYLL for males was liver disease (liver cancer and cirrhosis of the liver) (9.6%) while for females it was stroke (8.7%). Further suicides contributed to 6.5% of PYLL for females. IN conclusion, Taiwan should place accident prevention as a high priority since it needs limited resources and is more achievable than that of cancer elimination. The next level of preventive efforts should include stroke and suicide.

Incidence and cost of injury in an industrial population.

Using both occupational (workers' compensation) and non-occupational (group health insurance) data, the nature and magnitude of injuries were determined in a working population of 20,705. Approximately one third of the population sustained an injury in 1986 (the year of study). Men experienced a significantly higher injury rate than women (33.3 per 100 v 24.9 per 100) and hourly employees had significantly higher incidence rates than salaried employees (42.0 per 100 v 22.5 per 100). The majority of nonoccupational injury claims were for low back disorders, whereas most occupational injury claims were related to superficial wounds and contusions. Overall, the incidence of nonoccupational injuries (21.1 per 100) was twofold higher than that of occupational injuries (10.8 per 100). Total costs for occupational and nonoccupational injuries were $4.97 million. The per-capita costs were $120 for both nonoccupational and occupational injuries. However, if only health care expenses are included in this calculation, nonoccupational injury costs would be almost 3 times as high as occupational injury costs ($120 v $46). These findings argue for increasing the share of corporate resources for off-the-job injury prevention programs aimed at reducing injury incidence and resultant health care costs.

Mortality trends in a rapidly developing economy in Taiwan. Part I: Comparison with the USA and Japan 1976-1983.

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.

Participation in a periodic physical examination program and group health care utilization and costs.

The authors identified 710 male employees of a multinational US corporation eligible to take periodic physical examinations for a consecutive 3-year period (1983 to 1985) and insured by one of the company's health insurers. Group health insurance claims rates and costs for the calendar year 1985 were studied among executives who did not take an examination during the study period, those who took it once or twice, and those who took it all 3 years. Health care utilization for those who did not participate in the program was significantly lower than both groups of participants. Average claim costs in 1985 among those who participated all 3 years ($1,039) was 1.77 times the cost of those who participated one or two times ($588) and 2.30 times the cost of those who did not participate ($452). We conclude that short-term health care utilization and costs are higher among participants than non-participants of a periodic physical examination program.

Injury prevalence and associated costs among participants of an employee fitness program.

The prevalence, cost, and type of injury among participants of an employee fitness program and nonexercising co-workers were studied over a 2-year period from 1984 to 1985. The purpose of the study was to determine whether participants of an employee fitness program (n = 2,871) experienced a greater risk of injury and resultant higher costs than nonparticipants (n = 3,233). Overall, there were no significant differences in the rate or cost of injuries among the various participation levels (from 0 to 3 or more times per week). However, the data indicated that individuals who occasionally participated in the fitness program experienced a greater, but nonsignificant, risk of injury (6.3 per 100 persons who exercised less than 1 session per week, and 7.7 per 100 persons who exercised 1-2 sessions per week) than nonparticipants (5.7 per 100 persons). Injury prevalence was lower among individuals who exercised 3 or more sessions per week (5.4 per 100 persons) as was the resultant per capita cost of injuries ($32 vs $42 for nonparticipants). We conclude the impact of exercise at an onsite health and fitness facility on overall injury rates and costs among employees is negligible.

Obesity and morbidity prevalence in a working population.

As part of ongoing medical surveillance, the morbidity prevalence for obese individuals (20% to 40% and greater than 40% overweight) was compared with non-obese corporate employees utilizing group health insurance claims data for 1985. The advantages of claims data as a potential source of morbidity data for disease surveillance and research are discussed herein. The expected finding of a positive association between hypertension (P less than .05) and obesity noted for both male and female employees reiterates the important role of work site weight control programs in reducing hypertension. The positive association between prevalence of mental health disorders and obesity demonstrates the need to address the adverse psychologic risks of obesity in addition to the adverse physical risks. This finding suggests that employee assistance programs emphasize counseling services for obese individuals.

Effect of curtailed insurance benefits on use of mental health care. The Tenneco health plan.

This article presents the impact of a health insurance benefit redesign on utilization and costs for mental health care in a large corporation. The design change primarily limited coverage to 45 days of hospitalization and 20 outpatient visits. Group health insurance data before and after the benefit changes (effective January 1, 1984) were compared and analyzed. Per capita charges for mental health care between 1983 and 1985 decreased by 41%, from $89 to $53. Responses to the benefit modifications differed for inpatient and outpatient services. Inpatient costs and length of stay decreased dramatically, especially for dependents, while utilization rates remained about the same. Statistically significant increases occurred for outpatient care utilization and costs.