Author Correction: Personalized Risk Assessment in Never, Light, and Heavy Smokers in a prospective cohort in Taiwan.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Tobacco control within and beyond WHO MPOWER: outcomes from Taiwan SimSmoke.

INTRODUCTION: Adult smoking prevalence in Taiwan rapidly declined from 26.5% in 2005 to 20.0% in 2015. Nevertheless, future projections on smoking-attributable deaths and current per capita consumption do not paint an equally bright picture. METHODS: We used SimSmoke, a tobacco control simulation model to assess the impact of tax increases and other policies by predicting past and projecting over future decades smoking rates and smoking-attributable mortality. RESULTS: The model accurately depicts the decline in smoking prevalence observed in Taiwan from 2000 to 2015. Nonetheless, under the 'status quo' scenario, smoking-attributable mortality is projected to continue growing, peaking at 26 602 annual deaths in 2039 and cumulative deaths >1 million by 2044. By comparing projections with current policies with a counterfactual scenario based on the 2000 policy levels, SimSmoke estimates that tobacco control in Taiwan has been able to reduce smoking prevalence by 30% in 2015 with 450 000 fewer smoking-attributable deaths by 2060. Modified scenarios show that doubling the retail price of cigarettes and fully implementing the remaining MPOWER measures would avert approximately 45 000 lives by 2040 and 130 000 by 2060. CONCLUSIONS: Tobacco will be a leading cause of death in Taiwan for the coming decades, showing yet again the long-term consequences of smoking on public health. The MPOWER package, even if adopted at the highest level with a large tax increase, is unlikely to reduce smoking prevalence to the endgame goal of 5% in the next five decades.

Air pollution is not 'the new smoking': comparing the disease burden of air pollution and smoking across the globe, 1990-2017.

Air pollution has been labelled the 'new smoking', with news articles bearing titles such as 'If You Live in a Big City You Already Smoke Every Day' and 'The Air Is So Bad in These Cities, You May As Well Be Smoking'. Dr Tedros Adhanom Ghebreyesus, WHO Director-General, highlighted this attention-catching comparison, saying, 'The world has turned the corner on tobacco. Now it must do the same for the 'new tobacco' - the toxic air that billions breathe every day' and 'Globally, with smoking on the decline, air pollution now causes more deaths annually than tobacco' at the First Global Conference on Air Pollution and Health in 2018. The suggestion that the world has turned the corner on tobacco control and the reference to air pollution as the 'new smoking' raise a number of concerns. We generate outputs from GBD Compare (the online data visualisation tool of the Global Burden of Diseases and Injuries (GBD) Study) to demonstrate historical disease burden trends in terms of disability-adjusted life years and age-standardised mortality attributable to air pollution and tobacco use from 1990 to 2017 across the globe. We find that the disease burden caused by ambient air pollution declined significantly faster than the burden caused by tobacco use. We conclude that the world is still far from turning the corner on the tobacco endemic. Further, the suggestion that air pollution is as bad as actual smoking is not only inaccurate but also potentially dangerous to public health.

Exploiting a low tax system: non-tax-induced cigarette price increases in Taiwan 2011-2016.

INTRODUCTION: This study aims to analyse the non-tax-induced price increasing strategies adopted by tobacco industry in Taiwan, a high-income country with comprehensive tobacco control policies but low tobacco taxes and a declining cigarette market. METHODS: Using governmental tax, price and inflation data, we analysed cigarette sales volume, affordability, affordability elasticity of demand, market share, pricing and net revenue of the top five tobacco companies in Taiwan from 2011 to 2016 when no tax increases occurred. RESULTS: Total revenue after tax grew significantly for all the major transnational tobacco companies between 2011 and 2016 at the expense of the state-owned Taiwan Tobacco and Liquor Corporation. In terms of market share, Japan Tobacco (JT) was the leading company, despite experiencing a small decline, while British American Tobacco and Imperial Brands remained stable, and Philip Morris International increased from 4.7% to 7.0%. JT adopted the most effective pricing strategy by increasing the real price of its two most popular brands (Mevius and Mi-Ne) and, at the same time, doubling the sales of its cheaper and less popular brand Winston by leaving its nominal retail price unaltered. CONCLUSIONS: Low and unchanged tobacco taxes enable tobacco companies to use aggressive pricing and segmentation strategies to increase the real price of cigarettes without making them less affordable while simultaneously maintaining customers' loyalty. It is crucial to continue monitoring the industry's pricing strategies and to regularly increase taxes to promote public health and to prevent tobacco industry from profiting at the expense of government revenues.

Personalized Risk Assessment in Never, Light, and Heavy Smokers in a prospective cohort in Taiwan.

The objective of this study was to develop markedly improved risk prediction models for lung cancer using a prospective cohort of 395,875 participants in Taiwan. Discriminatory accuracy was measured by generation of receiver operator curves and estimation of area under the curve (AUC). In multivariate Cox regression analysis, age, gender, smoking pack-years, family history of lung cancer, personal cancer history, BMI, lung function test, and serum biomarkers such as carcinoembryonic antigen (CEA), bilirubin, alpha fetoprotein (AFP), and c-reactive protein (CRP) were identified and included in an integrative risk prediction model. The AUC in overall population was 0.851 (95% CI = 0.840-0.862), with never smokers 0.806 (95% CI = 0.790-0.819), light smokers 0.847 (95% CI = 0.824-0.871), and heavy smokers 0.732 (95% CI = 0.708-0.752). By integrating risk factors such as family history of lung cancer, CEA and AFP for light smokers, and lung function test (Maximum Mid-Expiratory Flow, MMEF25-75%), AFP and CEA for never smokers, light and never smokers with cancer risks as high as those within heavy smokers could be identified. The risk model for heavy smokers can allow us to stratify heavy smokers into subgroups with distinct risks, which, if applied to low-dose computed tomography (LDCT) screening, may greatly reduce false positives.

Physical activity to overcome the adversity of widowhood: Benefits beyond physical health.

Widowhood has been increasingly encountered because of increasing longevity of women, often characterized by social stigmatization and poor physical and mental health. However, applied research to overcome its adversity has been quite limited. The goal of this study is to explore the role of physical activity in improving the health of widows.A cohort of 446,582 adults in Taiwan who successively participated in a comprehensive medical screening program starting in 1994, including 232,788 women, was followed up for mortality until 2008. Each individual provided detailed health history, and extensive lab tests results.The number of widows increased with time trend. Every other woman above age 65 was a widow (44%). Widows were less active, more obese, and smoked and drank more, had sleep problems, were more depressed with taking sedatives or psychoactive drugs, leading to more suicides. In the global development of health policies by World Health Organization (WHO), physical activity is one of the main factors to reverse poor health. The poor health of inactive widow was mitigated when becoming fully active in this study. Exercise not only reduced the observed 18% increase in all-cause mortality, but also gained 4 years and as much as 14% mortality advantage over the married but inactive. More importantly, becoming physically active energized their mental status, improved sleep quality and quantity, reduced depressions and the need for psychoactive drugs, and increased socialization circles.Widows, a rapidly growing and socially stigmatized group, suffered from social and financial inequality and tended to develop poorer health. Sustained physical activity could be one of the ways for them to overcome and reverse some of the physical and mental adversities of widowhood, and improve their quality and quantity of life.

Chronic kidney disease and cardiovascular risk: epidemiology, mechanisms, and prevention.

Since the first description of the association between chronic kidney disease and heart disease, many epidemiological studies have confirmed and extended this finding. As chronic kidney disease progresses, kidney-specific risk factors for cardiovascular events and disease come into play. As a result, the risk for cardiovascular disease is notably increased in individuals with chronic kidney disease. When adjusted for traditional cardiovascular risk factors, impaired kidney function and raised concentrations of albumin in urine increase the risk of cardiovascular disease by two to four times. Yet, cardiovascular disease is frequently underdiagnosed and undertreated in patients with chronic kidney disease. This group of patients should, therefore, be acknowledged as having high cardiovascular risk that needs particular medical attention at an individual level. This view should be incorporated in the development of guidelines and when defining research priorities. Here, we discuss the epidemiology and pathophysiological mechanisms of cardiovascular risk in patients with chronic kidney disease, and discuss methods of prevention.

Comparison of risk prediction using the CKD-EPI equation and the MDRD study equation for estimated glomerular filtration rate.

CONTEXT: The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation more accurately estimates glomerular filtration rate (GFR) than the Modification of Diet in Renal Disease (MDRD) Study equation using the same variables, especially at higher GFR, but definitive evidence of its risk implications in diverse settings is lacking. OBJECTIVE: To evaluate risk implications of estimated GFR using the CKD-EPI equation compared with the MDRD Study equation in populations with a broad range of demographic and clinical characteristics. DESIGN, SETTING, AND PARTICIPANTS: A meta-analysis of data from 1.1 million adults (aged ≥ 18 years) from 25 general population cohorts, 7 high-risk cohorts (of vascular disease), and 13 CKD cohorts. Data transfer and analyses were conducted between March 2011 and March 2012. MAIN OUTCOME MEASURES: All-cause mortality (84,482 deaths from 40 cohorts), cardiovascular mortality (22,176 events from 28 cohorts), and end-stage renal disease (ESRD) (7644 events from 21 cohorts) during 9.4 million person-years of follow-up; the median of mean follow-up time across cohorts was 7.4 years (interquartile range, 4.2-10.5 years). RESULTS: Estimated GFR was classified into 6 categories (≥90, 60-89, 45-59, 30-44, 15-29, and <15 mL/min/1.73 m(2)) by both equations. Compared with the MDRD Study equation, 24.4% and 0.6% of participants from general population cohorts were reclassified to a higher and lower estimated GFR category, respectively, by the CKD-EPI equation, and the prevalence of CKD stages 3 to 5 (estimated GFR <60 mL/min/1.73 m(2)) was reduced from 8.7% to 6.3%. In estimated GFR of 45 to 59 mL/min/1.73 m(2) by the MDRD Study equation, 34.7% of participants were reclassified to estimated GFR of 60 to 89 mL/min/1.73 m(2) by the CKD-EPI equation and had lower incidence rates (per 1000 person-years) for the outcomes of interest (9.9 vs 34.5 for all-cause mortality, 2.7 vs 13.0 for cardiovascular mortality, and 0.5 vs 0.8 for ESRD) compared with those not reclassified. The corresponding adjusted hazard ratios were 0.80 (95% CI, 0.74-0.86) for all-cause mortality, 0.73 (95% CI, 0.65-0.82) for cardiovascular mortality, and 0.49 (95% CI, 0.27-0.88) for ESRD. Similar findings were observed in other estimated GFR categories by the MDRD Study equation. Net reclassification improvement based on estimated GFR categories was significantly positive for all outcomes (range, 0.06-0.13; all P < .001). Net reclassification improvement was similarly positive in most subgroups defined by age (<65 years and ≥65 years), sex, race/ethnicity (white, Asian, and black), and presence or absence of diabetes and hypertension. The results in the high-risk and CKD cohorts were largely consistent with the general population cohorts. CONCLUSION: The CKD-EPI equation classified fewer individuals as having CKD and more accurately categorized the risk for mortality and ESRD than did the MDRD Study equation across a broad range of populations.

Recent mortality from pleural mesothelioma, historical patterns of asbestos use, and adoption of bans: a global assessment.

BACKGROUND: In response to the health risks posed by asbestos exposure, some countries have imposed strict regulations and adopted bans, whereas other countries have intervened less and continue to use varying quantities of asbestos. OBJECTIVES: This study was designed to assess, on a global scale, national experiences of recent mortality from pleural mesothelioma, historical trends in asbestos use, adoption of bans, and their possible interrelationships. METHODS: For 31 countries with available data, we analyzed recent pleural mesothelioma (International Classification of Diseases, 10th Revision) mortality rates (MRs) using age-adjusted period MRs (deaths/million/year) from 1996 to 2005. We calculated annual percent changes (APCs) in age-adjusted MRs to characterize trends during the period. We characterized historical patterns of asbestos use by per capita asbestos use (kilograms per capita/year) and the status of national bans. RESULTS: Period MRs increased with statistical significance in five countries, with marginal significance in two countries, and were equivocal in 24 countries (five countries in Northern and Western Europe recorded negative APC values). Countries adopting asbestos bans reduced use rates about twice as fast as those not adopting bans. Turning points in use preceded bans. Change in asbestos use during 1970-1985 was a significant predictor of APC in mortality for pleural mesothelioma, with an adjusted R(2) value of 0.47 (p < 0.0001). CONCLUSIONS: The observed disparities in global mesothelioma trends likely relate to country-to-country disparities in asbestos use trends.

Assessing physical activity in an Asian country: low energy expenditure and exercise frequency among adults in Taiwan.

Leisure-time physical activity (LTPA) has been closely related to health improvement. The under-appreciation for energy output by nutritionists stems in part from limited data expressed in caloric equivalent. We converted the frequency, duration, and intensity of LTPA, reported from 15,390 adults in the Taiwan National Health Interview Survey 2001, into kilocalories (kcal). Half of Taiwanese adults admit to no LTPA. Women, lower education or income, younger age, smokers and chewers of betel quid; exercised significantly less than their counterparts. Less than 1/5 (18.9%) of the population in Taiwan was physically active at >or=750 kcal/week, and only 1/7 (13.9%) reached a more desirable goal of >or=1,000 kcal/week, compared with 1/3 in the U.S. The most disconcerting finding was the Taiwan unique U-shaped prevalence for males, with the 25-44 age group being the least active, >or=65 age group being the most active; and S-shaped for females, lowest at age 18-24 years and highest at the two older groups (45-64 and >or=65 years). LTPA was under-appreciated, particularly among the most productive work force (25-44-year group), who exercised with a prevalence only 1/4 of their U.S. counterparts. Expressing LTPA in kcal makes direct comparison easier. Invoking a goal of >or=750 kcal/week for Asians, attainable by exercising 4 hours/week, can facilitate nutritionists in assessing LTPA adequacy. Currently, 4/5 of adults in Taiwan failed to reach this goal. Recognizing the concept of cumulative energy expenditure, in contrast to disciplined daily work for 5 or more days, will encourage the infrequent exercisers such as "weekend warriors" to continue with their activities.

A 10-year experience with universal health insurance in Taiwan: measuring changes in health and health disparity.

BACKGROUND: Universal national health insurance, financed jointly by payroll taxes, subsidies, and individual premiums, commenced in Taiwan in 1995. Coverage expanded from 57% of the population (before the introduction of national health insurance) to 98%. OBJECTIVE: To assess the role of national health insurance in improving life expectancy and reducing health disparities in Taiwan. DESIGN: A before-and-after comparison of the decade before the introduction of national health insurance (1982-1984 to 1992-1994) with the decade after (1992-1994 to 2002-2004). SETTING: Taiwan. PATIENTS: All townships (n = 358) in Taiwan were ranked according to overall mortality rates before the introduction of national health insurance and then ranked into 10 health class groups in descending order of health (groups 1 [healthiest] to 10 [least healthy]). MEASUREMENTS: Health improvement (change in life expectancy after the introduction of national health insurance) and health disparity (reduction in the difference in life expectancy between the highest- and lowest-ranked health class groups). RESULTS: After the introduction of national health insurance, life expectancy increased more in health class groups that had higher mortality rates before the introduction of national health insurance and health disparity narrowed, reversing an earlier trend toward widening disparity. The major contributors to the reduction in disparity were relatively larger reductions in death from cardiovascular diseases, ill-defined conditions, infectious diseases, and accidents in the lower-ranked health class groups. However, death from cancer increased more in the lower-ranked health class groups. Utilization of medical services increased, whereas cost remained at 5% to 6% of the gross domestic product. The per capita average annual number of visits to the physician's office was 14. LIMITATION: The interpretation of comparisons before and after the introduction of national health insurance assumes that the changes were entirely due to the effect of national health insurance rather than secular trends. CONCLUSION: Life expectancy after the introduction of national health insurance improved more for lower-ranked health classes, resulting in narrowed health disparity. The magnitude of the reduced disparity was small compared with the size of the remaining gaps. Relying on universal insurance alone to eliminate health disparity does not seem realistic. To further reduce health disparity, universal insurance programs should incorporate primary prevention, focusing on lifestyle risk reductions.

High prevalence and low awareness of CKD in Taiwan: a study on the relationship between serum creatinine and awareness from a nationally representative survey.

BACKGROUND: The burden of chronic kidney disease (CKD) is a global challenge. Empirical evidence of low CKD awareness rates in developed countries speaks for an urgent need to strengthen strategies for CKD identification and prevention. The aim of this study is to estimate the awareness rate of CKD in Taiwan to promote early detection of CKD in this country. METHODS: Data from a nationally representative survey were used for analysis. The study included 6,001 subjects. The simplified Modification of Diet in Renal Disease equation was used to define glomerular filtration rate (GFR) and CKD stages according to criteria of the US National Kidney Foundation. Descriptive methods were used to analyze data. RESULTS: The prevalence of CKD stages 3 to 5 in Taiwan is 6.9% (95% confidence interval, 4.4 to 9.4). Awareness rates for CKD in Taiwan are low: 8.0% for individuals with stage 3, 25.0% for those with stage 4, and 71.4% for those with stage 5. Awareness rate is related closely to serum creatinine level: those with creatinine levels greater than 1.6 mg/dL (>141 micromol/L) are more likely to be informed of having a kidney disease. CONCLUSION: The high prevalence and low awareness of CKD in Taiwan explicitly show the need to advocate more strongly for CKD prevention and education for both physicians and the populace. Establishment of a mandated automatic GFR reporting system may be the first priority we need to accomplish in Taiwan to improve kidney well-being.