Using the Diabetes Care System for a County-Wide Hepatitis C Elimination: An Integrated Community-Based Shared Care Model in Taiwan.

INTRODUCTION: Despite the serious risks of diabetes with hepatitis C virus (HCV) infection, this preventable comorbidity is rarely a priority for HCV elimination. We aim to examine how a shared care model could eliminate HCV in patients with diabetes (PwD) in primary care. METHODS: There were 27 community-based Diabetes Health Promotion Institutes in each township/city of Changhua, Taiwan. PwD from these institutes from January 2018 to December 2020 were enrolled. HCV screening and treatment were integrated into diabetes structured care through collaboration between diabetes care and HCV care teams. Outcome measures included HCV care continuum indicators. Township/city variation in HCV infection prevalence and care cascades were also examined. RESULTS: Of the 10,684 eligible PwD, 9,984 (93.4%) underwent HCV screening, revealing a 6.18% (n = 617) anti-HCV seroprevalence. Among the 597 eligible seropositive individuals, 507 (84.9%) completed the RNA test, obtaining 71.8% positives. Treatment was initiated by 327 (89.8%) of 364 viremic patients, and 315 (86.5%) completed it, resulting in a final cure rate of 79.4% (n = 289). Overall, with the introduction of antivirals in this cohort, the prevalence of viremic HCV infection dropped from 4.44% to 1.34%, yielding a 69.70% (95% credible interval 63.64%-77.03%) absolute reduction. DISCUSSION: Although HCV prevalence varied, the care cascades achieved consistent results across townships/cities. We have further successfully implemented the model in county-wide hospital-based diabetes clinics, eventually treating 89.6% of the total PwD. A collaborative effort between diabetes care and HCV elimination enhanced the testing and treatment in PwD through an innovative shared care model.

Do abnormal screening results for chronic diseases motivate inactive people to start exercising? A community-based prospective cohort study in Changhua, Taiwan.

OBJECTIVE: Exercise improves health, but illnesses can cause changes in exercise behavior, including starting or stopping. This study investigated the effects of chronic disease screening on inactive individuals' exercise behavior and analyzed the impact of age and chronic disease history on this relationship using stratified analysis. METHODS: Using a community-based prospective observational cohort design and data from the Changhua Community-Based Integrated Screening (CHCIS) dataset from 2005 to 2020, we examined 12,038 people who were screened at least twice and self-reported having never exercised at their first screening. Changes in exercise behavior were classified as "initiating exercise" and "remaining inactive." We obtained chronic disease screening results from CHCIS records, which included measurements of waist circumference, blood glucose, blood pressure, triglycerides, and high-density lipoproteins. SAS version 9.4 was used for COX proportional hazards regression. RESULTS: The findings indicated that abnormal waist circumference and blood pressure increased the likelihood of initiating exercise compared to normal results. Age stratification showed that those aged 40-49 with abnormal results were more likely to start exercising than normal participants, but not those under 40 or over 65. When stratified by chronic disease history, abnormal screening results correlated with exercise initiation only in groups without chronic disease history, except for those with a history of hyperlipidemia. CONCLUSIONS: This is the first study to demonstrate that abnormal screening results may influence exercise initiation in individuals who have never exercised, and this association varies by screening item, age, and disease history.

Preparedness for containing COVID-19 outbreak in mass religious gathering with non-pharmaceutical interventions (NPIs).

BACKGROUND: The COVID-19 outbreaks associated with mass religious gatherings which have the potential of invoking epidemics at large scale have been a great concern. This study aimed to evaluate the risk of outbreak in mass religious gathering and further to assess the preparedness of non-pharmaceutical interventions (NPIs) for preventing COVID-19 outbreak in this context. METHODS: The risk of COVID-19 outbreak in mass religious gathering was evaluated by using secondary COVID-19 cases and reproductive numbers. The preparedness of a series of NPIs for preventing COVID-19 outbreak in mass religious gathering was then assessed by using a density-dependent model. This approach was first illustrated by the Mazu Pilgrimage in Taiwan and validated by using the COVID-19 outbreak in the Shincheonji Church of Jesus (SCJ) religious gathering in South Korea. RESULTS: Through the strict implementation of 80% NPIs in the Mazu Pilgrimage, the number of secondary cases can be substantially reduced from 1508 (95% CI: 900-2176) to 294 (95% CI: 169-420) with the reproductive number (R) significantly below one (0.54, 95% CI: 0.31-0.78), indicating an effective containment of outbreak. The expected number of secondary COVID-19 cases in the SCJ gathering was estimated as 232 (basic reproductive number (R0) = 6.02) and 579 (R0 = 2.50) for the first and second outbreak, respectively, with a total expected cases (833) close to the observed data on high infection of COVID-19 cases (887, R0 = 3.00). CONCLUSION: We provided the evidence on the preparedness of NPIs for preventing COVID-19 outbreak in the context of mass religious gathering by using a density-dependent model.

Review of epidemic, containment strategies, clinical management, and economic evaluation of COVID-19 pandemic.

The spread of the emerging pathogen, named as SARS-CoV-2, has led to an unprecedented COVID-19 pandemic since 1918 influenza pandemic. This review first sheds light on the similarity on global transmission, surges of pandemics, and the disparity of prevention between two pandemics. Such a brief comparison also provides an insight into the potential sequelae of COVID-19 based on the inference drawn from the fact that a cascade of successive influenza pandemic occurred after 1918 and also the previous experience on the epidemic of SARS and MERS occurring in 2003 and 2015, respectively. We then propose a systematic framework for elucidating emerging infectious disease (EID) such as COVID-19 with a panorama viewpoint from natural infection and disease process, public health interventions (non-pharmaceutical interventions (NPIs) and vaccine), clinical treatments and therapies (antivirals), until global aspects of health and economic loss, and economic evaluation of interventions with emphasis on mass vaccination. This review not only concisely delves for evidence-based scientific literatures from the origin of outbreak, the spread of SARS-CoV-2 to three surges of pandemic, and NPIs and vaccine uptakes but also provides a new insight into how to apply big data analytics to identify unprecedented discoveries through COVID-19 pandemic scenario embracing from biomedical to economic viewpoints.

Sex differences in the trajectories of and factors related to extracurricular sport participation and exercise: a cohort study spanning 13 years.

BACKGROUND: Extracurricular sport participation and exercise (ESPE) refers to regular exercise/sport participation in addition to the physical education in school among a school-aged population. Rather than general physical activity, ESPE is typically deliberately initiated and presents an efficient target for interventions. However, compared to physical activity, relatively few studies have investigated sex differences in the development of and factors associated with ESPE using a person-centered approach. This study aimed to examine the latent trajectories of ESPE from childhood to emerging adulthood across sexes, and to identify the associated sex-specific individual (i.e., body mass index, body dissatisfaction, stress, and screen behavior) and parental (i.e., parental exercise and parental screen behavior) factors. METHODS: This study used data from part of the Child and Adolescent Behavior in Long-term Evolution (CABLE) project, which comprised 2072 fourth graders (aged 9 years) in Northern Taiwan followed annually from 2001 to 2013 (13 waves). Repeated-measures latent class analysis was used to identify the trajectories of ESPE for males and females, respectively. Multinomial logistic regression was further used to identify sex-specific factors related to ESPE. RESULTS: Four trajectories of ESPE were identified for males and females. For males, these trajectories were Rarely-to-Never (20%), Often-to-Rarely (32%), Always-to-Never (21%), and Always (27%). For females, these trajectories were Rarely-to-Never (34%), Rarely (23%), Always-to-Rarely (33%), and Always (10%). We observed that the developmental patterns of ESPE varied by sex such that there was an earlier decline in the trajectories of ESPE in females than in males and that, compared with males, fewer females maintained exercise habits in young adulthood. Furthermore, we found several sex-specific factors related to ESPE, namely, stress, BMI, and parental exercise. Body dissatisfaction and individual screen behavior were associated with trajectories of ESPE for both sexes. CONCLUSIONS: We found distinct trajectories of ESPE from childhood to emerging adulthood for both sexes. The trajectories of ESPE for males and females, however, differ in terms of patterns and associated factors. Our findings suggest that efforts to increase ESPE should be initiated early, and may be made more effective by considering sex differences.

Defending behaviors, bullying roles, and their associations with mental health in junior high school students: a population-based study.

BACKGROUND: Students should be encouraged to help prevent or stop bullying. However, defending victims of bullying can impact on mental health. It is not only bystanders who may defend victims, but bullies, victims and bully-victims can also have defending behaviors. Nevertheless, most studies of defending behaviors have been limited to an examination of the reactions of bystanders or those not involved in bullying and have ignored the other players. The aim of this study is to investigate the associations between defending behaviors and mental health among bullies, victims, bully-victims and bystanders. METHODS: Associations among defending behaviors, mental health (including depressive symptoms and social anxiety), and bullying experiences were cross-sectionally examined in 3441 students (13-15 years old.) from 20 randomly selected junior high schools in Taiwan using a self-report questionnaire. SAS 9.3 Survey Analysis procedures were used to conduct descriptive analysis and multiple regression models. RESULTS: Defending behaviors were associated with bullying roles and were higher in victims than in bullies or bystanders. Defending behaviors were positively associated with social anxiety and depressive symptoms. After stratifying by bullying roles, defending behaviors were positively associated with social anxiety in bystanders, and were positively associated with depressive symptoms in victims and bystanders. However, defending behaviors were not significantly associated with mental health indicators in bullies. CONCLUSIONS: The associations between defending behaviors and mental health varied according to bullying roles. The results suggest that bystanders and victims experience more mental health effects than bullies. Intervention programs aimed at preventing bullying should focus on strategies that minimize social anxiety and depression in victims and bystanders, and urge students to help vulnerable peers during bullying events.

Trajectories of physical activity and risk factors among Taiwanese older adults.

BACKGROUND: The significance of physical activity has been noticed. However, the dynamic change and the heterogeneity of physical activity patterns among older people are little explored. PURPOSE: This study aimed to identify the trajectory patterns of engaging in physical activity over time and its related factors. METHOD: Nationally representative four-wave panel data from Taiwanese older adults, gathered between 1996 and 2007, were used (n = 4,018). The participants ranged in age from 50 to 96 years old. "Being physically active" was defined as performing physical activity in sports or exercises at least three times per week and lasting for at least 30 min each time. Group-based trajectory analysis was performed for analyzing the data. RESULTS: Four trajectory patterns were identified: inactive (47.83%), decreasing (12.21%), increasing (23.36%), and active (16.60%). Older respondents and those with more education were more likely to be active. Those respondents having more depressive symptoms, having more physical functional limitations, and having jobs were less likely to be physically active in the decreasing, increasing, and active patterns. CONCLUSION: There is heterogeneity among the trajectory patterns of physical activity across time in the older adults. Different strategies of physical activity promotion for the older people should be developed by the group characteristics.

Stages of change, determinants, and mortality for smoking cessation in adult Taiwanese screenees.

We aimed to investigate the associations between three smoking-related constructs (pros and cons of smoking, temptation to smoke, and self-efficacy of resisting smoking) and stage of change (precontemplation, contemplation, preparation, and action) based on the transtheoretical model among smokers attending a community-based screening program. We also assessed their effects on long-term all-cause mortality. A prospective cohort study, with an average of 7 years of follow-up, was conducted by enrolling 454 male smoking screenees. The comparisons of the mean score of each variable pertaining to three smoking-related constructs across four stages of smoking cessation were assessed by analysis of variance. The impacts of both smoking-related constructs and smoking cessation stage measured at baseline on 7-year mortality were assessed by using proportional hazards regression model. The differences in the mean scores of pros and cons of smoking, temptation to smoke, and self-efficacy of resisting smoking across four stages of smoking cessation were statistically significant (P < 0.01). The precontemplation group and the contemplation group as opposed to the action group increased the risk for all-cause mortality, but the size of effect was not statistically significant (P = 0.39) when age, duration of smoking, and three smoking- related constructs were controlled. Those with a lower social aspect of self-efficacy were approximately threefold [adjusted hazard ratio = 3.22 (95 % CI 1.26-8.21)] risk for all-cause death compared with those with a higher one. Three smoking-related constructs were highly associated with smoking cessation stage, and low self-efficacy was independently predictive of long-term mortality among male smokers attending a community-based screening program.

Sex differences in the change of exercise behavior leading to incident metabolic syndrome reduction: A community-based prospective study.

This study was undertaken to assess the role of sex differences in the effects of exercise behavior change on incident metabolic syndrome (MetS) in Changhua County, Taiwan. Using data derived from the Changhua Community-based Integrated Screening (CHCIS), 22,594 eligible residents aged 40 years or older had the screening at least twice from 2005 to 2018. A prospective cohort study was designed to follow up the normal cohort without MetS at baseline to ascertain incident MetS in the light of the criteria of the Epidemiology Task Force Consensus Group. We then evaluated whether there was a sex difference in the outcome of incident MetS attributed to the change in exercise behavior from three (no, irregular, and regular exercise) maintained patterns already defined at baseline to either the enhanced pattern or the reduced pattern by the end of follow-up. We applied Cox proportional hazards regression model stratified by sex for estimating the hazard ratio of any two-group comparison. After adjustment for sociodemographic factors, the number of screenings attended, personal disease history, and other health behaviors, the influence of change in exercise behavior on incident MetS was statistically significant only in men. Specifically, maintaining no exercise showed a lower risk of MetS than maintaining regular exercise 21 % in men. Regarding the change in exercise behavior, men with the enhanced pattern reduced the risk of MetS by 15 % compared with those maintaining regular exercise. The findings suggest that positive changes in exercise behavior reduce the incidence of MetS in men but not in women.

Respect in the Eyes of Non-Urban Elders: Using Qualitative Interviews to Distinguish Community Elders' Perspective of Respect in General and Healthcare Services.

This study aimed to describe the connotation of respect for community elders in daily situations, and discuss the elderly's views on respect for healthcare services. A qualitative research design was conducted to interview elders from a non-urban area in Changhua, Taiwan. Study sites were Lukang and Ershui. A total of 52 people were interviewed, with an average age of 75 years old. Based on Grounded theory, the thematic analysis method was used to analyze data. This study found that respect from the perspective of the elderly can be divided into three categories: (1) verbal expression, (2) non-verbal behavior, and (3) behavior combined with appropriate language. We found that elders use the performance of healthcare service providers to discuss respect in the field of healthcare services. Respect can also be shown in the physical environment in healthcare settings. This study found that, for the community elders, respect is an individual's subjective feelings regarding the process of interpersonal interaction. Compared to daily life, the respect of the elderly for the healthcare setting has increased the element of the environment. In addition, it was found that elderly people have lower expectations and requirements for respect in healthcare settings.

Smoking cessation advice from healthcare professionals helps those in the contemplation and preparation stage: An application with transtheoretical model underpinning in a community-based program.

INTRODUCTION: The efficacy of smoking cessation intervention has been proven with randomized controlled trials. Our study aims to elucidate the effects of the delivery method of smoking cessation advice on the process of stage of changes with transtheorectical model underpinning in a community setting. METHODS: A total of 436 subjects were recruited in a quasi-experimental untreated control design study, with 46 receiving advice from healthcare professionals (HCP group) and 390 in the control group, in 2003, Nantou, Taiwan. A discrete time Markov model was used to quantify the multi-state process of smoking cessation in light of the transtheorectical model. Multiple polytomous logistic regression models were simultaneously applied to different transitions. RESULTS: The estimated forward transition probabilities were higher in the HCP group compared to their counterparts in the control group. On the other hand, the backward transition probabilities were smaller in the HCP group. After adjusting for confounding factors, HCP had a 4.3-fold (95% CI: 2.21-8.46) odds ratio of moving forward from the contemplation stage, and 2.4-fold odds ratio (95% CI: 1.03-4.42) from the preparation stage. Elderly people were more reluctant to change from precontemplation (AOR=0.50; 95% CI: 0.34-0.74) and contemplation (AOR=0.58; 95% CI: 0.44-0.84), but once in the preparation stage, they were more likely to take action (AOR=1.28; 95% CI: 1.01-1.83). For those in the preparation stage, longer smoking years had a negative effect on taking action (AOR=0.74; 95% CI: 0.52-0.99), but cessation advice from others enhanced the likelihood to take action (AOR=1.36; 95% CI: 1.01-1.99). CONCLUSIONS: The direct advice on smoking cessation from healthcare professionals enforced the net forward transition towards smoking cessation, especially the transition from contemplation and preparation. The proposed Markov regression model assessed the net effect of different intervention approaches allowing for the simultaneous consideration of multiple transitions and the effects of other confounders.

Social Determinants and Disparities in Active Aging Among Older Taiwanese.

This study assesses equity in active aging across social determinants among older Taiwanese. The data were collected from face-to-face interviews with adults aged 55 years or more in Taiwan in 2017 (n = 738). A total of 30 individual-level Taiwan active aging indicators were chosen, and the relationship between social determinants and active aging indicators were analyzed by logistic regression models. Women were more likely to participate in volunteering and other social groups and in lifelong learning activities, whereas men were more likely to be employed, to engage in physical activity, to feel safe from violence, and to use preventive care. Higher education was related to higher employment, social participation, independent living, lifelong learning, and a lower likelihood of poverty and severe cognitive impairment. Those living in rural areas were more likely to be employed, perform physical activity, feel physically safe, have better mental well-being, and have higher social respect and social integration ratings, whereas living in urban areas was related to greater access to medical care, owning assets, less severe cognitive impairment, greater likelihood of using information and communications technology, higher level of education, and higher access to convenient transportation. The significant disparities that exist in active aging may suggest inequality.

Economic cost and burden of dengue during epidemics and non-epidemic years in Taiwan.

BACKGROUND: Determining the disease and economic burden of dengue is critical for the allocation of public health resources. Several studies have used disability-adjusted life-years (DALYs) to estimate the disease burden of dengue in different regions. However, there are no published studies discussing the estimates of dengue-related economic and disease burden specifically in Taiwan. OBJECTIVES: We assessed the economic cost and disease burden of dengue infections in Taiwan for the period 1998-2014, and compared these during epidemic and non-epidemic years. METHODS: We estimated the annual DALYs per million population using the disability weights for dengue fever (DF), dengue hemorrhagic fever (DHF), dengue shock syndrome (DSS), and death cases. Economic costs were estimated and divided into direct (medical costs) and indirect costs (lost work days and caregiver fees). RESULTS: For the period 1998-2014, a mean of 115.3 (range: 6.3-934.3) DALYs per million population annually were lost to dengue. In epidemic years, direct costs associated with dengue resulted mostly from hospitalization (86.09%), emergency (7.77%), outpatient (6.10%), and drug costs (0.03%). For indirect costs, lost productivity due to death (70.76%) was the dominant contributor. Overall, the costs were 12.3 times higher in epidemic years than in non-epidemic years (Wilcoxon rank sum test, p<0.05). CONCLUSIONS: This study is the first to evaluate the economic costs and disease burden of dengue infections for this period in Taiwan, and reveals significant differences in economic impact between epidemic and non-epidemic years.

Will personal values predict the development of smoking and drinking behaviors? A prospective cohort study of children and adolescents in Taiwan.

This study examined how personal values predict the development of smoking and drinking behaviors in adolescence. The longitudinal data of 1545 adolescents over a 6-year period were analyzed. The results showed that adolescents who valued health and academics had similarly lower odds of reporting cigarette and alcohol use and those who valued friends had significantly higher odds. While the odds increased over time, the trend on alcohol use lessened for adolescents who valued academics, while the trend accelerated for those who valued friends. The finding suggests the important role that personal values play in adolescent risk behavioral development.

Comparison of the social contact patterns among school-age children in specific seasons, locations, and times.

Social contact patterns among school-age children play an important role in the epidemiology of infectious disease. This study explored how people interact in specific seasons (flu season and non-flu season), environmental settings (city and county), and times (weekend and weekday). We conducted a survey of junior high school students (grades 7-8) using an established questionnaire during May-June 2013 and December 2013. The sample size with pair-wise comparisons for the times (weekday/weekend) and stratification by location and seasons were 75, 87, 105 and 106, respectively. The sample size with pair-wise comparisons for the seasons (flu/non-flu) and stratification by location were 54 and 83, respectively. Conversation and skin-to-skin contact behaviors were surveyed through diary-based questionnaires, of which 665 valid questionnaires were returned. There was no difference in the number of contacts during the flu and non-flu seasons, with averages of 16.3 (S.D.=12.9) and 14.6 (S.D.=9.5) people, respectively. However, statistical analysis showed that the average number of contacts in Taichung City and Yilan County were significantly different (p<0.001). Weekdays were associated with 23-28% more contacts than weekend days during both the non-flu and flu seasons (p<0.001) (Wilcoxon signed-rank test). Our work has important implications for the dynamic modeling of infectious diseases and performance analysis of human contact numbers and contact characteristics for schoolchildren in specific seasons, places, and times.

Health, healthy lifestyles and health examinations among the older people in Taiwan.

AIM: This aim of this study was to examine the relationship between the utilisation of general health examinations and health and a healthy lifestyle. METHODS: The data were from a 5-wave panel of older Taiwanese people. Health was defined as the absence of chronic diseases and physical function difficulties. A healthy lifestyle included no smoking, no alcohol consumption and engaging in regular exercise. Generalised linear modelling was applied. RESULTS: The individuals with more chronic diseases were more likely to undergo health examinations, but the rate of change declined over time. Having more physical function disabilities may reduce the likelihood of undergoing health examinations. Individuals who engaged in regular exercise were more likely to undergo health examinations. CONCLUSION: Health examination utilisation is related to health and healthy lifestyle among older people.

Effectiveness of advice from physician and nurse on smoking cessation stage in Taiwanese male smokers attending a community-based integrated screening program.

BACKGROUND: A screening program provides a teachable moment for primary prevention such as encouraging smoking cessation. However, little is known about the efficacy of smoking cessation intervention delivered to the general population through a community-based screening program. METHODS: A quasi-experimental untreated control design with pre-test and post-test was conducted with 42 subjects receiving advice from physician and nurses (the PNA group), 39 receiving an informational leaflet (the leaflet group), and 308 control subjects. RESULTS: The overall rate of reaching the action stage was 25 %, 5.7 %, and 7.8 in the PNA group, the leaflet group, and the control group, respectively. In approximately 45-60 % of all participants, the stage remained unchanged. Such an association between the intervention groups and stage changes was statistically significant (p = 0.02). The PNA group was more likely to have the improvement of stage (forward transition toward action stage) than the control group [adjusted odds ratio (aOR) = 2.27 (1.07-4.84)]. Deterioration (backward transition toward precontemplation) in the PNA intervention group was 37 % lower than that in the control group [aOR = 0.63 (0.20-2.01)]. CONCLUSIONS: This study demonstrated that smoking cessation advice from physician and nurse is conducive to smoking cessation, as shown by greater movement toward and less movement away from smoking cessation through a community-based integrated screening platform.

Do parents play different roles in drinking behaviours of male and female adolescents? A longitudinal follow-up study.

OBJECTIVE: Gender differences in the associations between adolescent drinking behaviour, and perceived parental drinking behaviours and attitudes towards underage drinking, were investigated. METHODS: Data were drawn from two cohorts in the Child and Adolescent Behaviours in Long-term Evolution project. We used data from 2009 to 2006, when cohorts 1 and 2, respectively, were in grade 9. No cohort effect was found, so the two cohorts were pooled; 3972 students (1999 boys and 1973 girls) participated in the study. The major variables included adolescent drinking behaviours over the last month, and perceived parental drinking behaviours and parental attitudes towards underage drinking. The effects of the combination of parental drinking behaviours, and attitudes on the drinking behaviours of male and female adolescents, were analysed by logistic regression. RESULTS: The drinking behaviour of boys was correlated with the drinking behaviours and attitudes of their fathers but not with those of their mothers. Among boys, having a non-drinking father who was against underage drinking (OR=0.27, 95% CI 0.16 to 0.46), a non-drinking father who was favourable towards underage drinking (OR=0.61, 95% CI 0.39 to 0.94), or a drinking father who was against underage drinking (OR=0.44, 95% CI 0.23 to 0.85) significantly decreased the likelihood of alcohol consumption, whereas maternal behaviour and attitude were not significant influences. Among girls, having a non-drinking father who was against underage drinking (OR=0.52, 95% CI 0.30 to 0.91) or a non-drinking father who was favourable towards underage drinking (OR=0.51, 95% CI 0.32 to 0.83) significantly decreased the likelihood of alcohol consumption, as did having a non-drinking mother who was against underage drinking (OR=0.23, 95% CI 0.09 to 0.60). CONCLUSIONS: The influences of fathers and mothers on the drinking behaviour of their adolescent children differed by offspring gender.

Effect of self-reported home smoking restriction on smoking initiation among adolescents in Taiwan: a prospective cohort study.

OBJECTIVE: The aims of this study were to investigate the influence of home smoking restriction (HSR) and the modified effect of parental smoking on smoking initiation among adolescents. DESIGN: Prospective Cohort Study. SETTING: Junior high school in Keelung City, Taiwan. PARTICIPANTS: This study collected and evaluated primary data from the Adolescent Smoking and Other Health-Related Behaviour Survey conducted in Keelung City, which aimed to investigate smoking and health-related behaviours in junior high school students (2008-2009). Data on students free of smoking in 2008 and following them until 2009 (n=901) to ascertain whether they had started smoking were analysed with logistic regression mode to examine the proposed postulates. MAIN OUTCOME MEASURE: The outcome variable was smoking initiation, which was defined as smoking status (yes/no) in the 2009 follow-up questionnaire. The main independent variable was HSR obtained from an adolescent self-reported questionnaire. Information on parental smoking was measured by adolescents self-reporting the smoking behaviour of their father and mother. RESULTS: The rate of HSR was 29.79% among 7th grade adolescents. The effect of HSR on smoking initiation in adolescents was statistically significantly modified by paternal smoking (p=0.04) but not by maternal smoking (p=0.54). The effect of HSR on smoking initiation was small for fathers with the habit of smoking (OR=0.89, 95% CI (0.42 to 1.88)), but the corresponding effect size was 3.2-fold (OR=2.84, 95% CI 1.19 to 6.81) for fathers without the habit of smoking. CONCLUSIONS: Paternal smoking behaviour may play an interactive role with HSR in preventing smoking initiation among Taiwanese adolescents.