Occupational Sitting Time, Leisure Physical Activity, and All-Cause and Cardiovascular Disease Mortality.

Importance: For the first time, the 2020 World Health Organization guidelines on physical activity recommended reducing sedentary behaviors owing to their health consequences. Less is known on the specific association of prolonged occupational sitting with health, especially in the context of low physical activity engagement. Objective: To quantify health risks associated with prolonged occupational sitting and to determine whether there is a certain threshold of physical activity that may attenuate it. Design, Setting, and Participants: This prospective cohort study included participants in a health surveillance program in Taiwan who were followed-up between 1996 and 2017. Data on occupational sitting, leisure-time physical activity (LTPA) habits, lifestyle, and metabolic parameters were collected. Data analysis was performed in December 2020. Main Outcomes and Measures: The all-cause and cardiovascular disease (CVD) mortality associated with 3 occupational sitting volumes (mostly sitting, alternating sitting and nonsitting, and mostly nonsitting) were analyzed applying multivariable Cox regression models to calculate the hazard ratios (HRs) for all participants and by subgroups, including 5 LTPA levels and a personal activity intelligence (PAI)-oriented metric. Deaths occurring within the initial 2 years of follow-up were excluded to prevent reverse causality. Results: The total cohort included 481 688 participants (mean [SD] age, 39.3 [12.8] years; 256 077 women [53.2%]). The study recorded 26 257 deaths during a mean (SD) follow-up period of 12.85 (5.67) years. After adjusting for sex, age, education, smoking, drinking, and body mass index, individuals who mostly sat at work had a 16% higher all-cause mortality risk (HR, 1.16; 95% CI, 1.11-1.20) and a 34% increased mortality risk from CVD (HR, 1.34; 95% CI, 1.22-1.46) compared with those who were mostly nonsitting at work. Individuals alternating sitting and nonsitting at work did not experience increased risk of all-cause mortality compared with individuals mostly nonsitting at work (HR, 1.01; 95% CI, 0.97-1.05). For individuals mostly sitting at work and engaging in low (15-29 minutes per day) or no (<15 minutes per day) LTPA, an increase in LTPA by 15 and 30 minutes per day, respectively, was associated with a reduction in mortality to a level similar to that of inactive individuals who mostly do not sit at work. In addition, individuals with a PAI score exceeding 100 experienced a notable reduction in the elevated mortality risk associated with prolonged occupational sitting. Conclusions and Relevance: As part of modern lifestyles, prolonged occupational sitting is considered normal and has not received due attention, even though its deleterious effect on health outcomes has been demonstrated. In this study, alternating between sitting and nonsitting at work, as well as an extra 15 to 30 minutes per day of LTPA or achieving a PAI score greater than 100, attenuated the harms of prolonged occupational sitting. Emphasizing the associated harms and suggesting workplace system changes may help society to denormalize this common behavior, similar to the process of denormalizing smoking.

Examining mediators of associations of food insecurity and being bullied with suicide among in-school adolescents in Eswatini: a cross-sectional study.

We examined the potential mediating roles of anxiety and loneliness on the association of concurrent food insecurity (FI) and being bullied (BB) with suicidal behavior (SB) in Eswatini, a lower-middle-income country. We used data from the Global School-based Student Health Survey (GSHS; N = 3264), which employed a two-stage cluster sampling: first, 25 schools were selected based on the proportionate probability of enrollment; second, classes were randomly selected. A self-reported 84-item GSHS questionnaire was used to collect data for students aged 13-17 years. FI was measured by requesting students to recall how often they went hungry because of a lack of food at home in the 30 days before the study. Multiple logistic regressions and binary mediation function was applied to examine mediating factors of SB. The prevalence of SB, FI, and BB among adolescents was 27.5%, 7.7%, and 30.2%, respectively. Moreover, the relationship between FI and BB with SB was partly (approximately 24%) mediated by anxiety and loneliness. Our results highlight the mediating roles of anxiety and loneliness in suicidal adolescents who experience FI and BB. In conclusion, interventions for alleviating SB in high-risk adolescents experiencing FI and BB should also be aimed at ameliorating anxiety and loneliness.

Are e-cigarettes reviving the popularity of conventional smoking among Taiwanese male adolescents? A time-trend population-based analysis for 2004-2017.

INTRODUCTION: In Taiwan, national tobacco use surveys show that e-cigarette use has increased since 2014 among youth, while, at the same time, conventional cigarette smoking has continuously decreased. The purpose of this study is to examine whether the increased popularity of e-cigarettes has undermined this favourable declining trend for cigarette smoking. METHODS: We examined conventional cigarette and e-cigarette prevalence among male high school students (aged 16-18 years) and adults from 2004 to 2017, using data from cross-sectional nationally representative surveys. Applying interrupted time series analysis, we assessed whether there was a change in trend in 2014, when e-cigarette use started to gain popularity from long-term trends in prior years (2004-2013). RESULTS: E-cigarette use prevalence increased from 2.5% in 2014 to 6.4% in 2017 among male high school students but was negligible among male adults, declining from 1.4% in 2015 to 0.8% in 2017. The annual relative decline in the cigarette smoking rate after e-cigarettes started to gain popularity was greater (-10%) than the long-term trend (-2%) among high school students. Among adults, the change in trend over time after e-cigarettes started to gain popularity was not significant (ie, not significantly different from 0). CONCLUSIONS: The increased popularity of e-cigarettes since 2014 is associated with a greater decline in youth smoking, compared with previous years. On the contrary, e-cigarette use has remained very low among Taiwanese male adults and no additional impact on the conventional smoking trend is found.

Geo-temporal distribution of 1,688 Chinese healthcare workers infected with COVID-19 in severe conditions-A secondary data analysis.

INTRODUCTION: The COVID-19 outbreak is posing an unprecedented challenge to healthcare workers. This study analyzes the geo-temporal effects on disease severity for the 1,688 Chinese healthcare workers infected with COVID-19. METHODS: Using the descriptive results recently reported by the Chinese CDC, we compare the percentage of infected healthcare workers in severe conditions over time and across three areas in China, and the fatality rate of infected healthcare workers with all the infected individuals in China aged 22-59 years. RESULTS: Among the infected Chinese healthcare workers whose symptoms onset appeared during the same ten-day period, the percentage of those in severe conditions decreased significantly from 19.7% (Jan 11-20) to 14.4% (Jan 21-31) to 8.7% (Feb 1-11). Across the country, there was also a significant difference in the disease severity, with Wuhan being the most severe (17.3%), followed by Hubei Province (10.2%), and the rest of China (6.6%). The case fatality rate for the 1,688 infected Chinese healthcare workers was significantly lower than that for the 29,798 infected patients aged 20-59 years-0.3% (5/1,688) vs. 0.65% (193/29,798), respectively. CONCLUSION: The disease severity among infected healthcare workers improved considerably over a short period of time in China. The more severe conditions in Wuhan compared to the rest of the country may be attributable to the draconian lockdown. The clinical outcomes of infected Chinese healthcare workers may represent a more accurate estimation of the severity of COVID-19 for those who have access to quality healthcare.

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.

Electronic Cigarette Use and Smoking Initiation in Taiwan: Evidence from the First Prospective Study in Asia.

A growing literature indicates that electronic cigarette use increases the risk of subsequent initiation of conventional smoking among cigarette-naïve adolescents in several Western countries. This research assesses the same relationship in an Asian country, Taiwan. The Taiwan Adolescent to Adult Longitudinal Study is a school-based survey that was carried out in two waves in 2014 (baseline) and in 2016 (follow-up). It employs probability sampling to create nationally representative samples of students in junior high school (mean age 13, 7th grade at baseline) and in senior high school (mean age 16, 10th grade at baseline). Data from this survey were analyzed via logistic regression to estimate the association between ever use of e-cigarettes at baseline and smoking initiation at follow-up, accounting for susceptibility to smoking, socio-demographic profile, depression status, and peer support. Among the 12,954 cigarette-naïve students surveyed, those with e-cigarette experience at baseline exhibited higher odds of smoking initiation at follow-up (Odds Ratio = 2.14, 95% CI (1.66, 2.75), p < 0.001). For the first time, we confirmed, through a longitudinal survey, a prospective association between ever use of e-cigarettes and smoking initiation in an Asian adolescent population. The restrictive policy on e-cigarettes currently in force in Taiwan is justified to prevent both e-cigarette and cigarette use among adolescents.

Juggling Two Balls-Smoking (Re)Normalization and Harm Reduction: E-Cigarettes-Facts and Misconceptions in Taiwan.

The increasing popularity of e-cigarettes, especially among adolescents, has alarmed health advocates and government officials, dominating the tobacco control narrative in the past few years. According to the Global Youth Tobacco Survey, the percentage of Taiwanese teenagers reporting use of e-cigarettes in the past 30 days rose from 2.01% (95% confidence interval [CI] = 1.82% to 2.23%) in 2014 to 3.54% (95% CI = 3.30% to 3.80%) in 2017. However, during the same period, prevalence of cigarettes declined from 11.51% (95% CI = 9.84% to 13.42%) to 8.26% (95% CI = 7.80% to 8.76%) among senior high school students, and from 5.00% (95% CI = 4.36% to 5.74%) to 2.66% (95% CI = 2.38% to 2.96%) among junior high school students, with figures for both groups reaching historical lows. This trend is similar to population-level trends observed in both the United Kingdom and the United States, but only future long-term studies will be able to clarify if it is consistent or not with the fears that e-cigarette may act as a "gateway" to cigarette smoking renormalization.

Spatial and Temporal Characteristics of 2014 Dengue Outbreak in Guangdong, China.

The record-breaking number of dengue cases reported in Guangdong, China in 2014 has been topic for many studies. However, the spatial and temporal characteristics of this unexpectedly explosive outbreak are still poorly understood. We adopt an integrated approach to ascertain the spatial-temporal progression of the outbreak in each city in Guangdong as well as in each district in Guangzhou, where the majority of cases occurred. We utilize the Richards model, which determines the waves of reported cases at each location and identifies the turning point for each wave, in combination with a spatial association analysis conducted by computing the standardized G* statistic that measures the degree of spatial autocorrelation of a set of geo-referenced data from a local perspective. We found that Yuexiu district in Guangzhou was the initial hot spot for the outbreak, subsequently spreading to its neighboring districts in Guangzhou and other cities in Guangdong province. Hospital isolation of cases during early stage of outbreak in neighboring Zhongshan (in effort to prevent disease transmission to the vectors) might have played an important role in the timely mitigation of the disease. Integration of modeling approach and spatial association analysis allows us to pinpoint waves that spread the disease to communities beyond the borders of the initially affected regions.

Ascertaining the impact of public rapid transit system on spread of dengue in urban settings.

Urbanization is an important factor contributing to the global spread of dengue in recent decades, especially in tropical regions. However, the impact of public transportation system on local spread of dengue in urban settings remains poorly understood, due to the difficulty in collecting relevant locality, transportation and disease incidence data with sufficient detail, and in suitably quantifying the combined effect of proximity and passenger flow. We quantify proximity and passenger traffic data relating to 2014-2015 dengue outbreaks in Kaohsiung, Taiwan by introducing a "Risk Associated with Metro Passengers Presence" (RAMPP), which considers the passenger traffic of stations located within a fixed radius, giving more weight to the busier and/or closer stations. In order to analyze the contagion risk associated with nearby presence of one or more Kaohsiung Rapid Transit (KRT) stations, we cluster the Li's (the fourth level administrative subdivision in Taiwan) of Kaohsiung based on their RAMPP value using the K-means algorithm. We then perform analysis of variance on distinct clusterings and detect significant differences for both years. The subsequent post hoc tests (Dunn) show that yearly incidence rate observed in the areas with highest RAMPP values is always significantly greater than that recorded with smaller RAMPP values. RAMPP takes into account of population mobility in urban settings via the use of passenger traffic information of urban transportation system, that captures the simple but important idea that large amount of passenger flow in and out of a station can dramatically increase the contagion risk of dengue in the neighborhood. Our study provides a new perspective in identifying high-risk areas for transmissions and thus enhances our understanding of how public rapid transit system contributes to disease spread in densely populated urban areas, which could be useful in the design of more effective and timely intervention and control measures for future outbreaks.

Temporal patterns of dengue epidemics: The case of recent outbreaks in Kaohsiung.

OBJECTIVE: To investigate whether major dengue outbreaks in the last two decades in Kaohsiung follow a precise temporal pattern. METHODS: Government daily lab-confirmed dengue case data from three major dengue outbreaks occurring during the last two decades in Kaohsiung in 2002, 2014 and 2015, is utilized to compute the corresponding weekly cumulative percentage of total case numbers. We divide each of the three time series data into two periods to examine the corresponding weekly cumulative percentages of case numbers for each period. Pearson's correlation coefficient was calculated to compare quantitatively the similarity between the temporal patterns of these three years. RESULTS: Three cutoff points produce the most interesting comparisons and the most different outcomes. Pearson's correlation coefficient indicates quantitative discrepancies in the similarity between temporal patterns of the three years when using different cutoff points. CONCLUSIONS: Temporal patterns in 2002 and 2014 are comparatively more similar in early stage. The 2015 outbreak started late in the year, but ended more like the outbreak in 2014, both with record-breaking number of cases. The retrospective analysis shows that the temporal dynamics of dengue outbreaks in Kaohsiung can strongly vary from one year to another, making it difficult to identify any common predictor.

Avoiding social traps in the ecosystem stewardship: The Italian Fontanile lowland spring.

Fontanile is a Po Valley (Italy) quasi-natural lowland spring built in the middle age. This paper identifies options for the conservation of the Fontanile water dependent ecosystem, using scenarios and simulations, and exploring different policy options. Three modeling analysis have been performed: the first was carried out for estimating groundwater contamination and recharge from above, the second for evaluating the function of vegetative filter strip on the surface water quality and the last one for testing pesticide drift reduction due to the vegetative filter strip. Uncertainty characterization included climate change projections. Despite the nitrate concentration in water could favorite the eutrophication phenomena, this not occurs because of the low phosphate concentration in water and of the presence of arboreal shade. Therefore, the protection strategies must focus on sustaining desirable water quantity conditions. Water saving and conservation technologies that improve the agricultural productivity but reduce the Fontanile water flow and large buffer strips that have a limited efficacy due to the Fontanile hydrological settings can be judged as ecological traps. Inefficient irrigation systems, good agricultural practices, integrated pest management and arboreal filter strip can preserve the quality of those ecosystems.

Designing a high-yielding maize ideotype for a changing climate in Lombardy plain (northern Italy).

The expected climate change will affect the maize yields in view of air temperature increase and scarce water availability. The application of biophysical models offers the chance to design a drought-resistant ideotype and to assist plant breeders and agronomists in the assessment of its suitability in future scenarios. The aim of the present work was to perform a model-based estimation of the yields of two hybrids, current vs ideotype, under future climate scenarios (2030-2060 and 2070-2100) in Lombardy (northern Italy), testing two options of irrigation (small amount at fixed dates vs optimal water supply), nitrogen (N) fertilization (300 vs 400 kg N ha(-1)), and crop cycle durations (current vs extended). For the designing of the ideotype we set several parameters of the ARMOSA process-based crop model: the root elongation rate and maximum depth, stomatal resistance, four stage-specific crop coefficients for the actual transpiration estimation, and drought tolerance factor. The work findings indicated that the current hybrid ensures good production only with high irrigation amount (245-565 mm y(-1)). With respect to the current hybrid, the ideotype will require less irrigation water (-13%, p<0.01) and it resulted in significantly higher yield under water stress condition (+15%, p<0.01) and optimal water supply (+2%, p<0.05). The elongated cycle has a positive effect on yield under any combination of options. Moreover, higher yields projected for the ideotype implicate more crop residues to be incorporated into the soil, which are positively correlated with the SOC sequestration and negatively with N leaching. The crop N uptake is expected to be adequate in view of higher rate of soil mineralization; the N fertilization rate of 400 kg N ha(-1) will involve significant increasing of grain yield, and it is expected to involve a higher rate of SOC sequestration.