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Mortality Attributable to Cigarette Smoking in Taiwan

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Mortality Attributable to Cigarette Smoking in Taiwan Tobacco Control 1998;7:141–148 141 Mortality attributable to cigarette smoking in Tob Control: first published as 10.1136/tc.7.2.141 on 1 June 1998. Downloaded from Taiwan: a 12-year follow-up study Kuo-Meng Liaw, Chien-Jen Chen Abstract deaths from various causes in the Taiwan- Background—Assessment of the impact ese population. Tobacco control should be of cigarette smoking on mortality helps to established as the top priority in public indicate the importance of tobacco health programmes in Taiwan. control in a given country. Objectives—To examine the relative risk (Tobacco Control 1998;7:141–148) of dying from various diseases for Keywords: mortality, smoking-attributable diseases, cigarette smoking and to estimate annual Taiwan mortality attributable to cigarette smok- ing in Taiwan. Design—Prospective cohort study. Introduction Subjects and setting—A cohort of 14 397 Evidence of the adverse health eVects of male and female residents aged 40 years tobacco smoking and the benefits of smoking or older recruited from 12 townships and cessation has accumulated during the second precincts in Taiwan from 1982 to 1986. half of the 20th century. Numerous prospective Information on cigarette smoking was studies on cigarette smoking and health collected from each subject at local health hazards have been published.1–13 These reports centres through a standardised personal identified cigarette smoking as an important interview based on a structured question- naire. They were followed up regularly to cause of several types of cancer, cardiovascular determine their vital status until 1994. diseases, chronic bronchitis, emphysema, and many other diseases. However, most epidemio- Main outcome measures—Cox’s propor- logical findings were derived from major tional hazards regression models were http://tobaccocontrol.bmj.com/ used to derive relative risks of cause- prospective studies carried out among North specific mortality for current cigarette American, European, and other white popula- smokers compared with never-smokers, tions. and to examine dose-response relation- Only a few prospective studies have been ships between mortality from various reported from developing countries. A causes and several measures of cigarette prospective study was carried out to evaluate smoking (daily consumption, duration, the health risks of cigarette smoking in middle- age of initiation, and cumulative smoking aged men in Shanghai.14 This study showed in pack-years). that 36% of all cases of cancer and 21% of all Results—A total of 2552 persons died dur- deaths could be attributed to cigarette ing the study period. Among men, smoking. The results are important because cigarette smoking was significantly asso- this study was the first to assess the hazards of on September 27, 2021 by guest. Protected copyright. ciated with an increased risk of dying from cigarette smoking in Chinese men. However, all causes combined (relative risk (RR) = there remain no data on tobacco-related health 1.3); cancer of all sites combined (RR = hazards in Chinese women, who smoke far less 1.5); cancers of the stomach (RR = 1.9), than Western women. liver (RR = 2.2), and lung (RR = 3.7); The prevalence of cigarette smoking in ischaemic heart disease (RR = 1.8); other Taiwan increased strikingly after the second heart diseases (RR = 1.4); and chronic world war and reached its plateau in the obstructive pulmonary disease (RR = 1960s.15 The incidence of and mortality from 1.9). Among women, cigarette smoking lung cancer has increased eightfold between was significantly associated with an the 1960s and 1990s. If the latent period for increased risk of dying from all causes Graduate Institute of cigarette smoking to induce lung cancer is combined (RR = 1.8), cancer of the lung Epidemiology, College about 20–30 years, as documented previously, of Public Health, (RR = 3.6), and peptic ulcer (RR = 17.8). National Taiwan The estimated number of deaths attribut- it is reasonable to attribute most of the increase University, Taipei, in lung cancer mortality and morbidity to ciga- Taiwan, China able to cigarette smoking in Taiwan in K-M Liaw 1994 was 8161 (13.9% of total deaths) for rette smoking. C-J Chen men and 1216 (3.3% of total deaths) for Cigarette smoking has become the most important health problem in Taiwan. We stud- Correspondence to: women. In the same year cigarette Prof Chien-Jen Chen, smoking caused 21.3% and 2.9% of cancer ied a cohort of Taiwanese residents, including Graduate Institute of men and women, to assess mortality related to Epidemiology, National deaths in men and women, respectively, in Taiwan University, 1 Jen-Ai Taiwan. cigarette smoking over a 12-year span. This is Road Section 1, Taipei the first prospective study on cigarette smoking 10018, Taiwan, China. Conclusions—Cigarette smoking has a [email protected] striking impact on overall mortality and and deaths from various causes in Taiwan. 142 Liaw, Chen Tob Control: first published as 10.1136/tc.7.2.141 on 1 June 1998. Downloaded from Table 1 Sociodemographic characteristics and smoking They were further grouped as current smokers status in the study cohort or ex-smokers. Ex-smokers were defined as those who had abstained from cigarette Males Females smoking during the six months immediately Characteristics n (%) n (%) preceding recruitment, or who had quit smoking and remained abstinent for at least six Age (years) 41–50 3 618 (32.6) 1402 (42.5) months during the follow-up period (and were 51–60 3 946 (35.5) 1033 (31.3) still abstinent at the time of the follow-up visit 61–70 2 536 (22.9) 638 (19.3) or interview). Current smokers were those who >71 1 002 (9.0) 228 (6.9) Educational level had never quit cigarette smoking at the time of No formal recruitment or during the follow-up period. education 1 808 (16.3) 1857 (56.3) Elementary school 6 556 (59.1) 1196 (36.2) Almost all tobacco users in Taiwan smoke ciga- High school 2 016 (18.2) 184 (5.6) rettes; they rarely use chewing tobacco or snuff. College or above 498 (4.5) 24 (0.7) Unknown 218 (2.0) 40 (1.2) MORBIDITY AND MORTALITY FOLLOW UP AND Residence Metropolitan 1 029 (9.3) 965 (29.2) DATA LINKAGE Urban 3 281 (29.6) 597 (18.1) Study subjects were followed up for their Rural 6 198 (55.9) 1160 (35.1) health status during 1989–1993. The Unknown 588 (5.3) 579 (17.5) Smoking status occurrence of major diseases was investigated Never-smoker 4 613 (41.6) 3160 (95.7) at the hospitals or clinics where the diagnosis Former smoker 1 258 (11.3) 11 (0.3) was made. To validate vital status and cause of Current smoker 5 225 (47.1) 130 (3.9) Total 11 096 (100.0) 3301 (100.0) death among study subjects, computerised annual data files of the death certification sys- tem in Taiwan during the entire 12-year study Methods period were used to link with identification COHORT RECRUITMENT AND INCLUSION CRITERIA Between October 1982 and March 1986, 12 profiles of subjects. In Taiwan, every newborn townships and precincts (Nankang, Nantzu, is given a national identification number. The Tayuan, Tashu, Tounan, Chunan, Kuanhsi, Table 2 Sex-specific prevalence of cigarette smoking (%) Hsinpu, Hengshan, Yuanshan, Chutien, and by age, residence, and educational level, in the study cohort Checheng) were selected as the study areas for and the general population in Taiwan, 1994* the prospective study of multiple risk factors Men Women for major diseases in Taiwan. These areas were General Study General Study selected to represent metropolitan precincts population cohort population cohort and urban and rural townships in the north, middle, and south of Taiwan. Residents in the Total 53.4 57.7 4.2 3.8 http://tobaccocontrol.bmj.com/ study areas were invited to participate provided Age (years) 41–45 54.3 56.4 3.5 1.7 they were at least 18 years old and had no pre- 46–50 56.4 3.2 vious history of cancer or other major diseases 51–55 59.5 60.7 3.4 3.9 56–60 59.4 4.2 such as cardiovascular disease, diabetes 61–65 54.4 57.8 5.4 5.8 mellitus, or hypertension. Informed consent 66–70 49.5 5.4 was given verbally in the presence of a witness. >71 49.3 54.0 4.5 7.5 Residence This study received approval and grant funding Rural 51.1 59.3 4.1 2.4 from the Department of Health and Urban 56.7 53.3 2.5 1.4 conformed to the provision of the World Medi- Metropolitan 59.7 62.1 2.4 6.8 Educational level cal Assembly in Tokyo in 1975. A total of Not formally 17 538 residents (25% of eligible subjects) educated 57.2 63.7 5.2 3.5 participated in the study. Elementary school 60.8 59.3 3.5 2.9 on September 27, 2021 by guest. Protected copyright. High school 60.8 51.8 3.2 8.2 College or above 34.4 41.0 1.4 8.3 DATA COLLECTION All participants were interviewed at recruit- *See reference 15. ment by well-trained public health nurses in Table 3 Characteristics of cigarette smoking among local health centres in the study townships and current smokers at recruitment precincts. The standardised interview was based on a pre-tested, structured questionnaire Men Women Cigarette smoking which inquired about sociodemographic characteristics n (%) n (%) characteristics, history of cigarette smoking and alcohol drinking, vegetarian habit, Daily cigarette consumption (cigarettes/day) 1–10 2638 (34.1) 102 (78.5) frequency of consuming various food items, 11–20 4463 (57.7) 24 (18.5) personal and family history of various cancers >21 640 (8.3) 4 (3.1) and major diseases.
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