Factors associated with Taiwanese junior high school personnel advising students to quit smoking.

BACKGROUND: Most smokers in developing countries begin smoking before age 18, and smoking prevalence is rising among adolescents. School personnel represent a target group for tobacco-control efforts because they interact daily with students, are role models for students, teach about tobacco-use prevention in school curricula, and implement school tobacco-control policies. The prevalence of teenage smoking has been examined in numerous studies, but few have focused on the influence of school personnel and the characteristics of school personnel who enforce school nonsmoking policy. The purpose of this study was to determine the factors associated with junior high school personnel advising students to quit smoking. METHODS: School personnel (N = 7129) were recruited by cluster sampling from 60 junior high schools in Taiwan; of these, 5280 voluntarily returned self-administered, anonymous questionnaires (response rate = 74.06%) in 2004. RESULTS: Most personnel (70%) had advised students to quit smoking. School personnel who were older, male, responsible for teaching health, smokers, with positive attitude against tobacco, or with more knowledge of tobacco hazards were more likely to advise students to quit smoking. Personnel with more interest in and access to tobacco-related materials were more likely to advise students to quit smoking. Personnel who had received tobacco-prevention training were 2.41 times more likely to persuade students to quit smoking after adjusting for other factors. However, only half of the participants had ever had access to educational materials about tobacco use, and 8% had ever received training to prevent tobacco use. CONCLUSIONS: To reduce youth smoking prevalence, school tobacco-control programs should support tobacco-prevention training for school personnel.

Effect of media campaigns and smoke-free ordinance on public awareness and secondhand smoke exposure in Taiwan.

This study evaluated the effect of Taiwan's smoke-free ordinance and media campaigns on public awareness and secondhand smoke exposure. The authors conducted 3 waves of research--in July 2008 (before media campaigns), in December 2008 (during media campaigns), and in March 2009 (3 months after implementation of the smoke-free law). National representative samples of 1074, 1084, and 1094 people, respectively, were interviewed successfully by telephone in the 3 surveys. The results showed that general awareness of smoke-free workplace legislation rose dramatically from 28.5% in July 2008 to 87.6% in December 2008 to 93.6% in March 2009. Exposure to secondhand smoke in the workplace fell from 28.5% in July 2008 to 24.9% in December 2008 to 7.3% in March 2009, and household secondhand smoke exposure decreased from 36.8% to 34.3% to 21.3%, respectively, during the same period. Multivariate analyses results indicated that media campaigns, smoke-free ordinance implementation, having higher education, and having higher income were associated with more awareness of the smoke-free workplace legislation. In addition, smoke-free ordinance implementation, being female, having higher education, and having higher income were associated with less likelihood of reporting secondhand smoke exposure in the workplace. In conclusion, smoke-free ordinance implementation and media campaigns were effective in raising public awareness of the new law and reducing secondhand smoke exposure in workplaces, in public places, and at home.

The impact of graphic cigarette warning labels and smoke-free law on health awareness and thoughts of quitting in Taiwan.

The present study evaluated the impact of Taiwan's graphic cigarette warning labels and smoke-free law on awareness of the health hazards of smoking and thoughts of quitting smoking. National representative samples of 1074 and 1094 people, respectively, were conducted successfully by telephone in July 2008 (pre-law) and March 2009 (post-law). Results reveal that the prevalence of thinking about the health hazards of smoking among smokers increased from 50.6% pre-law to 79.6% post-law, while the prevalence among non-smokers increased from 68.8 to 94.1% during the same period. The prevalence rates of smokers who reported thinking of quitting rose from 30.2% pre-law to 51.7% post-law. Multivariate analyses results indicated that the implementation of graphic warning labels and the smoke-free law significantly increased the odds of awareness about the health hazards of smoking [odds ratio (OR) = 6.39, 95% confidence interval (CI) = 4.84-8.44] and thoughts of quitting smoking (OR = 2.39, 95% CI = 1.48-3.87). In conclusion, the implementation of a smoke-free law in combination with graphic cigarette warning labels has been effective in increasing thoughts about the health hazards of smoking and quitting smoking.

Association between social climate for smoking and youth smoking behaviors in Taiwan: an ecological study.

BACKGROUND: Social acceptance of smoking is associated with smoking prevalence. Higher smoking rates and ETS exposure might be considered as important indicators for pro-tobacco social norms or social climate. Among studies indicating the association between youth smoking and adult smoking behaviors, most were from individual-level study designs. OBJECTIVES: An ecological study was conducted to determine the role of social climate, i.e., adult smoking behaviors and exposure to environmental tobacco smoke (ETS), on youth smoking behaviors. METHODS: Data on the smoking behavior and ETS of 16,688 Taiwanese adults were collected in 2004 by telephone administration of the Taiwan Adult Smoking Survey. Similar data on 22,339 junior high school students were collected in 2004 by school-based administration of the Taiwan Youth Tobacco Survey. City/county-level data were analyzed across 25 counties by descriptive statistics, Pearson's correlation, and hierarchical multiple regression. RESULTS: In both adult and youth populations, overall or gender-specific smoking prevalence and ETS varied widely across counties/cities. The current youth smoking rate within counties was significantly positively correlated with the current adult smoking prevalence as well as home ETS exposure in adults or youth. For male youth, a 1% increase in the rate of home ETS exposure reported by youth increased the current male youth smoking rate by 0.20% after controlling the female youth smoking rate and home ETS exposure reported by adults (p=0.0197). For female youth, male youth smoking prevalence was the only variable that contributed significantly (Beta=0.46, p<0.001). CONCLUSIONS: Community health nurses should develop tobacco-control interventions that are tailored to support smoke-free environments by decreasing the social acceptability of smoking.

Quit smoking advice from health professionals in Taiwan: the role of funding policy and smoker socioeconomic status.

OBJECTIVES: In 2002, Taiwan launched a program to encourage doctors to provide brief cessation counselling to their patients during routine outpatient visits. This study is to compare and analyse the annual prevalence rate of receiving advice to quit smoking from health professionals before (2004) and after (2005, 2006) the increase in funding and the withdrawal of additional funding (2007). METHODS: We analysed pooled data from 2004 to 2007 Taiwan Adult Tobacco Survey, an annual random digit dialling telephone survey, to estimate the prevalence of receiving quit advice among ever smokers across these years. Smoking characteristics and the socioeconomic factors of smokers associated with receipt of advice to quit smoking were also examined. RESULTS: The prevalence rate of receiving quit advice increased from 21.1% in 2004 to 28.2% in 2006, and then decreased slightly to 27.6% in 2007 after the funds were cut. Multivariate analyses results indicated that increasing financing for smoking cessation services in 2005, being male, older, a daily cigarette user, having previously attempted to quit, perceiving oneself as having poor health and being aware of the benefits of smoking cessation services were significantly positively associated with receiving quit advice from health professionals. In contrast, smokers who were younger, female and occasional cigarette users were less likely to receive quit advice. Also, smokers with socioeconomic disadvantages were not less likely to receive quit advice. CONCLUSIONS: During the period of increased funding for smoking cessation services, the rates of receiving quit advice increased among all smokers and across different socioeconomic groups.

Susceptibility to initiate smoking among junior and senior high school nonsmokers in Taiwan.

OBJECTIVES: Most smokers begin using tobacco in their teens and recent reports indicate that smoking prevalence is climbing among youth in Taiwan. The purpose of this paper was to determine the associated factors of susceptibility of youth smoking by different types of schools. METHODS: A total of 4689 junior high students and 3918 senior high students participated in a school-based survey to determine the associated factors of susceptibility of youth smoking through anonymous self-administered questionnaire in 2004-2005. RESULTS: Susceptibility to initiate smoking ranged from 11.3% for junior high to 12.7% for general senior high and 12.4% for vocational senior students. For all/male smoking-susceptible students, more junior high students had one or more parents or best friends who smoked than did general or vocational senior high students. For all/female smoking-susceptible students, significantly more junior high students experienced secondhand smoke in public places than did non-susceptible students. CONCLUSIONS: Developing tailored, comprehensive smoking-prevention programs for junior high students should involve establishing tobacco-free households and communities.

Moving toward people's needs for smoke-free restaurants: before and after a national promotion program in Taiwan, 2003-2005.

INTRODUCTION: In Taiwan, the Smoke-Free Restaurant Program (SFRP) was implemented from 2003 to 2005 as an initial phase before the introduction of restrictive legislation promoting smoke-free restaurants (SFRs). No studies have evaluated trends in public opinion before and after a national health promotion campaign for the introduction of SFRs on a voluntary basis. The present study investigated whether public opinion with respect to eliminating environmental tobacco smoke (ETS) in restaurants changed after implementation of the SFRP. METHODS: Data were obtained from four large-scale, nationally representative surveys conducted in 2003-2005 before and after implementation of the SFRP. Weighted analyses were performed to obtain nationally representative results. RESULTS: After a series of SFRP campaigns, reported exposure to ETS in restaurants by survey participants decreased by approximately 14%. Approximately 20% more people had heard of SFRs, and approximately 25% more had chosen to dine in a smoke-free restaurant. We found consistently high community support for SFRs (ca. 95%), and approximately 80% supported smoke-free restaurant legislation, although both rates dropped slightly in 2005. People aged 60 years or more, nonsmokers, and those who had greater knowledge of ETS hazards were more likely to support smoke-free restaurant legislation. DISCUSSION: The SFRP was effective at promoting SFRs on a voluntary basis. Strong community endorsement has major implications for legislators who are considering the nature and extent of further smoke-free restaurant legislation in Taiwan and other countries.

Estimation of burden of lead for offspring of female lead workers: a quality-adjusted life year (QALY) assessment.

This study demonstrates an empirical example that uses quality-adjusted life year (QALY) as a common metric for occupational health assessment to measure the utility loss of potential lead-exposed children delivered by female lead-battery-exposed workers. A set of nationwide health examination data was used for 1726 lead workers. Among them, there were 649 female workers. The numbers of offspring from female lead workers were estimated by multiplying the age-specific fertility rate (ASFR) by the number of workers in each age stratum. The quality of life assessment for these offspring was assumed impaired by increased absorption of lead using a measure of utility for quality of life that was adapted from Rosser's index of health-related quality of life. The total utility loss was calculated by summing up the loss of QALY for these expected offspring. Dose-response and exposure assessments were based on their mothers' blood lead levels. It was estimated that more than 38 babies were delivered in 1 yr. There would be 19 babies born with blood lead levels over 30 microg/dl, and about 17 babies with blood lead between 10 and 29 microg/dl. The expected utility loss of the babies was estimated to be about 216 QALY, of which 51.6 QALY was attributed to the babies with moderate blood lead level, while that of high blood lead was 164.4 QALY. An effective industrial hygiene program to reduce blood lead to 5, 10, and 15 microg/dl in female lead-exposed workers would decrease the utility loss to 169.5, 126.8, and 92.3 QALY, respectively, in the offspring. An alternative policy of raising the age of female workers by 5 or 10 yr before employment would also reduce the loss to 174.6 or 107.4 QALY. Data suggest that an effective industrial hygiene program should be implemented, and the use of QALY as a common metric for comparative assessment of occupational health policy may be feasible.

Reversible neurobehavioral performance with reductions in blood lead levels--a prospective study on lead workers.

Lead poisoning remains an occupational hazard in Taiwan. Many studies, based on crossed-section design, have focused on changes in lead-associated neurobehavioral dysfunctions that occur at increased blood lead levels. This study evaluates the changes in neurobehavioral performance of lead workers as blood levels are reduced. We tested 27 lead workers in a lead glaze factory using the computer-based and automated Chinese edition of Neurobehavioral Evaluation System 2 (C-NES II) in 1994, 1996, and 1997. The association of blood lead levels and C-NES II results were analyzed by longitudinal data analysis methods, repeated ANOVA and mixed model analyses after adjustment for potential confounders. Over these 4 years, the mean lead blood levels of workers were reduced from 26.3(SD=12.0) to 8.3(SD=6.9) microg/dL. Based on a mixed model analysis, we found that the negative effects of exposure to lead on neurobehavioral performance can be reversed to some extent with lowering levels of blood lead. During this period, we found significant improvements in 3 subtests: finger tapping, pattern comparison reaction time, and memory. This study tentatively concluded that reversibility of the neurobehavioral performance after reduction of the lead exposure, which encourages industrial hygiene and personal health promotion to reduce their body lead burden. However, though use of NES is more sensitive to detect the changes, the chronic symptoms (using standardized questionnaire) were found to decline slowly when blood lead level is reduced, with no statistically significant difference. The result means that to avoid the lead exposure primarily is essential to prevent chronic symptoms. We conclude that the most important way to prevent and possibly reverse chronic symptoms of lead poisoning remains to be the avoidance of exposure to lead.

The influence of milk intake on the lead toxicity to the sensory nervous system in lead workers.

The dietary calcium supplement has been suggested to children and pregnant women for prevention of lead toxicity, because of lead-calcium interaction. Lead workers were supplied free milk in Taiwan; however, part of workers did not drink milk due to lactose intolerance. The goal of this study is to evaluate the effects of milk-intake on the peripheral nervous system in workers with long-term lead exposure. We measured 181 workers' current perception thresholds (CPT) as neurological outcomes. The outcome variables were then correlated to the subject's milk intake, blood lead levels, and index of long-term lead exposure that was calculated by the subject's serial blood lead data in a period of working duration. The potential confounders, including age, gender, body height, smoking and alcohol consumption, were also collected and analyzed in multiple regressions. 23 workers who reported never or rarely drinking milk, which meant that they have suffered from diarrhea or abdomen discomfort after drinking milk since childhood, had higher blood lead parameters but not statistically significant, and higher thresholds in sensory nerve tests, especially, statistically significance on 5 and 250 Hz of hand CPTs, which represent C fiber and A-delta fiber. In multiple regression models with control of potential confounders, significant protective effects of milk intake were found on reducing hand CPTs, but not on foot CPTs. Our study, using measurement of sensory nerve CPTs, revealed that drinking milk (two bottles a day, about 700 g per day) might have an effect to protect lead peripheral neurotoxicity. The detail biochemical mechanisms need further investigations. However, reduction of occupational lead exposure is the essential way to protect lead neuropathy. The authors did not emphasize that offers of milk to workers could be instead of occupational hygiene efforts. Furthermore, lead workers with lactose intolerance might be more susceptible, and need more industrial hygiene interventions.

The distribution of blood lead levels and job titles among lead-acid battery workers in Taiwan.

There were several reports about elevated blood lead levels in lead battery workers. However, their subjects came from only one or several plants. We visited all the 23 registered lead-acid battery plants in Taiwan and collected their health examination records in 1992, the blood lead analyses of which were completed in 3 medical college hospitals. In total, we have obtained 1726 records. The average blood lead concentration was 37.1 ug/dl, and 37% of blood lead levels were more than 40 ug/dl (action level). The overall participation rate for health examination among employees was 69.4%. The participation rates were different among both plant sizes and job titles. Assuming that there was no peculiar variation within the four working zones (plate manufacture jobs, assembly jobs, part-time exposure jobs, and office jobs) in each plant, and that blood lead levels of our samples were stable after deleting newly hired workers, we estimated that the blood lead distributions of 2486 employees in these plants were 63.3%, 26.4%, 9.25% and 1.05% for below 40, 40-59, 60-79, and above 80 ug/dl respectively. We conclude that such an analysis should be performed each year to monitor the effectiveness of occupational hygiene in workplace of lead battery plants.

Using structural equation model to explore occupational lead exposure pathways.

The aim of the present study was to demonstrate the use of a structural equation model to explore the complicated lead exposure pathways in a lead battery plant. A total of 96 out of 113 assembly workers were recruited in this study. Lead measurements included blood lead, respirable airborne lead, and body surface lead loadings. Latent variables of inadvertent contact of lead on fingers and ingested lead had indirect and direct effects on the blood lead levels, respectively, and so did the variables of respirable airborne lead, smoking, and the working-place clothes being washed. A model chi(22)2 value of 31.1 (P=0.094) for a goodness of fit test indicates that the derived structural equation model appropriately accounted for the variation of blood lead levels. It is concluded that lead loadings on fingers and lips had significant effects on occupational lead uptake, and, after-work hours and break times at work were the critical time periods for inadvertent lead exposure.

Percutaneous absorption of inorganic lead compounds.

The objective of this study was to determine percutaneous absorption of lead compounds, including lead sulfate, lead oxide, lead powder, and lead stearate. The lead content on the skin surface of 10 lead-battery workers was measured by the method of skin stripping, and urinary lead content of rats was measured with epicutaneous application of four lead compounds: lead sulfate, lead oxide, lead powder, and lead stearate. There were significant amounts of lead on the 9th and 10th skin strippings of the dorsal hand and the back of lead workers. The amount of lead on the dorsal hand was significantly correlated with the amount in the blood (n = 10, r 2 = 0.66, p < 0.05, linear regression). In rats, after lead compounds were applied for 12 days, total lead amount in urine significantly increased to 146.0 +/- 6.4 ng (SD) for lead stearate, 123.1 +/- 7.2 ng for lead sulfate, 115.9 +/- 5.3 ng for lead oxide, 47.8 +/- 6.9 ng for lead powder, and 10.3 ng for the control, which indicated significant skin absorption. It was concluded that significant amounts of inorganic lead compounds can be absorbed through the skin, and skin protection in lead-working or any contaminated environment should be carefully considered.