Childhood Lead Poisoning: Conservative Estimates of the Social and Economic Benefits of Lead Hazard Control

Background

This study is a cost–benefit analysis that quantifies the social and economic benefits to household lead paint hazard control compared with the investments needed to minimize exposure to these hazards.

Objectives

This research updates estimates of elevated blood lead levels among a cohort of children ≤ 6 years of age and compiles recent research to determine a range of the costs of lead paint hazard control ($1–$11 billion) and the benefits of reduction attributed to each cohort for health care ($11–$53 billion), lifetime earnings ($165–$233 billion), tax revenue ($25–$35 billion), special education ($30–$146 million), attention deficit–hyperactivity disorder ($267 million), and the direct costs of crime ($1.7 billion).

Results

Each dollar invested in lead paint hazard control results in a return of $17–$221 or a net savings of $181–269 billion.

Conclusions

There are substantial returns to investing in lead hazard control, particularly targeted at early intervention in communities most likely at risk. Given the high societal costs of inaction, lead hazard control appears to be well worth the price.     

Local governments’ dependence on tobacco tax revenue: a?deterrent to tobacco control in the Republic of Korea

Objective

To investigate, in the Republic of Korea, whether local governments’ participation in an anti-smoking programme supported by the National Health Promotion Fund in 2002–2003 was related to the percentage of local tax revenue comprised by the tobacco consumption tax (TCT).

Methods

Using financial and administrative data on 163 municipalities, the authors estimated logit models of local governments’ participation in the anti-smoking programme as a function of the proportion of local tax revenue that came from the TCT and a set of control variables, namely local socioeconomic characteristics and the size of the staff in the local public health centre (PHC).

Findings

Local governments that derived a greater percentage of their local tax revenue from the TCT, particularly those that ranked in the upper fourth in terms of this percentage, were less likely to participate in the anti-smoking programme. Insufficient staff in the PHC was also found to be associated with lower participation in the anti-smoking programme.

Conclusion

Local governments’ dependence on revenue from the TCT may be a deterrent to tobacco control in the Republic of Korea.     

Peer Reviewed: State-Level Medicaid Expenditures Attributable to Smoking

Introduction

Medicaid recipients are disproportionately affected by tobacco-related disease because their smoking prevalence is approximately 53% greater than that of the overall US adult population. This study estimates state-level smoking-attributable Medicaid expenditures.

Methods

We used state-level and national data and a 4-part econometric model to estimate the fraction of each state''s Medicaid expenditures attributable to smoking. These fractions were multiplied by state-level Medicaid expenditure estimates obtained from the Centers for Medicare and Medicaid Services to estimate smoking-attributable expenditures.

Results

The smoking-attributable fraction for all states was 11.0% (95% confidence interval, 0.4%-17.0%). Medicaid smoking-attributable expenditures ranged from $40 million (Wyoming) to $3.3 billion (New York) in 2004 and totaled $22 billion nationwide.

Conclusion

Cigarette smoking accounts for a sizeable share of annual state Medicaid expenditures. To reduce smoking prevalence among recipients and the growth rate in smoking-attributable Medicaid expenditures, state health departments and state health plans such as Medicaid are encouraged to provide free or low-cost access to smoking cessation counseling and medication.     

Smoking-attributable mortality in Bangladesh: proportional mortality study

Objective

To directly estimate how much smoking contributes to cause-specific mortality in Bangladesh.

Methods

A case–control study was conducted with surveillance data from Matlab, a rural subdistrict. Cases (n = 2213) and controls (n = 261) were men aged 25 to 69 years who had died between 2003 and 2010 from smoking-related and non-smoking-related causes, respectively. Cause-specific odds ratios (ORs) were calculated for “ever-smokers” versus “never-smokers”, with adjustment for education, tobacco chewing status and age. Smoking-attributable deaths among cases, national attributable fractions and cumulative probability of surviving from 25 to 69 years of age among ever-smokers and never-smokers were also calculated.

Findings

The fraction of ever-smokers was about 84% among cases and 73% among controls (OR: 1.7; 99% confidence interval, CI: 1.1–2.5). ORs were highest for cancers and lower for respiratory, vascular and other diseases. A dose–response relationship was noted between age at smoking initiation and daily number of cigarettes or bidis smoked and the risk of death. Among 25-year-old Bangladeshi men, 32% of ever-smokers will die before reaching 70 years of age, compared with 19% of never-smokers. In 2010, about 25% of all deaths observed in Bangladeshi men aged 25 to 69 years (i.e. 42 000 deaths) were attributable to smoking.

Conclusion

Smoking causes about 25% of all deaths in Bangladeshi men aged 25 to 69 years and an average loss of seven years of life per smoker. Without a substantial increase in smoking cessation rates, which are low among Bangladeshi men, smoking-attributable deaths in Bangladesh are likely to increase.     

Prenatal and Postnatal Tobacco Exposure and Behavioral Problems in 10-Year-Old Children: Results from the GINI-plus Prospective Birth Cohort Study

Background

Prenatal and postnatal tobacco exposure have been reported to be associated with behavioral problems. However, the magnitude of the association with tobacco exposure at specific periods of exposure is unclear.

Objective

We assessed the relative risk of behavioral problems in children who had been exposed to tobacco smoke in utero and postnatally.

Methods

We analyzed data from a prospective birth cohort study in two cities in Germany: the German Infant Nutrition Intervention. Our sample included 5,991 children born between 1995 and 1998 as well as their parents. We measured behavioral problems using the Strength and Difficulties Questionnaire (SDQ) at follow-up 10 years after birth. According to prespecified SDQ cutoff values, children were classified as “normal,” “borderline,” or “abnormal” according to the subscales “emotional symptoms,” “conduct problems,” “hyperactivity/inattention,” “peer-relationship problems,” and a total difficulties score. Smoke exposure and further covariates were assessed using parent questionnaires.

Results

Compared with children not exposed to tobacco smoke, children exposed both pre- and postnatally to tobacco smoke had twice the estimated risk [95% confidence interval (CI), 1.4–3.1] of being classified as abnormal according to the total difficulties score of the SDQ at 10 years of age. Children who were only prenatally exposed had a 90% higher relative risk (95% CI, 0.9–4.0), whereas children who were only postnatally exposed had a 30% higher relative risk (95% CI, 0.9–1.9). These results could not be explained by confounding by parental education, father’s employment, child’s time spent in front of computer or television screen, being a single father or mother, or mother’s age.

Conclusions

Prenatal exposure to tobacco smoke is associated with behavioral problems in school-age children. Although our findings do not preclude the influence of postnatal exposure, prenatal exposure seems to be more important.     

Lung Cancer in Chinese Women: Evidence for an Interaction between Tobacco Smoking and Exposure to Inhalants in the Indoor Environment

Background

Epidemiologic data suggest that Chinese women have a high incidence of lung cancer in relation to their smoking prevalence. In addition to active tobacco smoke exposure, other sources of fumes and airborne particles in the indoor environment, such as cooking and burning of incense and mosquito coils, have been considered potential risk factors for lung cancer.

Objectives

We used a case–control study to explore effects of inhalants from combustion sources common in the domestic environment on lung cancer and their modification by active tobacco smoking.

Methods

We analyzed 703 primary lung cancer cases and 1,578 controls. Data on demographic background and relevant exposures were obtained by face-to-face interviews in the hospital.

Results

We observed a positive relationship with daily exposure to incense or mosquito coils and to cooking fumes only among smokers, and no association among lifetime nonsmokers. Interactions between smoking and frequency of cooking, or exposure to incense or mosquito coils were statistically significant and consistent with synergistic effects on lung cancer. The odds ratio (OR) comparing smokers without daily incense or mosquito coil exposure with nonsmokers without daily exposure was 2.80 [95% confidence interval (CI), 1.86–4.21], whereas the OR comparing smokers with daily exposure to the same referent group was 4.61 (95% CI, 3.41–6.24). In contrast, daily exposure to incense or mosquito coils was not associated with lung cancer among nonsmokers (OR = 0.91; 95% CI, 0.72–1.16). We observed the same pattern of associations for smokers without (OR = 2.31; 95% CI, 1.52–3.51) and with (OR = 4.50; 95% CI, 3.21–6.30) daily cooking exposure compared with nonsmokers, with no evidence of an association with daily cooking exposure among nonsmokers.

Conclusion

Our results suggest that active tobacco smoking not only is an important risk factor for development of lung cancer, but also may cause smokers to be more susceptible to the risk-enhancing effects of other inhalants.     

Tobacco Price Increase and Smoking Cessation in Japan,a Developed Country With Affordable Tobacco: A National Population-Based Observational Study

Background

Longitudinal assessment of the impact of tobacco price on smoking cessation is scarce. Our objective was to investigate the effect of a price increase in October 2010 on cessation rates according to gender, age, socioeconomic status, and level of tobacco dependence in Japan.

Methods

We used longitudinal data linkage of two nationally representative studies and followed 2702 smokers for assessment of their cessation status. The odds ratios (ORs) for cessation were calculated using logistic regression. To estimate the impact of the 2010 tobacco price increase on cessation, data from 2007 were used as a reference category.

Results

Overall cessation rates significantly increased from 2007 to 2010, from 3.7% to 10.7% for men and from 9.9% to 16.3% for women. Cessation rates were 9.3% for men who smoked 1–10 cigarettes per day, 2.7% for men who smoked 11–20 cigarettes per day, and 2.0% for men who smoked more than 20 cigarettes per day in 2007. These rates increased to 15.5%, 10.0%, and 8.0%, respectively, in 2010. The impact was stronger among subjects who smoked more than 11 cigarettes per day than those who smoked 1–10 cigarettes per day in both sexes: ORs for 2010 were 4.04 for those smoking 11–20 cigarettes per day, 4.26 for those smoking more than 20 cigarettes per day, and 1.80 for those smoking 1–10 cigarettes per day in the main model in men. There were no obvious differences in the relationship between tobacco price increase and smoking cessation across age and household expenditure groups.

Conclusions

The tobacco price increase in Japan had a significant impact on smoking cessation in both sexes, especially among heavy smokers, with no clear difference in effect by socio-demographic status.Key words: tobacco price increase, smoking cessation, Japan, linkage study     

Tobacco smoking and tuberculosis treatment outcomes: a prospective cohort study in Georgia

Objective

To assess the effect of tobacco smoking on the outcome of tuberculosis treatment in Tbilisi, Georgia.

Methods

We conducted a prospective cohort study of adults with laboratory-confirmed tuberculosis from May 2011 to November 2013. History of tobacco smoking was collected using a standardized questionnaire adapted from the global adult tobacco survey. We considered tuberculosis therapy to have a poor outcome if participants defaulted, failed treatment or died. We used multivariable regressions to estimate the risk of a poor treatment outcome.

Findings

Of the 591 tuberculosis patients enrolled, 188 (31.8%) were past smokers and 271 (45.9%) were current smokers. Ninety (33.2%) of the current smokers and 24 (18.2%) of the participants who had never smoked had previously been treated for tuberculosis (P < 0.01). Treatment outcome data were available for 524 of the participants, of whom 128 (24.4%) – including 80 (32.9%) of the 243 current smokers and 21 (17.2%) of the 122 individuals who had never smoked – had a poor treatment outcome. Compared with those who had never smoked, current smokers had an increased risk of poor treatment outcome (adjusted relative risk, aRR: 1.70; 95% confidence interval, CI: 1.00–2.90). Those who had ceased smoking more than two months before enrolment did not have such an increased risk (aRR: 1.01; 95% CI: 0.51–1.99).

Conclusion

There is a high prevalence of smoking among patients with tuberculosis in Georgia and smoking increases the risk of a poor treatment outcome.     

Trawler fuel exhaust and respiratory impairments: a cross-sectional pilot study among Indian fishermen working in informal sectors

Background:

An estimated half a billion people are engaged in fishing related occupations in India. Exposure to adulterated fuel exhaust is common among deep-sea fishermen, yet little is known about the potential impacts on the exposure to health.

Objective:

The aim of this study was to investigate whether fuel emission exposure was associated with increased respiratory impairments among fishermen who were occupationally exposed to fuel exhaust compared to fisherman occupationally unexposed to fuel exhaust.

Methods:

This cross-sectional study compared the prevalence of respiratory symptoms and lung function variables between 152 marine-water and 107 fresh water fishermen considering the use of fuel-driven trawlers. Data were obtained from questionnaires and computerized spirometer.

Results:

Fishermen exposed to trawler fuel exhaust reported more than double the number of respiratory symptoms compared to the unexposed fisherman (86.2 vs. 40.2%). They also had a significantly higher chance experiencing chronic cough (adjusted OR = 3.51, 95% confidence interval (CI) = 2.09–6.35), chronic phlegm (8.61, 4.76–15.97), and wheezing (4.29, 2.55–7.61) symptoms. Finally, there was a significant reduction of the ratio of mid portion of forced expiratory flow rate and forced vital capacity (FEF_25–75/FVC) in the exposed fishermen compared to the unexposed (0.84 vs. 0.73 second⁻¹, P = 0.015).

Conclusion:

Fuel exhaust may negatively impact on the respiratory health of Indian fishermen. More attention and surveillance of occupational health for fishermen in India is needed.     

Economic and Political Influence on Tobacco Tax Rates: A Nationwide Analysis of 31 Years of State Data

Objectives. We evaluated state-level characteristics associated with cigarette excise taxes before and after the Master Settlement Agreement (MSA).Methods. We gathered annual cigarette excise tax rates for all US states and the District of Columbia, between 1981 and 2011, and matched each state–year tax rate with economic, political, attitudinal, and demographic characteristics, creating a data set of 1581 observations. We used panel data regression techniques to assess relationships between key characteristics and state cigarette excise tax levels.Results. Cigarette excise tax rates grew at more than 6 times the rate of inflation between 1981 and 2011; growth varied by time period and region. We found strong negative associations between Republican Party control of state legislatures and governors’ offices and state cigarette tax rates. Tobacco production, citizens’ attitudes toward taxes and tobacco control, and cigarette tax rates in neighboring states were significantly associated with cigarette tax rates. We found no association between unemployment and tax rates.Conclusions. Future excise tax growth rate may depend more on the political leanings of state legislators, and the attitudes of the people they represent, than on economic circumstances.Smoking prevalence has declined in the past few decades, but recently, progress has stalled.1,2 In 1997, nearly 1 in 4 adults, and more than 1 in 3 youths, smoked at least 1 cigarette in the previous month. Although by 2007 rates for both groups had dropped to about 20%, no declines have been observed since.2,3 Without further progress, Healthy People 2020 goals for smoking among adults (12%) and youths (16%) will not be met.4Cigarette excise taxes are considered one of the most effective strategies for reducing smoking.5,6 Higher cigarette prices are associated with decreased consumption,7–9 and taxes are an effective tool for raising product price.10 Furthermore, in almost half of all states, some portion of excise tax revenues fund tobacco control programs.11Although all states levy cigarette taxes, rates vary extensively.12 In 2011, New York’s $4.35 tax rate was more than 25 times higher than Missouri’s $0.17 rate.13 Geographic variation in taxes may promote regional disparities in smoking prevalence and encourage cross-border smuggling or online tobacco sales, limiting the public health impact and revenue generation capabilities of high taxes.13–15 In 2007, the Institute of Medicine recommended that states with excise taxes below those in the top quintile raise their rates to match those in high-tax states.6Yet raising cigarette taxes, especially in low-tax states, has proven difficult. Between 2007 and 2011, only 43% of states in the bottom 4 quintiles raised taxes, whereas 91% of the highest-tax states increased their rates.12 Little is known about what motivates recent changes in state excise tax levels. Tobacco control advocates have suggested that economic contractions may drive states to raise cigarette taxes to generate revenue, noting high numbers of tax hikes following national recessions.16Political scientists, however, argue that political factors and regional pressures may also be important policy predictors.17–19 Nonelection years and neighboring tax initiatives, in addition to poor fiscal health, have been associated with diffusion of gasoline and income taxes.18 Public support of tobacco control, as well as actions of local and neighboring governments, influence the uptake of indoor air and tobacco sales restriction policies.20,21 The extent to which economic circumstances, state politics, constituency beliefs, or regional pressures influence state cigarette excise tax rates, however, remains unclear.Moreover, the key determinants of cigarette taxes can change over time, as public opinion evolves. The 1998 Master Settlement Agreement (MSA) with tobacco manufacturers generated new allocations of tobacco control revenue, some of which was used to fund social marketing campaigns about smoking and the tobacco industry (e.g., the “truth” campaign). One study did document some economic and political correlates of state cigarette tax rates, but relied on data through 2000, just as the impact of the MSA began.22 In the years since the MSA, the public has increasingly identified smoking as hazardous, and the majority now supports some form of tobacco control legislation.23 If these public sentiments influence beliefs about cigarette taxes, the political landscape in which tax decisions are made could be changing.Better understanding of which factors most strongly predict cigarette taxes could help tobacco control professionals target their advocacy. We used annual data from all 50 states between 1981 and 2011 to explore the magnitude of the associations between key economic, political, and regional characteristics and state cigarette excise tax levels, both before and after the MSA.     

Taxation Categories for Long-term Care Insurance Premiums and Mortality Among Elderly Japanese: A Cohort Study

Background

This cohort study examined the association between taxation categories of long-term care insurance premiums and survival among elderly Japanese.

Methods

A total of 3000 participants aged 60 years or older were randomly recruited in Y City, Japan in 2002, of whom 2964 provided complete information for analysis. Information on income level, mobility status, medical status, and vital status of each participant was collected annually from 2002 to 2006. Follow-up surveys on survival were conducted until August 2007. Hazard ratios (HRs) were estimated by a Cox model, using taxation categories at baseline. In these analyses, age-adjusted and age- and mobility-adjusted models were used.

Results

A significantly higher mortality risk was seen only in the lowest taxation category among men: as compared with men in the second highest taxation category, the HR in the lowest category was 2.53 (95% CI, 1.26–5.08, P = 0.009). This significant association between taxation category and mortality was lost after adjustment for mobility. There was no other difference in mortality among taxation categories in men or women.

Conclusions

The present findings only partly supported our hypothesis that taxation category is a good indicator of socioeconomic status in examining health inequalities among elderly Japanese.Key words: Japan, income, cohort study, aged, long-term care     

Smoking-related deaths averted due to three years of policy progress

Objective

To evaluate the global impact of adopting highest-level MPOWER tobacco control policies in different countries and territories from 2007 to 2010.

Methods

Policy effect sizes based on previously-validated SimSmoke models were applied to determine the reduction in the number of smokers as a result of policy adoption during this period. Based on previous research suggesting that half of all smokers die from smoking, we also derived the estimated smoking-attributable deaths (SADs) averted due to MPOWER policy implementation. The results from use of this simple yet powerful method are consistent with those predicted by using previously validated SimSmoke models.

Findings

In total, 41 countries adopted at least one highest-level MPOWER policy between 2007 and 2010. As a result of all policies adopted during this period, the number of smokers is estimated to have dropped by 14.8 million, with a total of 7.4 million SADs averted. The largest number of SADs was averted as a result of increased cigarette taxes (3.5 million), smoke-free air laws (2.5 million), health warnings (700 000), cessation treatments (380 000), and bans on tobacco marketing (306 000).

Conclusion

From 2007 to 2010, 41 countries and territories took action that will collectively prevent nearly 7.5 million smoking-related deaths globally. These findings demonstrate the magnitude of the actions already taken by countries and underscore the potential for millions of additional lives to be saved with continued adoption of MPOWER policies.     

Betel quid use and mortality in Bangladesh: a cohort study

Objective

To evaluate the potential effects of betel quid chewing on mortality. (A quid consists of betel nut, wrapped in betel leaves; tobacco is added to the quid by some users).

Methods

Prospective data were available on 20 033 individuals aged 18–75 years, living in Araihazar, Bangladesh. Demographic and exposure data were collected at baseline using a standardized questionnaire. Cause of death was defined by verbal autopsy questionnaires administered to next of kin. We estimated hazard ratios (HR) and their 95% confidence intervals (CI) for associations between betel use and mortality from all causes and from specific causes, using Cox proportional hazards models. We adjusted for age, sex, body mass index, educational attainment and tobacco smoking history.

Findings

There were 1072 deaths during an average of 10 years of follow-up. Participants who had ever used betel were significantly more likely to die from all causes (HR: 1.26; 95% CI: 1.09–1.44) and cancer (HR: 1.55; 95% CI: 1.09–2.22); but not cardiovascular disease (HR: 1.16; 95% CI: 0.93–1.43). These findings were robust to adjustment for potential confounders. There was a dose–response relationship between mortality from all causes and both the duration and the intensity of betel use. The population attributable fraction for betel use was 14.1% for deaths from all causes and 24.2% for cancer.

Conclusion

Betel quid use was associated with mortality from all causes and from cancer in this cohort.     

Vital Signs: Disparities in Nonsmokers’ Exposure to Secondhand Smoke — United States, 1999–2012

Background

Exposure to secondhand smoke (SHS) from burning tobacco causes disease and death in nonsmoking children and adults. No risk-free level of SHS exposure exists.

Methods

National Health and Nutrition Examination Survey (NHANES) data from 1999–2012 were used to examine SHS exposure among the nonsmoking population aged ≥3 years. SHS exposure among nonsmokers was defined as a serum cotinine level (a metabolite of nicotine) of 0.05–10 ng/mL. SHS exposure was assessed overall and by age, sex, race/ethnicity, poverty level, education, and whether the respondent owned or rented their housing.

Results

Prevalence of SHS exposure in nonsmokers declined from 52.5% during 1999–2000 to 25.3% during 2011–2012. During this period, declines were observed for all population subgroups, but disparities exist. During 2011–2012, SHS was highest among: children aged 3–11 years (40.6%), non-Hispanic blacks (46.8%), persons living below the poverty level (43.2%), and persons living in rental housing (36.8%). Among children aged 3–11 years, 67.9% of non-Hispanic blacks were exposed to SHS compared with 37.2% of non-Hispanic whites and 29.9% of Mexican Americans.

Conclusion

Overall, SHS exposure in the United States has been reduced by half since 1999–2000. However, 58 million persons were still exposed to SHS during 2011–2012, and exposure remains higher among children, non-Hispanic blacks, those living in poverty, and those who rent their housing.

Implications for Public Health Practice

Eliminating smoking in indoor spaces fully protects nonsmokers from SHS exposure; separating smokers from nonsmokers, cleaning the air and ventilating buildings cannot completely eliminate exposure. Continued efforts to promote implementation of comprehensive statewide laws prohibiting smoking in workplaces and public places, smoke-free policies in multiunit housing, and voluntary smoke-free home and vehicle rules are critical to protect nonsmokers from this preventable health hazard in the places they live, work, and gather.     

A Case–Control Study of Lung Cancer Nested in a Cohort of European Asphalt Workers

Background

We conducted a nested case–control study in a cohort of European asphalt workers in which an increase in lung cancer risk has been reported among workers exposed to airborne bitumen fume, although potential bias and confounding were not fully addressed.

Objective

We investigated the contribution of exposure to bitumen, other occupational agents, and tobacco smoking to the risk of lung cancer among asphalt workers.

Methods

Cases were cohort members in Denmark, Finland, France, Germany, the Netherlands, Norway, and Israel who had died of lung cancer between 1980 and the end of follow-up (2002–2005). Controls were individually matched in a 3:1 ratio to cases on year of birth and country. We derived exposure estimates for bitumen fume and condensate, organic vapor, and polycyclic aromatic hydrocarbons, as well as for asbestos, crystalline silica, diesel motor exhaust, and coal tar. Odds ratios (ORs) were calculated for ever-exposure, duration, average exposure, and cumulative exposure after adjusting for tobacco smoking and exposure to coal tar.

Results

A total of 433 cases and 1,253 controls were included in the analysis. The OR was 1.12 [95% confidence interval (CI), 0.84–1.49] for inhalation exposure to bitumen fume and 1.17 (95% CI, 0.88–1.56) for dermal exposure to bitumen condensate. No significant trend was observed between lung cancer risk and duration, average exposure, or cumulative exposure to bitumen fume or condensate.

Conclusions

We found no consistent evidence of an association between indicators of either inhalation or dermal exposure to bitumen and lung cancer risk. A sizable proportion of the excess mortality from lung cancer relative to the general population observed in the earlier cohort phase is likely attributable to high tobacco consumption and possibly to coal tar exposure, whereas other occupational agents do not appear to play an important role.     

Input–output analysis on the economic impact of medical care in Japan

Objectives

Since the Cabinet’s decision concerning the Basic Policies 2005, the Japanese government has implemented specific measures to suppress increases in national medical care expenditure. However, we believe that the economic significance of medical care should be quantified in terms of its economic impact on national medical care expenditure. No one has examined the economic impact of all medical institutions in Japan using data from a statement of profits and losses. We used an input–output analysis to quantitatively estimate economic impact of medical care and examined its estimation range with a probabilistic sensitivity analysis.

Methods

To estimate the economic impact and economic impact multipliers of all medical institutions in Japan, an input–output analysis model was developed using an input–output table, statement of profits and losses, margin rates, employee income rates, consumption propensity and an equilibrium output model. Probabilistic sensitivity analysis was conducted using a Monte Carlo simulation.

Results

Economic impact of medical care in all medical institutions was ¥72,107.4 billion ($661.5 billion). This impact yielded a 2.78-fold return of medical care expenditure with a 95 % confidence interval ranging from 2.74 to 2.90.

Conclusion

Economic impact of medical care in Japan was two to three times the medical care expenditure (per unit). Production inducement of medical care is comparable to other industrial sectors that are highly influential toward the economy. The contribution to medical care should be evaluated more explicitly in national medical care expenditure policies.     

A follow-up of cancer incidence among former Finnish dump site residents: 1999–2011

Background:

In an analysis of the years 1976–1998, a 50% excess in cancer incidence was observed among residents in twelve blockhouses in Helsinki, Finland on a former dump area containing industrial and household waste.

Objective:

To assess cancer risk over a 13-year period 1999–2011 among residents formerly living in houses built on a dump area.

Methods:

All 1879 persons who ever lived in the former dump area were identified and the number of cancer cases in this population was obtained from the Finnish Cancer Registry.

Results:

After 5 years of residence at the dump site, the standardized incidence ratio of cancer (all sites combined) was 1.32 (95% CI: 0.94–1.79) in men and 0.53 (95% CI: 0.33–0.82) for women, in comparison with the general Helsinki population (1999–2011). No significant excess cancer risks were found.

Conclusions:

Residing on a former dump area was not found to result in an increased risk of cancer.     

Active Smoking,Passive Smoking,and Risk of Nonalcoholic Fatty Liver Disease (NAFLD): A Population-Based Study in China

Background

The effect of active smoking on development of nonalcoholic fatty liver disease (NAFLD) is controversial, and there are limited clinical data on the relationship between passive smoking and NAFLD. We investigated whether active and passive smoking are associated with NAFLD.

Methods

A total of 8580 subjects (2691 men) aged 40 years or older participated in a community-based survey in Shanghai, China. Information on active and passive smoking was collected using a validated questionnaire. NAFLD was diagnosed by abdominal B-mode ultrasound testing and serum liver enzymes.

Results

NAFLD prevalence was 29.4% in never smokers, 34.2% in former smokers, 27.8% in light smokers (<20 cigarettes/day), 30.8% in moderate smokers (20–39 cigarettes/day), and 43.5% in heavy smokers (≥40 cigarettes/day). Fully adjusted logistic regression analyses revealed that, as compared with never smoking, former and heavy smoking were associated with increased risk of prevalent NAFLD, with odds ratios of 1.45 (95% CI 1.05–2.00) and 2.29 (95% CI 1.30–4.03), respectively. Active smoking and body mass index (BMI) had a synergistic effect on the risk of prevalent NAFLD; the combination of these risk factors was associated with the highest observed odds ratio for NAFLD: 8.58. In never-smoking women, passive smoking during both childhood and adulthood was associated with a 25% increase in the risk of prevalent NAFLD (OR = 1.25, 95% CI 1.05–1.50) as compared with no passive smoking.

Conclusions

Passive smoking and heavy active smoking are associated with prevalent NAFLD in middle-aged and elderly Chinese. Active smoking and BMI have a synergistic effect on prevalent NAFLD.Key words: active tobacco smoking, passive tobacco smoking, fatty liver     

Hormonal contraceptives and asthma in women of reproductive age: analysis of data from serial national Scottish Health Surveys

Objectives

Sex steroid hormones may explain known gender-related variations in asthma prevalence and clinical manifestation. We investigated the relationship between use of hormonal contraceptives and asthma in women, and assessed evidence of biological interaction between use of hormonal contraceptives and body mass index in this relationship.

Design

Population-based analysis using data from serial (i.e. 2003, 2008 and 2010) Scottish Health Surveys.

Setting

Random samples of the Scottish general population.

Participants

A total of 3257 non-pregnant, 16–45-year-old women.

Exposure

Current use of hormonal contraceptives.

Main outcome measures

Self-reported current physician-diagnosed asthma, current wheezing symptoms, wheezing attacks and treatment for asthma or wheeze.

Results

Women comprising 30.9% (95% confidence interval 29.3–32.5) were currently using any hormonal contraceptive and current physician-diagnosed asthma was present in 6.5% (95% confidence interval 5.7–7.4). Use of any hormonal contraceptive was associated with reduced risk of current physician-diagnosed asthma (odds ratio 0.68; 95% confidence interval 0.47–0.98) and receiving ≥3 asthma care episodes (odds ratio 0.45; 95% confidence interval 0.25–0.82), but the evidence was equivocal for wheezing attacks. Use of hormonal contraceptives among overweight or obese women was non-statistically significantly associated with asthma, but there was 42–135% increased risk in overweight and obese non-contraceptive using women.

Conclusions

Use of hormonal contraceptives may reduce asthma exacerbations and number of care episodes. Overweight and obese non-contraceptive-using women may be at increased risk of asthma. Prospective studies are now needed to confirm these findings. Both oestrogen and progesterone may stimulate smooth airway muscle function and inhibit the activities of TH2 responses. Future studies should investigate these underlying mechanisms.