菸害防制法施行對心臟血管及呼吸道疾病住院率影響之研究

二手菸的暴露與疾病之間的因果關係在許多研究中已被證實，其中包括了心血管、腦血管和呼吸道疾病等。菸害防制法的實施，其目的除了降低國內吸菸盛行率和保護非吸菸者暴露二手菸，最重要地，是降低國內吸菸和二手菸相關的總疾病負擔。台灣自民國86年9月首度實施菸害防制法，並在民國98年1月修法擴大為所有室內場所禁止吸菸。對於我國菸害防制法的成效評估，到目前為止僅有少數國內文獻進行探討，且主要著重於法令實施前後吸菸者行為上的改變，對於疾病急、門診和住院率的趨勢變化，相關文獻仍未見到。因此，本研究主要便是探討台灣菸害防制法實施對心臟血管疾病和呼吸道疾病住院率之影響。研究中收集了1996年1月至2012年11月間二手菸相關的疾病住院資料，所觀察的疾病包括了缺血性心臟疾病、中風、慢性阻塞性肺病、氣喘、肺炎以及對照疾病（闌尾炎、腸套疊和胰臟疾病），並根據第九版的國際疾病分類標準加以定義。研究中採用波以松回歸（Poisson regression）分析探討菸害防制法的實施對疾病住院率的影響，干擾因子的校正包括了月份、時間趨勢、SARS發生期間、沙塵暴和論質計酬的實施。觀察的主要結果包括了各個階段的疾病住院率差異（step change）以及與時間趨勢交互作用下的疾病住院率趨勢變化（slope change）。研究結果顯示，第一階段及第二階段菸害防制法實施後的所有缺血性心臟疾病與中風住院率，和尚未實施法令前相比，結果呈顯著增加[缺血性心臟疾病:+13.8% （95%CI 12%-15.6%）、+59.5% （95%CI 51.9%-67.4%）; 中風:+8.7%（95%CI 7.0%-10.4%）、+21.8%（95%CI 15.3%-28.6%）]。與時間趨勢交互作用後，第一階段及第二階段菸害防制法實施後的每個月住院率趨勢，和尚未實施法令前相比，結果呈顯著下降[缺血性心臟疾病: -0.8%（95%CI 0.6%-0.9%）、-1.1%（95%CI 0.9%-1.2%）; 中風:-0.4%（95%CI 0.2%-0.5%）、-0.5%（95%CI 0.4%-0.6%）]。第一階段菸害防制法實施後的所有慢性阻塞性肺病住院率、氣喘和肺炎住院率，和尚未實施法令前相比，結果呈顯著增加，第二階段實施後的疾病住院率則是顯著下降或增加較小[慢性阻塞性肺病:+17%（95%CI 14.9%-19.1%）、-22.1%（95%CI 16.3%-27.5%）;氣喘:+24.8%（95%CI 22.4%-27.4%）、-71.6%（95%CI 68.5%-74.4%）;肺炎:+26.7%（95%CI 25.4%-28.1%）、+11.8%（95%CI 8.5%-15.1%）]。與時間趨勢交互作用後，第一階段及第二階段菸害防制法實施後的每個月住院率趨勢，和尚未實施法令前相比，結果呈顯著下降[慢性阻塞性肺病:-0.6%（95%CI 0.4%-0.7%）、-0.4%（95%CI 0.2%-0.5%）;氣喘:-1.4%（95%CI 1.3%-1.6%）、-0.4%（95%CI 0.2%-0.6%）;肺炎: -0.8%（95%CI 0.7%-0.9%）、-0.8%（95%CI 0.7%-0.9%）]。本研究探討台灣菸害防制法成效，並發現在心臟血管疾病方面，疾病的住院率隨著兩階段菸害防制法實施而增加，但此一增加趨勢已逐漸和緩；在呼吸道疾病方面，疾病的住院率隨著兩階段法令的實施，產生先升高後下降的情形，住院率下降的趨勢也逐漸和緩。

關鍵字

菸害防制法；心臟血管疾病；呼吸道疾病；疾病住院率；全民健康保險研究資料庫

並列摘要

Numerous studies have shown that second hand smoke (SHS) exposure increases the risk of cardiovascular, cerebrovascular and respiratory diseases. Active smoking and SHS exposure can be effectively reduced by creating smoke-free public environments enacted through national legislation. Furthermore, such legislation has been proved that it will bring health benefits to the public. The government of Taiwan implemented the Tobacco Hazards Prevention Act in 1997. In January 2009, an amendment to the Act took effects by prohibiting smoking in almost all indoor work places and public areas. However, no national studies evaluating the association between smoke-free legislation and hospitalizations for cardiorespiratory conditions were identified. Given that the strong relationship between SHS exposure and cardiorespiratory conditions was confirmed, this study aimed to examine the impact of smoke-free legislation on hospitalizations for cardiorespiratory conditions. The study used the National Health Insurance Research Database (NHIRD) to obtain nationwide data on hospital admissions for cardiorespiratory and control disease, which included ischemic heart disease(IHD), stroke, chronic obstructive pulmonary disease (COPD), asthma, pneumonia, and control disease (intestinal obstruction, acute appendicitis and acute pancreatitis) from January 1996 to November 2012. The hypothesis that there was a step and slope change in hospitalizations for cardiorespiratory conditions after implementation of smoke-free legislation was tested. Potential confounders were adjusted for: month, time trend, SARS, dust storms, and pay for performance. Compared with pre-stage smoke-free legislation, both first and second stages of smoke-free legislation were associated with an immediate increase (step change) in cardiovascular admissions (IHD: +13.8% (95%CI 12%-15.6%), +59.5% (95%CI 51.9%-67.4%); stroke: +8.7% (95%CI 7.0%-10.4%), +21.8% (95%CI 15.3%-28.6%)), followed by a gradual decrease (slope change) in monthly admission rate (IHD: -0.8% (95%CI 0.6%-0.9%) per month, -1.1% (95%CI 0.9%-1.2%) per month; stroke: -0.4% (95%CI 0.2%-0.5%) per month, -0.5% (95%CI 0.4%-0.6%) per month). Hospitalization for respiratory disease significantly increased after the implementation of the first-stage smoke-free legislation, conversely, the introduction of second-stage smoke-free legislation was associated with a significant reduction in hospitalization of respiratory disease (COPD: +17% (95%CI 14.9%-19.1%), -22.1% (95%CI 16.3%-27.5%); asthma: +24.8% (95%CI 22.4%-27.4%), -71.6% (95%CI 68.5%-74.4%); pneumonia: +26.7% (95%CI 25.4%-28.1%), +11.8% (95%CI 8.5%-15.1%)). The gradual decrease of respiratory admissions was shown in both first and second stages of smoke-free legislation (COPD: -0.6% (95%CI 0.4%-0.7%) per month, -0.4% (95%CI 0.2%-0.5%) per month; asthma: -1.4% (95%CI 1.3%-1.6%) per month, -0.4% (95%CI 0.2%-0.6%) per month; pneumonia: -0.8% (95%CI 0.7%-0.9%) per month, -0.8% (95%CI 0.7%-0.9%) per month). Findings suggest the strong evidence that smoke-free legislations in Taiwan are associated with positive health outcomes. For cardiovascular disease, an immediate increase and a gradual decrease of hospitalizations in both stages were found. For respiratory disease, it was found an immediate increase on the hospitalization, and then a gradual decrease in monthly rate in the first-stage legislation. In the second stage, the hospitalization of respiratory disease was found to have an immediate decrease and then a sustained decrease in monthly rate.

並列關鍵字

smoke-free legislation ； cardiovascular disease ； respiratory disease ； cardiorespiratory conditions ； hospitalization ； National Health Insurance Research Database