檳榔、吸菸、飲酒習慣之死亡別及平均餘命影響：前瞻性社區追蹤探討

Abstract

背景 國內外有關嚼食檳榔、吸菸、飲酒的相關研究多以研究單項或2項危險因子對健康造成的危害為主，較少針對多因子及多種疾病之死亡原因及平均餘命的影響提出探討。主要原因是競爭死因在方法學上應用不普及而且也較缺乏長時間的觀察及以社區群體為基礎之世代追蹤研究。 研究目的 本論文擬以社區闔家歡健康篩檢作為研究基礎，進而探討嚼食檳榔、吸菸、飲酒等危險因子對死因別及平均餘命的影響。 材料與方法 本論文的研究族群來自於參與某社區闔家歡健康篩檢的民眾，該項篩檢計畫為整合性篩檢服務計畫，主要是針對年滿20歲以上的民眾提供多項癌症及慢性病篩檢，並利用結構式問卷收集受檢者的生活習慣及相關病史(個人及家族)等資料。研究期間自1999-2009年間總計有254,439人次參與社區闔家歡健康篩檢，扣除重複參加次數，本篩檢世代共計有107,006人，其中男性42,494人(佔39.71%)、女性64,512人(佔60.29%)，篩檢涵蓋率約為42.1%。在本篩檢服務計畫中，除了利用結構式問卷中所蒐集到的生活型態部分(如吸菸、嚼食檳榔及飲酒史)相關資料，針對三項危險因子考慮劑量效應及初始使用年齡下，以Fine-Gray競爭風險模式探討對於不同疾病死亡原因之影響及平均餘命之影響。 結果 男性嚼食檳榔盛行率約8.0%，女性嚼食檳榔盛行率約0.6%，男性吸菸盛行率約43.8%，女性吸菸盛行率約8.0%，男性飲酒盛行率約37.7%，女性飲酒盛行率約7.8%。已戒檳榔者，其全死因死亡風險為無嚼食檳榔者之1.39(1.18-1.63)倍，持續嚼食檳榔者則為1.80 (1.55-2.08)倍。已戒菸者，其全死因死亡風險為無吸菸者之1.16(1.05-1.27)倍，持續吸菸者則為1.53(1.43-1.62)倍。已戒飲酒者之全死因死亡風險為無飲酒者之1.28(1.16-1.41)倍，但持續飲酒者為全死因死亡之保護因子。檳榔嚼食每日超過20顆以上者，其全死因死亡風險為無嚼食檳榔者之3.03(2.12-4.32)倍，每日吸菸支數超過20支以上者，其全死因死亡風險為無吸菸者之1.69 (1.50-1.91)倍，每日飲酒杯數超過2杯以上者，全死因死亡風險為無飲酒者之1.84 (1.52-2.22)倍。嚼食檳榔者較無嚼食檳榔者其慢性肝炎及肝硬化、腦血管疾病、意外及自殺死亡風險分別為6.12倍(95%CI:3.64-10.29)、2.49倍(95%CI:1.58-3.92)、2.74倍(95%CI:1.60-4.71) 及1.93倍(95%CI:1.13-1.31)。吸菸者較無吸菸者其在全癌症死亡風險約1.7倍(95%CI:1.51-1.90) 、口腔癌死亡風險約3.18倍(95%CI:1.34-7.57) 、食道癌死亡風險約3.61倍(95%CI:2.01-6.51)、心血管疾病死亡風險約1.6倍(95%CI:1.36-1.95) 、腦血管疾病死亡風險約1.32倍(RR=1.32, 95%CI:1.06-1.64) 、肺炎死亡風險為1.39倍(95%CI:1.05-1.84)、自殺死亡風險約1.9倍95%CI:1.27-2.76)。飲酒者較無飲酒者其食道癌死亡風險為1.97倍(95%CI:1.13-3.44)。有吸菸習慣者與無吸菸習慣者相比，男、女性其30歲平均餘命分別約短少3.27及2.78年;有嚼食檳榔習慣者與無檳榔嚼食者相比，男、女性其30歲平均餘命分別約短少3.76及3.07年;而有飲酒習慣者與無飲酒習慣者相比，男、女性其30歲平均餘命分別約分別約短少1.67及1.0年。 結論 本研究為少見以族群為主的大規模針對吸菸、飲酒及嚼食檳榔與平均餘命的探討研究。此以族群為主之嚼食檳榔、吸菸及飲酒習慣不僅對全死因死亡造成影響，其劑量效應亦與全死因死亡相關。嚼食檳榔與慢性肝炎及肝硬化、腦血管疾病、意外及自殺等疾病死亡有關，吸菸與全癌症、口腔癌、食道癌、心血管、腦血管，肺炎及自殺等疾病死亡相關，飲酒與食道癌死亡有關，而檳榔嚼食及吸菸的暴露均會顯著降低平均餘命。本研究發現可做為未來對衛生教育及疾病防治策略之參考。

Background: Most of literatures on the adverse health effects of areca nut chewing, smoking, or drinking rarely assessed the joint effect of areca nut chewing combined with the other two habits on specific causes of death and also life expectancy (all-cause death) due to unfamiliarity with the methodology making allowance for competing causes of death or lacking of a longitudinal population-based study. Objectives: This study aimed to elucidate the effect of joint use of areca nut chewing with smoking and drinking on the life expectancy with the Keelung Community-based Screening (KCIS) program. Materials and Methods: A total of 107,006 subjects participating the KCIS program between 1999 and 2009 were enrolled in the current study. The KCIS program provided screening for multiple cancers and chronic diseases for Keelung residents aged 20 years or older. Structural questionnaire was administed to collect data on the life habits, and medical history (including personal and family histories). To measure life expectancy and mortality rate, the mortality until the end of 2009 for each participant was ascertained from the National Cause of Death Register. Over a mean follow-up of 6.32 years, the 6,947 deaths occurred. Comparison between groups with and without those habits by different disease categories in mortality was further conducted. Person years and number of death in two groups were used to estimate the relative ratio of mortality for the overall group and age-specific group. Several leading causes of death including carcinoma, cardiovascular disease, cerebrovascular disease, diabetes mellitus, chronic respiratory disease, and chronic liver disease or cirrhosis were selected for elucidating case-specific relative mortality. By using standard life table methods, age specific mortality rates were used to estimate life expectancy from aged 30. We categorized the three main risk factors: areca-nut chewer (current, ex-user, and none); smoker (current, ex-user, and none); alcoholic (current, ex-user, and none) and then separately estimated life expectancy from age 30 in each of the different combinations of these risk factors. Result: There were 42,494 male (39.71%) and 64,512 female (60.29%) participants in the current study. Among them, 8.0% was areca-nut chewer. 43.8% was smoker, and 37.7 %was alcoholic in male. 0.6% was areca-nut chewer. 8.0% was smoker, and 7.8 %was alcoholic in female. In males,the proportion of ever smoking increases with advancing age up to 50 years being from 40 % for age group 20-29 to 64% for age group 40-49,and then declined to 58% for age group 50-69,47% for those aged 70 years and older.The similar finding was noted for alcohol drinking.Regarding areaca nut chewing, it was rampant among young adults aged 20-30 years then declined with advancing age from 11% for age group 40-49 to 0.48% for those aged 70 years and older.The proportion of ever smoking for females was lower then that for males.It was prevalent among those aged 20-39 years and decrease with age form 13% for age group 20-29 to 6~8% for old age group.The similar findings were noted for alcohol drinking.The habit of areca nut chewing was rare in females,being constant but less than 1% for all age groups. For all-causes death, the adjusted relative rate (RR) for former areca-nut chewer versus non-chewer was 1.39 (95%CI: 1.18-1.63). The 1.80 (95%CI: 1.55-2.08) of RR was found for current areca-nut chewer versus non-chewer. The RR for former smoker (relative to non-smoker) was 1.16 (95%CI: 1.05-1.27) and was 1.53 (95%CI: 1.43-1.62) for current smoker. The RR for former drinker (relative to non-drinker) was 1.28 (95%CI: 1.16-1.41) and was 0.90 (95%CI: 0.84-0.97) for current drinker. The RR for high dose chewer (over 20 pieces per day) (relative to non-chewer) was 3.03 (95%CI: 2.12-4.32). The RR for high dose smoker (over 20 sticks per day) (relative to non-smoker) was 1.69 (95%CI: 1.50-1.91). The RR for high dose drinker (over 2 glasses per day) (relative to non-drinker) was 1.84 (95%CI: 1.52-2.22). For specific-diseases death, current areca-nut chewers had high risk on chronic liver disease or cirrhosis (RR: 6.12; 95%CI: 3.64-10.29), cerebrovascular disease (RR: 2.49; 95%CI:1.58-3.92), accidence (RR: 2.74; 95%CI: 1.60-4.71), and suicide (RR: 1.93; 95%CI: 1.13-1.31). The current smokers had high risk on carcinoma (RR: 1.7; 95%CI: 1.51-1.90), oral cancer (RR: 3.18; 95%CI: 1.34-7.57), esophageal cancer (RR: 3.61; 95%CI: 2.01-6.51), cardiovascular disease (RR: 1.6; 95%CI: 1.36-1.95), cerebrovascular disease (RR: 1.32; 95%CI: 1.06-1.64), pneumonia (RR: 1.39; 95%CI: 1.05-1.84), , and suicide (RR: 1.9; 95%CI: 1.27-2.76). The current drinkers had high risk on esophageal cancer (RR: 1.97; 95%CI: 1.13-3.44). The risk of death was still significantly higher for ex-chewer in comparison with non-chewer. In these areas, the average life expectancy for male and female was 52.88 years and 56.51 years at age 30, respectively. Compared with subjects without any baseline risk factors, the life expectancy of ever smoker was shorter by 3.27 and 2.78 years for male and female from age 30, respectively. Compared with subjects without any baseline risk factors, the life expectancy of ever areca-nut chewer was shorter by 3.76 and 3.07 years for male and female from age 30, respectively. Compared with subjects without any baseline risk factors, the life expectancy of drinker was shorter by 1.67 and 1.0 years for male and female from age 30, respectively. Conclusion: This research was to explore the relation between the risk factors, smoking, drinking, and betel nut chewing and life expectancy. It was found that the three risk factors showed a significant influence on all-cause death and life expectancy. The dose-response relationships for deaths were also noted for areca nut chewing, smoking and drinking. The results were very useful to apply the life-style modification based on the light of risk factors from our findings to increase life expectancy by health education.