臺灣博碩士論文加值系統

背景及目的 世界衛生組織(WHO)統計每年60萬人死於二手菸相關疾病下，如心臟病、呼吸道疾病、癌症。近年亞太地區，發現呼吸道疾病的盛行率增高及醫療費用劇增，主要以COPD最多，次之為氣喘疾病。在歐美文獻中，發現在公共場所、餐廳推行無菸立法後，對慢性阻塞性肺病及氣喘的住院率及死亡率皆有顯著降低。然而，台灣在菸害防制法第二次修法後，迄無相關研究探討氣喘及慢性阻塞性肺病在門急診之醫療利用。
材料及方法 資料來源出自國家衛生研究院之全民健康保險研究資料庫，包含2005年至2013年醫事機構基本資料檔(HOSB)、門診處方及治療明細檔(CD)。使用卜瓦松回歸(Poisson regression)模式分析菸害防制法第二次修法前後，及禁菸場所違規吸菸之處分程度，對氣喘及慢性阻塞性肺病之門急診風險。
結果 菸害防制法第二次修法後，氣喘門診風險較實施前減少。但在氣喘急診風險卻比實施前呈顯著增加。對於慢性阻塞性肺病的門診及急診風險，在實施後均無顯著減少。另在違規吸菸處分程度差異上，對氣喘及慢性阻塞性肺病的門急診風險，違規處分程度較高均比違規處分程度較低有顯著下降。
討論 以全人口資料庫進行氣喘及慢性阻塞性肺病之醫療利用探討，進行整體分析呈現。未來研究，如使用病人就醫資料庫，並納入疾病嚴重度、肺功能，或利用問卷增加個人吸菸史、二手菸暴露環境，對疾病之個人分析層面將更完整。
結論 二手菸暴露範圍縮小，對氣喘之門診風險有顯著減少。因無菸立法未涵蓋家庭，而未成年之急診就醫人次佔60%，可能與氣喘急診風險未減少有關。慢性阻塞性肺病之門診及急診風險未有顯著下降，因本研究大於等於65歲以上長者之門急診就醫人次佔90%以上，而因長者已離開職場環境，故無菸立法對工作場所之環境因素的影響，可能並不顯著。執行違規吸菸處分，違規吸菸處分程度較高，對氣喘及慢性阻塞性肺病之門診、急診風險均有顯著減少。

Background and Objective: The World Health Organization (WHO) estimated annual 600,000 mortality cases due to second-hand tobacco smoke-related diseases, such as heart diseases, respiratory tract diseases, and cancer. Respiratory tract diseases, mainly chronic obstructive pulmonary disease (COPD) and asthma, have become progressively prevalent with increasing costs in the past years in the Asia-Pacific region. In Europe and America, reports demonstrated that smoke-free legislation in public places and restaurants have significantly reduced the hospitalization rate and mortality rate of COPD and asthma. However, no study examined the second stage of smoke-free legislation on ambulatory and emergency visits for COPD and asthma.
Materials and Methods: We collected and analyzed the data on ambulatory care expenditures by visits (CD), and registry for contracted medical facilities (HOSB) files between 2005 and 2013 from the National Health Insurance Research Databases (NHIRD) of Taiwan. We applied Poisson regression analysis to assess the relative risk of ambulatory and emergency visits of patients with COPD or asthma following the second stage of smoke-free legislation.
Results: The implementation of the second stage of smoke-free legislation was associated with a significant reduction in ambulatory visits, but no reduction of emergency visits, in patients with asthma. In patients with COPD, both ambulatory and emergency visits were not reduced. The penalty for smoke ban violations was associated with a significant reduction in ambulatory and emergency visits for asthma and COPD.
Discussion: We provided an overall analysis of the medical utilization of asthma and COPD from the analysis of a population-based database. Future studies, such as the use of the patient medical database, and the inclusion of disease severity, lung function, and the use of questionnaires to obtain personal smoking history and exposure to secondhand smoke, will provide more understanding of the individual profile of the disease.
Conclusions: Second-hand smoke exposure has been decreasing, and there is a significant reduction in the risk of outpatients with asthma. The facts that smoke-free legislation does not cover families and 60% emergency visits in our study were young individuals might explain the lack of reduction in emergency visits for asthma. In patients with COPD, both ambulatory and emergency visits did not decrease significantly. Since the elderly individuals, who had left their workplaces, accounted for more than 90% of those visits in our study for COPD, workplace factors which could be affected by smoke-free legislation may not play a significant role. The implementation of non-compliance penalty for smoking and higher penalty are associated with a significant reduction in the relative risk of outpatients and emergency visits in patients with asthma and COPD.

目錄
第一章 緒論 1
第一節 研究背景 1
第二節 研究重要性 7
第三節 研究目的 9
第四節 研究範圍界定 10
本章小結 12
第二章 文獻探討 13
第一節 菸(菸害)與健康 13
第二節 全球菸害防治趨勢 25
第三節 台灣菸害防制趨勢 29
第四節 無菸立法之醫療利用成效 34
本章小結 43
第三章 研究方法 44
第一節 研究架構與設計 44
第二節 研究假說 49
第三節 研究資料來源與處理 51
第四節 變項之操作定義 59
第五節 統計分析方法 65
本章小結 66
第四章 結果 67
第一節 政策介入之氣喘門急診描述分析 67
第二節 政策介入之慢性阻塞性肺病門急診的描述分析 75
第三節 菸害防制法第二次修法前後之氣喘、慢性阻塞性肺病門急診的影響 83
第四節 違規吸菸之處分程度對氣喘、慢性阻塞性肺病門急診的影響 86
研究結果小結 91
第五章 討論與結論 93
第一節 菸害防制法第二次修法前後對氣喘、慢性阻塞性肺病的醫療利用情形 93
第二節 強化菸害防制政策對氣喘、慢性阻塞性肺病之門急診差異性 96
第三節 研究限制 97
第四節 未來研究之建議 98
第五節 總結 100
參考文獻 101
中文文獻 101
英文文獻 104
附錄一 五大洲吸菸率及吸菸人數 124
附錄二 2009-2013年各縣市違規吸菸之處分數、稽查數 127

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