OBJECTIVE:This study evaluates whether Taiwan's national oral cancer screening programme, implemented in 1999, has led to a reduction in late-stage oral cancer and mortality. DESIGN:An observational population-based ecological cohort study (2004-2022) using data from the Taiwan Cancer Registry, a nationwide cancer registry. SETTING:Taiwan, an island nation with a population of 23.5 million. PARTICIPANTS:The entire male population in the nation diagnosed with oral cancer between 2004 and 2022. MAIN OUTCOME MEASURES:Change in stage-specific, age-standardised incidence and mortality of oral cancer and their annual percentage change (APC). We hypothesised that an effective screening programme would lead to an increase in early-stage cancer diagnoses while reducing late-stage cancer incidence and mortality. RESULTS:A total of 92 342 males were diagnosed with oral cancer in Taiwan between 2004 and 2022. Following the introduction of the national oral cancer screening programme, the incidence of early-stage (stages 0-1) oral cancer increased 2.4-fold from 6.6 to 14.5 per 100 000 males between 2004 and 2013 (APC: 11.3% (95% CI 9.4% to 13.5%), p<0.001). However, early-stage incidence subsequently declined to 11.8 per 100 000 males by 2022 (APC: -3.2% (95% CI -5.2% to -1.6%), p<0.001), corresponding to a period of decreased screening uptake between 2015 and 2022. The late-stage (stages 2-4) oral cancer increased from 24.5 to 28.3 per 100 000 males between 2004 and 2009 (APC: 3.3% (95% CI 1.8% to 6.6%), p<0.001) and then remained relatively stable between 2009 and 2022 (APC: 0.1% (95% CI -0.5% to 0.5%), p=0.65). Oral cancer mortality increased from 14.4 to 16.6 per 100 000 males over the entire examined period between 2004 and 2022 (APC: 0.76% (95% CI 0.5% to 1.1%), p<0.001), showing no observed decline despite two decades of screening efforts and a continued decrease in prevalence of betel quid use. CONCLUSIONS:Although oral cancer screening detected more early-stage cancer, no reduction in population late-stage incidence or mortality was observed. Therefore, reducing betel quid and cigarette consumption should be the primary focus for oral cancer control. The public health response to oral cancer should borrow from lessons learnt in tobacco control.

We propose a restrictiveness measure for economic models based on how well they fit pre-defined synthetic data. This measure, together with a measure for how well the model fits real data, outlines a Pareto frontier, where models that rule out more regularities, yet capture the regularities that are present in real data, are preferred. To illustrate our approach, we evaluate the restrictiveness of models in two laboratory settings—certainty equivalents and initial play—and one field setting—takeup of microfinance in Indian villages. The restrictiveness measure reveals insights about each, including that some economic models with only a few parameters are very flexible.

Large language models (LLMs) are increasingly used to predict human behavior. We propose a measure for evaluating how much knowledge a pretrained LLM brings to such a prediction: its equivalent sample size, defined as the amount of task-specific data needed to match the predictive accuracy of the LLM. We estimate this measure by comparing the prediction error of a fixed LLM in a given domain to that of flexible machine learning models trained on increasing samples of domain-specific data. We further provide a statistical inference procedure by developing a new asymptotic theory for cross-validated prediction error. Finally, we apply this method to the Panel Study of Income Dynamics. We find that LLMs encode considerable predictive information for some economic variables but much less for others, suggesting that their value as substitutes for domain-specific data differs markedly across settings.

Unmet need for family planning (UNFP) among adolescent girls and young women (AGYW) remains a major public health concern because it contributes to unintended pregnancy and adverse reproductive health outcomes. Although Nepal has expanded family planning programs over the past decade, evidence on trends and factors associated with UNFP among AGYW is limited. This study assessed trends and factors associated with UNFP among currently married AGYW aged 15–24 years using nationally representative data from the 2011, 2016, and 2022 Nepal Demographic and Health Surveys. Data from currently married AGYW aged 15–24 years were analyzed. UNFP was categorized as unmet need for spacing or limiting, defined as non-use of contraception despite intending to delay or stop childbearing. A binary overall UNFP variable (no unmet need vs. total unmet need) and a multinomial UNFP variable (no unmet need, unmet need for spacing and unmet need for limiting) were analyzed. In the first case, modified Poisson regression with robust standard errors was used to estimate Adjusted Prevalence Ratios (aPRs), while, in the second case, multinomial logistic regression was performed to calculate adjusted Relative Risk Ratios (RRR) for UNFP related to spacing and limiting needs, compared to no UNFP. All statistical analyses were performed using R version 4.6.1. Overall UNFP declined from 39.1

BackgroundCervical cancer remains a major public health challenge in sub-Saharan Africa (SSA), mainly due to low screening uptake. Mass media exposure (including radio, newspapers, and television) can play a key role in promoting health services utilisation; however, little is known about its relationship with cervical cancer screening uptake in SSA. This study examined the association between mass media exposure and cervical cancer screening uptake among women aged 30-49 years in four SSA countries.MethodsThis cross-sectional study utilized data from the Demographic and Health Surveys conducted between 2022 and 2023 in four SSA countries: Ghana, Kenya, Mozambique, and Tanzania. A pooled weighted sample of 26,936 women aged 30-49 years was analysed. Univariable and multivariable logistic regression models were fitted to assess the association between mass media exposure and cervical cancer screening uptake. Adjusted odds ratios with their corresponding 95% confidence intervals were estimated.ResultsThe pooled prevalence of cervical cancer screening was 15.2% (95% CI: 14.5-15.9), with the lowest rate in Ghana at 7.3% and highest in Kenya at 27.0%. The multivariable analysis revealed that women exposed to mass media were 74% more likely to have been screened for cervical cancer (AOR: 1.74; 95% CI: 1.40-2.16.) compared to those without media exposure.ConclusionThis study demonstrated a positive association between mass media exposure and uptake of cervical cancer screening among women in SSA. This highlights the important role that mass media can play in promoting the uptake of screening in the region. Thus, increasing access to media platforms, such as radio, television, and newspapers could enhance awareness and participation in cervical cancer screening services, ultimately helping reduce the disease burden in SSA.

INTRODUCTION:Amidst the global effort to curb cross-border transmission of COVID-19, numerous nations enforced international travel restrictions. One example is Taiwan, which witnessed an 85%-90% reduction in international travel during 2020-2022 compared with the preceding decade's average. Consequently, sales of duty-free cigarettes plummeted by approximately 90%. OBJECTIVES:This study leverages the virtual elimination of duty-free cigarette sales during the COVID-19 pandemic in Taiwan as a natural experiment to scrutinise the impact of banning such sales on cigarette consumption. The focus is on whether the drastic reduction in duty-free sales was compensated by an increase in taxed cigarette sales. METHODS:We analysed trends in sales of both duty-free and taxed cigarettes, using data from Taiwan Ministry of Finance and Customs Administration between 2010 and 2023. We used quadratic regression models to fit historical taxed and duty-free sales data from 2010 to 2019. Subsequently, we projected total sales between 2020 and 2023 under a business-as-usual scenario where no travel ban occurred and duty-free sales were not disrupted. RESULTS:The virtual eradication of duty-free cigarette sales was only partially offset by an upturn in taxed cigarette sales. The sales projected under the business-as-usual scenario consistently exceed the actual observations, with real data falling below the lower bound of the 95% CI in both 2021 and 2022. CONCLUSIONS:Duty-free tobacco sales associated with international travel should be abolished for the benefit of both public health and government tax revenue.

Wayne Gao and colleagues argue that high detection rates and high survival rates in never smokers are less likely to be evidence of screening benefit and more likely to be evidence of its harm—overdiagnosis

Cervical cancer is the leading cause of cancer deaths among women in Malawi. Women living with HIV (WLHIV) are more susceptible to developing cervical cancer due to their compromised immune system. Screening facilitates early detection and timely management of the disease. However, there is limited evidence regarding the factors associated with its uptake. Thus, the aim of this study was to assess the uptake of cervical cancer screening and its associated factors among WLHIV in Malawi. This study was based on nationally representative data from the 2020–2021 Malawi Population-based HIV Impact Assessment, which included a sample of 1696 WLHIV aged 15 years and older. Descriptive statistics were conducted to ascertain the proportion of WLHIV screened for cervical cancer, while multivariable logistic regression was used to determine the factors associated with cervical cancer screening uptake. In total 668 women reported having ever been screened for cervical cancer, representing a screening rate of 38.0

ABSTRACT Background The randomized trials of low dose computed tomography (LDCT) screening enrolled individuals at high risk of lung cancer: heavy cigarette smokers. Nevertheless, opportunistic screening of never smokers has become commonplace in certain regions of East Asia. Lung cancer detection rates reported for this low-risk group regularly exceed those reported in the randomized trials. We sought to determine the lead time, the length of time between screen detection and when symptoms would manifest (clinical presentation) associated with LDCT detection rates reported in Taiwan. Objective To estimate the lead time for LDCT lung cancer detection in never smoking Taiwanese females, under the assumption that all detected cancers progress. Methods We analyzed data from the Taiwan Lung Cancer Screening in Never-Smoker Trial (TALENT), a prospective cohort of 12000~ never smokers aged 55 to 75, and compared age-specific screen detection rates to lung cancer incidence rates in the pre-screening period. Lead time was estimated using Morrison's approximation: one-half the ratio of screen detection to pre-screening incidence. Results: Invasive lung cancer detection rates in non-smoking females were 18 (age 70-74) to 37 (age 55-59) times higher than the respective age-specific lung cancer incidence rates prior to widespread screening. The estimated lead times for invasive lung cancers thus ranged from 9 (age 70 to 74) to 18.5 years (age 55 to 59). Had we included in situ lung cancer detection, the estimated lead time of screening would range from approximately 10 to 20 years. Conclusion If all detected cancers progress, the lead times for LDCT lung cancer detection in never smokers would be 5 to 20 times longer than that reported in the randomized trials of heavy smokers (1 to 2 years). Such extended lead times are not only undesirable (Why label and treat a patient for a cancer not destined to clinically present in the next 1 or 2 decades?), but also a major source of overdiagnosis, providing plenty of time for a patient to die from other causes before developing a symptomatic cancer (Type 1 overdiagnosis). Furthermore, some screen-detected cancers may not progress and thus have an infinite lead time (Type 2 overdiagnosis). Regardless, it appears that substantial overdiagnosis has occurred in screening low-risk, never smoking individuals. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript

Importance For the first time, the 2020 World Health Organization guidelines on physical activity recommended reducing sedentary behaviors owing to their health consequences. Less is known on the specific association of prolonged occupational sitting with health, especially in the context of low physical activity engagement.Objective To quantify health risks associated with prolonged occupational sitting and to determine whether there is a certain threshold of physical activity that may attenuate it.Design, Setting, and Participants This prospective cohort study included participants in a health surveillance program in Taiwan who were followed-up between 1996 and 2017. Data on occupational sitting, leisure-time physical activity (LTPA) habits, lifestyle, and metabolic parameters were collected. Data analysis was performed in December 2020.Main Outcomes and Measures The all-cause and cardiovascular disease (CVD) mortality associated with 3 occupational sitting volumes (mostly sitting, alternating sitting and nonsitting, and mostly nonsitting) were analyzed applying multivariable Cox regression models to calculate the hazard ratios (HRs) for all participants and by subgroups, including 5 LTPA levels and a personal activity intelligence (PAI)-oriented metric. Deaths occurring within the initial 2 years of follow-up were excluded to prevent reverse causality.Results The total cohort included 481 688 participants (mean [SD] age, 39.3 [12.8] years; 256 077 women [53.2%]). The study recorded 26 257 deaths during a mean (SD) follow-up period of 12.85 (5.67) years. After adjusting for sex, age, education, smoking, drinking, and body mass index, individuals who mostly sat at work had a 16% higher all-cause mortality risk (HR, 1.16; 95% CI, 1.11-1.20) and a 34% increased mortality risk from CVD (HR, 1.34; 95% CI, 1.22-1.46) compared with those who were mostly nonsitting at work. Individuals alternating sitting and nonsitting at work did not experience increased risk of all-cause mortality compared with individuals mostly nonsitting at work (HR, 1.01; 95% CI, 0.97-1.05). For individuals mostly sitting at work and engaging in low (15-29 minutes per day) or no (<15 minutes per day) LTPA, an increase in LTPA by 15 and 30 minutes per day, respectively, was associated with a reduction in mortality to a level similar to that of inactive individuals who mostly do not sit at work. In addition, individuals with a PAI score exceeding 100 experienced a notable reduction in the elevated mortality risk associated with prolonged occupational sitting.Conclusions and Relevance As part of modern lifestyles, prolonged occupational sitting is considered normal and has not received due attention, even though its deleterious effect on health outcomes has been demonstrated. In this study, alternating between sitting and nonsitting at work, as well as an extra 15 to 30 minutes per day of LTPA or achieving a PAI score greater than 100, attenuated the harms of prolonged occupational sitting. Emphasizing the associated harms and suggesting workplace system changes may help society to denormalize this common behavior, similar to the process of denormalizing smoking.

Background It has been known that smoking and various lung diseases including lung cancer can cause lung function impairment. However, the impact of different types of lung function impairments, such as preserved ratio impaired spirometry (PRISm) and airflow obstruction (AO), on the incidence and mortality of lung cancer in both general and never-smoker populations remains unclear. We wished to examine the effect of lung function impairments on lung cancer risks.Methods This was a retrospective cohort study (1 January 1994 to 31 December 2017) of individuals from a health surveillance programme in Taiwan who underwent baseline spirometry tests at the entry point. PRISm was defined as an FEV1/FVC (forced expiratory volume in 1 s/forced vital capacity) ratio >0.7 and FEV1 <0.8, while AO was defined as an FEV1/FVC ratio <0.7. Cox proportional hazards models and cubic spline curves were used to examine the associations between lung function impairments and lung cancer risks.Results The study included 461,183 individuals, of whom 14.3% had PRISm and 7.9% had AO. A total of 4038 cases of lung cancer and 3314 lung cancer-related deaths were identified during the 23 years of follow-up. Individuals with PRISm and AO exhibited a higher risk of lung cancer incidence and mortality compared with those with normal lung function. The adjusted HRs and 95% CIs were 1.14 (1.03 to 1.26) and 1.23 (1.10 to 1.37) in the overall cohort, and 1.08 (0.93 to 1.24), and 1.23 (1.05 to 1.45) in the never-smoker cohort. The risks of both developing and dying of lung cancer increased with the severity levels of lung function impairments and lower FEV1 values.Conclusion Impaired lung function is associated with increased risks of developing lung cancer and subsequent mortality. The study highlights the importance of considering lung function in lung cancer screening for better candidate selection.

Abstract Background A substantially elevated Body Mass Index (BMI) is one of the largest global modifiable risk factors for stroke and heart diseases. Most studies classify BMI according to the WHO BMI cut-off point in stroke and heart disease studies. However, there is a limited understanding of the association between the BMI cut-off point in the Asian population category and stroke and heart disease. This study aimed to investigate the incidence rate ratio of stroke and heart disease by BMI categories for the Asian population. Methods A 7-year prospective longitudinal study (2007–2014) was conducted on 6,688 adult Indonesian individuals (≥ 35 years) residing across 13 different provinces in Indonesia during the survey periods. Data on BMI were collected in 2007. Information on stroke and heart disease was obtained in both 2007 and in 2014. A multivariate-adjusted Poisson regression model was used to estimate the incidence rate ratio (IRR) and 95% confidence intervals (CIs) of either stroke or heart disease or both stroke and heart disease by BMI. Results Among the 6,688 eligible participants, 334 (5%) were judged as stroke and heart disease in 2014. The IRR (95% CI) of stroke and heart disease for participants with obesity was 2.57 (1.64–4.04) compared with those within normal weight. This incidence rate ratio was more pronounced among middle-aged adults (< 55 years) rather than the older adults (≥55 years).The IRR of stroke and heart disease among obese middle-aged adults was 4.18 (95% CI 2.10–8.31). Conclusions An association was observed between obesity and the risk of stroke and heart disease, especially in middle-aged adults. These findings suggest that lowering BMI through the adoption of healthy dietary habits and increasing physical activity, particularly among middle-aged adults with high education, occupational employment, and residence in either urban or rural areas, may be beneficial for preventing stroke and heart disease.

Background The relationship between resting heart rate (RHR) and the risk of end‐stage renal disease (ESRD) among those without cardiovascular disease remains unclear. We aim to establish temporal consistency and elucidate the independent relationship between RHR and the risk of ESRD. Methods and Results This cohort enrolled participants from 476 347 individuals who had taken part in a screening program from 1996 to 2017. We identified 2504 participants who had ESRD, and the median follow‐up was 13 years. RHR was extracted from electrocardiography results, and the study assessed the relationship between RHR and the risk of ESRD using the Cox proportional hazards model. Of the participants, 32.6% had an RHR of 60 to 69 beats per minute (bpm), and 22.2% had an RHR of ≥80 bpm. Participants with an RHR of ≥80 bpm had a higher stage of chronic kidney disease, lower estimated glomerular filtration rate, and more proteinuria than those with an RHR of 60 to 69 bpm. Participants with an RHR of 80 to 89 and ≥90 bpm had a 24% (hazard ratio [HR], 1.24 [95% CI, 1.09–1.42]) and 64% (HR, 1.64 [95% CI, 1.42–1.90]) higher risk of ESRD, respectively. The risk of ESRD remained significantly elevated (HR, 1.32 [95% CI, 1.10–1.58] per 10‐beat increase from 60 bpm) after excluding participants who smoked; had hypertension, diabetes, or hyperlipidemia; or were overweight. Conclusions An RHR of ≥80 bpm is significantly associated with an increased risk of ESRD. These results suggest that RHR may serve as a risk factor for kidney disease in individuals without established cardiovascular disease risk factors.

Population Medicine considers the following types of articles:• Research Papers -reports of data from original research or secondary dataset analyses.• Review Papers -comprehensive, authoritative, reviews within the journal's scope.These include both systematic reviews and narrative reviews.• Short Reports -brief reports of data from original research.• Policy Case Studies -brief articles on policy development at a regional or national level.• Study Protocols -articles describing a research protocol of a study.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.

Abstract BackgroundFor the first time, the 2020 WHO guidelines on physical activity recommend reducing sedentary behaviors due to their health consequences. Less is known on the effect of prolonged occupational sitting, especially in the context of low physical activity engagement.This study aims at quantifying cardiovascular risk associated with prolonged occupational sitting and determining the additional amount of physical activity that may be needed to attenuate it.MethodsA cohort comprising 481,688 participants in a health surveillance program in Taiwan was followed between 1996 and 2017, collecting data on occupational sitting time, leisure-time physical activity (LTPA) habits, lifestyle, and metabolic parameters. The all-cause and expanded cardiovascular disease (CVD + diabetes mellitus + kidney disease) mortality associated with three occupational sitting volumes (mostly sitting, alternating sitting and non-sitting, mostly non-sitting) was analyzed applying multivariate Cox regression models to calculate the hazard ratios (HRs) for all participants and by subgroups, including five levels of LTPA. Deaths in the first two years of follow-up were excluded to avoid reverse causality.ResultsThe study recorded 26,257 deaths during a mean follow-up period of 12.85 years. Individuals mostly sitting at work had a higher mortality risk than those mostly non-sitting, both from all causes (HR: 1.16, 95% CI: 1.11-1.20) and from expanded CVD (HR:1.46, 95% CI:1.35-1.58), after adjusting for gender, age, education, smoking, drinking, and body mass index. Individuals alternating sitting and non-sitting at work did not experience increased risk for all-cause mortality, compared to individuals mostly non-sitting at work (HR: 1.01, 95% CI: 0.97-1.05), but did experience higher risk of deaths due to expanded CVD (HR: 1.13, 95% CI: 1.04-1.23). Individuals engaged in low (15-29 min/day) or no (<15 min/day) LTPA, who mostly sit at work, would need to increase their LTPA by 15 and 30 minutes respectively to reduce their risk of mortality to that of similarly inactive individuals who mostly do not sit at work.ConclusionsAs part of modern lifestyles, prolonged occupational sitting is considered normal and has not received due attention, even though its deleterious effect has been largely proved. Alternating sitting and non-sitting at work, as well as an extra 15 to 30 min/day of LTPA, can attenuate the harms of prolonged occupational sitting. Thus, emphasizing the associated harms and suggesting workplace system changes could help the society to de-normalize this common behavior, similarly to the process of de-normalizing smoking.

The effectiveness of interventions such as public mask-wearing, contact tracing, and vaccination presents an important lesson for control of the further COVID-19 outbreaks without of whole country lockdowns and the restriction of individual movement. We simulated different scenarios of COVID-19 waves in Taiwan from 2020 to the beginning of March 2022 and considered the following interventions: travel restrictions, quarantine of infected individuals, contact tracing, mask-wearing, vaccination, and mass gathering restrictions. We propose an epidemiological compartmental model modified from the susceptible-exposed-infectious-removed (SEIR) model and derive a formula for the basic reproduction number (R) describing its dependence on all investigated parameters. The simulation results are fitted with the official Taiwanese COVID-19 data. Thus, the results demonstrate that the fast introduction of the interventions and maintaining them at a high level are able the outbreak control without strict lockdowns. By estimation of the R, it was shown that it is necessary to maintain on high implementation level of both non- and pharmaceutical intervention types to control the COVID-19 transmission. Our results can be useful as advice or recommendation for public health policies, and our model can be applied for other epidemiological simulation studies.### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementThis study was funded by the National Health Research Institutes, Taiwan, grant number BN-109-PP-08, and the Ministry of Science and Technology, Taiwan, grant number MOST 106 2115 M 400 001.### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesI confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesAll data produced in the present work are contained in the manuscript

Objective: To investigate the association between the amount and intensity of leisure-time physical activity (LTPA) and the risk of end-stage renal disease (ESRD).Methods: The study examined a cohort of 543,667 participants aged 20 years and older who participated in a health screening program from January 1, 1996, through December 31, 2017. We identified 2520 individuals undergoing dialysis or who had a kidney transplant by linking participants' encrypted personal identification with the registry for ESRD with a median follow-up of 13 years. We classified participants into 5 categories measured by metabolic equivalent of tasks. Within each category, we analyzed the effect of moderate- and vigorous-intensity LTPA in reducing risk of ESRD. We used a Cox proportional hazards model to calculate hazard ratios (HRs).Results: We observed a dose-response relationship between LTPA and the risk of ESRD. The fully active group had a 12% lower hazard of ESRD compared with the no reported LTPA group (HR, 0.88; 95% CI, 0.80 to 0.98) adjusting for covariates including baseline estimated glomerular filtration rate and proteinuria. Within the same category of LTPA, vigorous-intensity exercise carried a 35% lower HR for ESRD compared with moderate-intensity exercise (HR, 0.65; 95% CI, 0.52 to 0.81). The effect was observed stronger among men, younger participants, and participants with diabetes or hyperlipidemia. Conclusion: Sustained LTPA (> 150 minutes per week), particularly with vigorous intensity, significantly lowered the ESRD risk, even among individuals with comorbidities such as diabetes or hyperlipidemia. This finding suggested that patients with no reported LTPA with cardiovascular risks should engage in more LTPA to lower their risk of ESRD.

This paper considers the effect of contracting limitations in risk-sharing networks, arisingfor example from observability, verifiability, complexity or cultural constraints. Wederive necessary and sufficient conditions for Pareto efficiency under these constraints ina general setting, and we provide an explicit characterization of Pareto efficient bilateraltransfer profiles under CARA utility and normally distributed endowments. Our modelpredicts that network centrality is positively correlated with consumption volatility, asmore central agents become quasi-insurance providers to more peripheral agents. The proposedframework has important implications for the empirical specification of risk-sharingtests, allowing for local risk-sharing groups that overlap within the village network.

IMPORTANCE As smoking continues to decline in many developed countries, the proportion of lung cancers in nonsmokers will rise. This shiftmay create substantial pressure to further expand lung cancer screening to lower-risk groups. OBJECTIVE To determine the association of lung cancer incidence with the promotion of screening in a largely nonsmoking population. DESIGN, SETTING, AND PARTICIPANTS This population-based ecological cohort study of stage-specific lung cancer incidence used the Taiwan Cancer Registry to identify women diagnosed with lung cancer from January 1, 2004, to December 31, 2018. Smoking prevalence among Taiwanese women has been less than 5% since 1980. Data were analyzed from February 13, 2020, to November 10, 2021. EXPOSURES Low-dose computed tomography (LDCT) screening for lung cancer, initiated during the early 2000s. MAIN OUTCOMES AND MEASURES Change in stage-specific lung cancer incidence. An effective cancer screening program will not only increase the incidence of early-stage cancer but also decrease the incidence of cancer presenting at a late stage. RESULTS A total of 57 898 women were diagnosed with lung cancer in a population of approximately 12 million Taiwanese women. After the introduction of LDCT screening, the incidence of early-stage (stages 0-I) lung cancer in women increased more than 6-fold, from 2.3 to 14.4 per 100 000 population (absolute difference, 12.1 [95% CI, 11.3-12.8]) from 2004 to 2018. There was no change, however, in the incidence of late-stage (stages II-IV) lung cancer, from 18.7 to 19.3 per 100 000 (absolute difference, 0.6 [95% CI, -0.5 to 1.7]). Because the additional 12.1 per 100 000 early-stage cancers were not accompanied by a concomitant decline in late-stage cancers, virtually all the additional cancers detected represent overdiagnosis. Despite stable mortality, 5-year survival more than doubled from 2004 to 2013, from 18% to 40%, which is arguably the highest lung cancer survival rate in the world. CONCLUSIONS AND RELEVANCE This population-based ecological cohort study found that low-dose computed tomographic screening of mostly nonsmoking Asian women was associated with considerable lung cancer overdiagnosis. Five-year survival is biased by the increased LDCT detection of indolent early-stage lung cancers. Unless randomized trials can demonstrate some value to low-risk groups, LDCT screening should remain targeted only to heavy smokers.