Human papillomaviruses (HPV) infection is now known to be responsible for almost all cervical cancers, and for a substantial fraction of Head and Neck cancers (HNCs). However, comprehensive epidemiological and economic data is lacking in France, especially for rarer potentially HPV-related cancers, which include anal, vulvar and vaginal cancers. Using the national comprehensive database of French public and private hospital information (PMSI), we assessed prevalence and incidence of patients with in-hospital diagnosis for potentially HPV-related cancers in 2013, and estimated costs related to their management over a 3-year period after diagnosis in France. Concerning female genital cancers, 7,597, 1,491 and 748 women were hospitalized for cervical, vulvar and vaginal cancer in 2013, respectively, with 3,120, 522 and 323 of them being new cases. A total of 4,153 patients were hospitalized for anal cancer in 2013, including 1,661 new cases. For HNCs, 8,794 and 14,730 patients were hospitalized for oral and oropharyngeal cancer in 2013, respectively; 3,619 and 6,808 were new cases. Within the 3 years after cancer diagnosis, the average cost of hospital care per patient varied from €28 K for anal cancer to €41 K for oral cancer. Most expenditures were related to hospital care, before outpatient care and disability allowance; they were concentrated in the first year of care. The total economic burden associated with HPV-potentially related cancers was about €511 M for the French National Health Insurance over a 3 years period (2011 to 2013), ranging from €8 M for vaginal cancer to €222 M for oropharyngeal cancer. This study reported the most up-to-date epidemiological and economic data on potentially HPV-related cancers in France. These results may be used to evaluate the potential impact of new preventive strategies, namely the generalized organized screening of cervical cancer and the nine-valent HPV vaccine, indicated in the prevention of cervical, vaginal, vulvar and anal cancers. Human papillomaviruses (HPV) infection is known to be responsible for various diseases including precancerous lesions, which may progress towards cancer within 5 to 20 years .Most common HPV-related cancers are represented by female genital cancers—including cervical, vulvar and vaginal cancers -, anal cancers, and head and neck cancers (HNCs). Among genital cancers, the primary HPV-related cancer is cervical cancer; since HPV is a key agent for their development almost all cervical cancers would be related to HPV, genotypes 16/18/31/33/45/52/58 being responsible for up to 92% of cervical cancers . Anal caProgramme de Médicalisation des Systèmes d’Information, PMSI) (i) to report epidemiological data of the most frequent cancers potentially related to HPV in hospitalized patients in France and (ii) to describe long-term total direct medical costs related to the management of these cancers. In addition, based on Population Attributable Fractions (PAFs) available from the literature, a complementary analysis has been conducted to estimate epidemiological data and costs associated to cancers attributable to HPV.The epidemiology of potentially HPV-related cancers is well documented in the literature for most common cancers, including cervical cancers and HNCs –4. On thStudy methods have been validated by a multidisciplinary qualified independent scientific committee (ISC).i.e. number of new cases) in hospitalized patients based on a longitudinal analysis of PMSI data. Both prevalence and incidence were estimated for three years studied: 2011 (i.e. 1 January 2011 to 31 December 2011), 2012 and 2013.The epidemiological analysis consisted of the assessment of (i) prevalence of potentially HPV-related cancers in hospitalized patients through a cross-sectional analysis of PMSI data in France and (ii) their incidence  and medical data, this later including dates of start and end of stays, length of stay, reasons for hospital admission (i.e. discharge diagnosis), medical unit(s) of stays, medical procedures performed during the stay, costly drugs dispensed during the stay, and, where applicable, hospital inpatient date of death. It also contains economic information for each hospital stay [Classification commune des actes médicaux, CCAM).The PMSI database is a national and comprehensive database of all hospital discharges in French health care facilities, including public and private hospitals ,17. It ptal stay . All inftal stay . They artal stay ,17. Medii.e. with at least 100 observed new cases per year [i.e. potentially HPV-related cancers) from the literature . Patients with two or more ICD-10 codes belonging to different cancer locations were accounted for each of them.The prevalent population included patients with at least one hospital stay with selected ICD-10 codes as primary, related or associated diagnosis . It was The incident population of hospitalized patients with potentially HPV-related cancer(s) included patients with a first primary, related or associated diagnosis corresponding to one of the selected ICD-10 codes , based oThe economic analysis was performed on patients with a first in-hospital diagnosis of potentially HPV-related cancers in 2011. Patients who presented another primary tumour than those presented in i.e. stay with both surgery and chemotherapy was accounted as surgery). It is to be noticed that radiotherapy performed in ambulatory care and private hospitals are not recorded into the PMSI.The following information was extracted for each of selected patients: sex, age, number of hospital stays, and, for each stay, the corresponding DRG and the type of stay attributed through a stepwise backward classification for the following order: surgery, radiotherapy, chemotherapy, palliative care, other  was calculated the same way but dividing the number of incident hospitalised patients as defined in the “Selection criteria and study populations” section. Both results are presented by the total per 5-years age groups, and per gender where appropriate. Incidence rate was also calculated per 100,000 persons based on the French population size for each 5-years age groups [Prevalence was calculated by dividing the number of prevalent patients by the total number of French women population for female genital cancers, or the total French population for other cancers, for the year corresponding to the studied year . Incidene groups .A sensitivity analysis was conducted determining prevalence and incidence also including patients who presented cancers with location contiguous to uterus (ICD-10 code: C53.8), to vulva (C51.8) and to rectum, anus and anal canal (C21.8), as relation between HPV infection and those location contiguous cancers has not been formally proved to date.® V9.3 software .Analyses were performed using SASIn-hospital care costs were directly extracted from reimbursement tariffs completed in the PMSI database. In France, inpatient healthcare costs are reimbursed by the French National Health Insurance to hospitals through a national Diagnosis Related Group (DGR)-based payment system. The DRG of a hospital stay is notably determined based on recorded discharge diagnosis and classifying procedures performed during the stay. A reimbursement rate is defined for each DRG to cover treatments (except expensive drugs), medical procedures, nursing and physician fees. We used the published DRG tariffs for the year corresponding to the hospital stay. In-hospital care costs were described per patient, as mean ± standard-deviation (SD), and for the whole study population, per cancer location and per item of expenditure.Caisse nationale de l'assurance maladie des travailleurs salaries, Cnamts) report, which details expenditures by group of pathologies, treatments and health events, and daily allowances related to work interruption and disability pensions [Since outpatient care costs are not available in the PMSI but represent a significant part of total direct medical costs related to cancer management, they were estimated based on the National Health Insurance Fund (pensions . OutpatiCosts are reported in Euros (€), year 2018, with costs prior to 2018 being revalued according to a consumer price index published by INSEE . Healthcet al. study has been identified as the most suitable source of data, since it provides the most recent PAF values obtained in France, for all cancer locations assessed in the present study [et al. study  were less finely distributed between oral and oropharyngeal cancers compared to our study  prevalence and incidence of patients that would be HPV positive among those identified for the different cancer locations, and (ii) the amount of health care costs that would actually be due HPV-related cancers for each of the cancer locations. From a literature review, Shield nt study . It shouur study . We thusFinally, PAF value used to perform the complementary analysis were 100.0% for cervical cancers, 23.0% for the gathered group of vulva and vagina cancers, 91.3% for anal cancer, and 18.5% for the whole group of HNCs.Commission Nationale de l'Informatique et des Libertés, CNIL), including confidentiality at the individual level. Indeed, stève consultants, consultancy company responsible for the study analysis design and implementation, is approved by the CNIL for confidentiality, expertise and independence commitment criteria for access to French Health Data (http://doc.indsante.fr/20171128-%20Engagement%20de%20conformite%20au%20%20r%C3%A9f%C3%A9rentiel.pdf). Its CNIL authorization number for permanent access to PMSI data is n°1976885.Processing and exploitation of the data was done with respect to the Chair of the French data protection authority (i.e. number of new cases) are presented for the year 2013; data for the years 2011 and 2012, which were very similar to 2013, are available in supplementary tables  and 14,730 (men 79.1%) patients were hospitalized for oral and oropharyngeal cancer, respectively, with a mean age of 64.0±13.3 and 61.9±10.4 years old; 2,439 patients (men 71.7%) were hospitalized for oral and/or unspecified oropharyngeal cancer, with a mean age of 63.0±12.1 years old . OverallThe complementary analysis allowed estimating at 4,803 the number of women hospitalized for HNC attributable to HPV, and at 2,052 the number for new cases.i.e. with a first hospital admission for potentially HPV-related cancer of interest in 2011, and after exclusion of patients with another primary tumour—was 14,388 patients. Among female genital cancer, the number of women was 3,005 for cervical cancer, 471 for vulvar cancer, and 279 for vaginal cancer; their mean age was 57.7±15.4, 71.7±14.3 and 66.5±16.6 years old for cervical, vulvar and vaginal cancer, respectively. The number of patients for anal cancer was 1,476, with a mean age of 65.2±13.4 years old. Similarly, the number of patient with potentially HPV-related oral cancer accounted in the economic analysis was 3,139 for oral cancers, and 6,018 for oropharyngeal cancers, with a mean age of 62.6±12.7 and 61.0±10.2 years old, respectively.The total number of patients accounted for the economic analysis—Patients with cervical cancers equally benefited from surgery , chemotherapy  and radiotherapy , permitting the study of potentially HPV-related cancer epidemiology and costs, including rare locations such as anus, vulva and vaginal.The objectives of this study were to estimate prevalence and number of new cases of potentially HPV-related cancers based on in-hospital diagnosis information, and to evaluate costs related to their management. We used the national database of French public and private hospital information . Theet al. reported a total number of 1,237 patients hospitalized for vulvar cancer and 728 for vaginal cancer in 2006 [To our knowledge, no French data for vulvar and vaginal HPV potentially-related cancers are available ,12. In E in 2006 . We iden in 2006 .et al. estimated the size of the prevalent population of patients hospitalized for anal cancer in 2006 from the PMSI database at 3,640 patients [A French study reported that anal cancer has been attributed to HPV in about 96% of cases, more particularly to HPV 16/18 in 78% of cases . Concernpatients . Comparepatients . Similarpatients .The prevalence of HPV in HNCs was found to be 46.5% and 10.5% for oropharyngeal and oral cancers in France, respectively, with HPV genotype 16 being responsible for 89.7% and 95.5% of them . In addiThis study is the first to evaluate the direct medical cost of HPV potentially related cancers using an incident cohort over a period of 3 years follow-up.We adopted a 3-year time horizon based on a published cost analysis from a Danish registry . The assThis economic analysis allowed an accurate calculation of hospital care costs and an estimation of totals cost for cancers care. Most expenditures were related to hospital care costs and were concentrated in the first year of care, which accounted for more the ¾ of total costs. Similar results were observed with the Danish registry that estimated health care costs of anal, penile, vaginal and vulvar cancer, with 2/3 of costs observed over the 3-year study period that were concentrated on the first year . For hosNuméro d’Identification au Repertoire, NIR), allows performing both transversal and longitudinal analysis to accurately assess prevalence and incidence or new events at a nationwide level. Furthermore, comprehensiveness and very detailed levels of cost data are highly valuable to perform economic analysis.The PMSI is a national comprehensive medico-administrative database that provides extensive data covering a population of more than 65 million French inhabitants ,41. The This study has however to be interpreted in light of certain limitations due to the nature of the source of data. Indeed, errors in diagnosis coding would influence the epidemiological data; however, errors are expected to be very rare for these well-known diseases. In addition, quality control and audits are performed on PMSI data to identify aberrant or missing data ,41.versus 15%) [versus 4%) [A second limitation is the lack of detailed clinical data, which leads us to create a third group for HNCs gathering unspecified location cancers. In addition, due to the absence of biological results in the PMSI, we could not determine the effective part of HPV-related cancers among cases identified; however, we clearly stated that the study aimed at assessing epidemiology and burden of potentially HPV-related cancers. We still performed a complementary analysis to estimate the number of potentially HPV-related cancers identified through our study that would actually be related to HPV. We used PAF values available from the most recent French study in the literature . Howeversus 15%) . Among Hrsus 4%) .Finally, main limitations would concern the cost calculation. Indeed, only hospital care costs are recorded into the PMSI; ambulatory care costs and disability allowances were estimated extrapolating hospital care costs, applying distribution of care costs for active cancers reported by the Cnamts. The Cnamts examines the structure of expenditures by group of pathologies, treatments and health events in 2013 based on data from long-term disorders. However, the principle of full reimbursement of medical care related to long-term disorders may lead to a bias, when it includes abusively care unrelated to these specific diseases. This may result in slightly overestimating the part of expenditures related to primary care. On the other hand, the same distribution of expenses was used for all cancers, assuming that the work absenteeism and disability degrees were the same for all cancers in our study. Although this may be incorrect, in the absence of recent specific data, these extrapolations make it possible to estimate the most complete costs associated with HPV potentially related cancers. In addition, it is to be noticed that costs available in the PMSI do not include physician fees which are paid in addition to the DRG. Lastly, costs of radiotherapy are not available for private hospitals. Lastly, we had a conservative approach by including only patients with a single cancer in the economic analysis, which may lead to underestimate the total cost of health insurance expenditure.This study reported the most up-to-date epidemiological and cost data for potentially HPV-related cancers, including locations such as anus, vulva and vagina cancers, for which data were scarce. These cancers represent a significant cost to the Health Insurance. A substantial fraction of these cancer is related to HPV and most of them could be averted. These data may be used to evaluate the potential impact of new preventive strategies to reduce the number of new cases of these cancers, including the nine-valent vaccine, indicated in the prevention of cervical, vaginal, vulvar and anal cancers caused by specific HPV types.S1 Table(DOCX)Click here for additional data file.


IGFBP2, IGF2BP3, PRDX1, NOV, NEFL, HOXA10, GNG12, SPRY4, and BCL11A, were identified. In addition, the underlying rules of classifying the three subtypes were produced by Johnson reducer algorithm. We found that in diffuse astrocytoma, PRDX1 is highly expressed, and in glioblastoma, the expression level of PRDX1 is low. These rules revealed the difference among the three subtypes, and how they are formed and transformed. These genes are not only biomarkers for glioma subtypes, but also drug targets that may switch the clinical features or even reverse the tumor progression.As a common brain cancer derived from glial cells, gliomas have three subtypes: glioblastoma, diffuse astrocytoma, and anaplastic astrocytoma. The subtypes have distinctive clinical features but are closely related to each other. A glioblastoma can be derived from the early stage of diffuse astrocytoma, which can be transformed into anaplastic astrocytoma. Due to the complexity of these dynamic processes, single-cell gene expression profiles are extremely helpful to understand what defines these subtypes. We analyzed the single-cell gene expression profiles of 5057 cells of anaplastic astrocytoma tissues, 261 cells of diffuse astrocytoma tissues, and 1023 cells of glioblastoma tissues with advanced machine learning methods. In detail, a powerful feature selection method, Monte Carlo feature selection (MCFS) method, was adopted to analyze the gene expression profiles of cells, resulting in a feature list. Then, the incremental feature selection (IFS) method was applied to the obtained feature list, with the help of support vector machine (SVM), to extract key features (genes) and construct an optimal SVM classifier. Several key biomarker genes, such as  Glioma is a general term describing a specific subgroup of brain cancers derived from glial cells . Glial c(IDH1), is found in more than 80% of secondary glioblastomas and only 5% of primary glioblastoma, implying that, at least in some conditions, genetic background  may be an optimal biomarker for the recognition of certain glioma subtypes . Clearly, this interval should contain the size of feature subset that can yield the best performance for SVM.In the first stage, we used a large step of 10 to generate several feature subsets, denoted as i features in feature list F. For example, if min = 300 and max = 600, the second stage of IFS method constructed the feature subsets containing first 300–600 features in the feature list F. It is clear that we did careful searching at this stage to find a better feature subset, which may not be tested in the first stage. Similarly, the SVM was executed on cells that were represented by features in each of these feature subsets, also evaluated by ten-fold cross-validation. According to the predicted results, the feature subset producing the best performance for SVM can be extracted. The features in this subset were considered as optimal features, and a corresponding optimal classifier was built on these optimal features.In the second stage, we further constructed a series of feature subsets based on the interval  obtained in the first stage. In detail, feature subsets, denoted as SVM  is a widIn this study, we used the tool “SMO” in Weka (version 3.8.0), which implements one type of SVMs that is optimized by sequential minimum optimization (SMO) . For conIn this study, we considered cells in three glioma tissues. As mentioned in N samples  and C classes  are formulated. Let i is predicted to be class j; otherwise, i belongs to class j; otherwise, it is set to 0.For example, The MCC can be defined as a discretization of the correlation for binary variables, which is specified byF that was obtained by increasing order of features’ RI values, are provided in the In this study, we first used MCFS to rank the genes for different glioma subtypes. The corresponding RI values of the 23,686 genes involved in this study, and the feature list F, was constructed. We trained an SVM classifier on each of these feature subsets, which was evaluated using ten-fold cross-validation. We obtained the best MCC 0.888 using the first 540 features in F. Furthermore, the second highest MCC (0.886) was yielded by the first 370 features. In view of this, we determined the feature interval as . Then, we further constructed a second series of feature subsets with a step of one in the feature number interval  in the second stage of IFS method, that is, we constructed the feature subsets containing first 300–600 features in F. Similarly, by testing on these feature subsets, we yielded the highest MCC 0.889 when the top 539 features were used to train the SVM classifier. Meanwhile, the predicted accuracy values for three glioma subtypes  were 0.981, 0.969, and 0.871, respectively, and the overall accuracy was 0.963. Furthermore, we showed the trends of MCCs corresponding to the number of features involved in building the SVM classifiers  in the feature list yielded by the MCFS method, which are listed in IGFBP2, as the top gene in the feature list yielded by MCFS method, encodes one of the six similar proteins that bind to insulin-like growth factors I and II (IGF-I and IGF-II) [IGFBP2 has been confirmed to be highly expressed in gliomas with high malignancies, such as glioblastoma and anaplastic astrocytoma, but expressed low in the relatively binary astrocytoma, the diffuse astrocytoma [IGFBP2 may be another potential biomarker for the distinction of the three glioma subtypes with positive IDH-1. Similarly, another insulin-like growth factor-binding protein encoded by IGF2BP3 (rank 7) may also be an optimal differential marker for the identification of different glioma subtypes. The next gene, PRDX1 (rank 2), encodes an antioxidant enzyme as a member of the peroxiredoxin family [PRDX1 may be connected to the poor prognosis of glioma subtypes, including glioblastoma and astrocytoma [PRDX1 may be a potential biomarker for the recognition of astrocytoma in elderly patients, confirming its potential role in the differential diagnosis of glioma [NOV (rank 3), encodes a small secreted cysteine-rich protein in the CCN family, and participates in fibrosis and cancer development-associated biological processes [NOV inhibits the proliferation and promotes the migration and invasion of the malignant cells in glioblastoma [NOV in astrocytoma, implying the differential biological function and expression pattern of such gene in different glioma subtypes. The next gene, NEFL (rank 4), encodes a member of the neurofilaments and is involved in the maintenance of neuronal caliber [NEFL  has been functionally connected to a ligand of PPAR gamma PGJ2, and participates in the tumorigenesis of glioblastoma [NEFL, glioblastoma, one of the glioma subtypes, can be accurately identified by such a gene. IGF-II) . As for rocytoma ,50. Thern family . As for rocytoma ,53. In arocesses ,55. Accoblastoma . However caliber . NEFL (ablastoma . With thHOXA10 (rank 5) is involved in a developmental regulatory system that provides cells with specific positional identities on the anterior–posterior axis as a member of transcription factors called homeobox genes [HOXA10 has been functionally connected to the stem cell pattern of glioma cells [HOXA10 may be a potential biomarker for the identification of diffuse astrocytoma cells and validating the efficacy and accuracy of our prediction [GNG12 (rank 6), as another optimal biomarker, contributes to the distinction of different glioma subtypes. As a modulator and transducer in various transmembrane signaling system, such a gene is required for the guanosine triphosphatases (GTPase) activity, which participates in the replacement of guanosine diphosphate (GDP) by GTP [GNG12, may have different expression pattern in glioma. The following two optimal genes, SPRY4 (rank 8) and BCL11A (rank 9), act differentially on the three glioma subtypes according to recent publications. No direct evidence confirmed that SPRY4 may act differentially in glioblastoma and the two astrocytomas. However, a recent study confirmed that, in gliomas, the expression pattern of SPRY4 may be related to the cell proliferation, metastasis, and epithelial–mesenchymal transition processes [SPRY4 may have a differential expression pattern in such subtypes, and act as a potential biomarker based on its expression level [BCL11A, encoding a C2H2 type zinc-finger protein, participates in brain development, leukemogenesis, and hematopoiesis [BCL11A has been reported to contribute to glioblastoma with specific expression pattern [BCL11A on astrocytoma, validating that it may be a potential biomarker for the distinction of the three glioma subtypes.The gene ox genes ,60. The ma cells . Accordiediction ,63. GNG1) by GTP . GTPase-) by GTP ,66. Cons) by GTP , we specrocesses . Therefoon level ,70. BCL1opoiesis ,72. Earl pattern . HoweverTo sum up, the top nine optimal genes have been confirmed to have specific expression patterns in the three candidate glioma subtypes, contributing to further subclassification by recent publications and validating the efficacy and accuracy of our study.Apart from potential biomarkers, we further set up a quantitative identification system involving 24 quantitative rules based on the expression level of each specific parameter (gene). According to recent publications, the tendency and specific threshold of each rule can be confirmed, proving the utility of these rules. Limited by the article length, we screened out the representative rules for the identification of each glioma subtype.XIST with different thresholds. At relatively early stage of gliomas, the degree of malignancy is low in diffuse astrocytoma. XIST, as the shared gene, has been confirmed to participate in tumor-suppressive biological processes; its high expression corresponds with a specific pathological pattern [XIST has been shared by most of the diffuse astrocytoma, validating their efficacy and accuracy of such rules. Apart from XIST, the two homologues, namely, RPL7 and RPL8, have also been predicted to have quantitative patterns in diffuse astrocytoma. Based on the rules, RPL7 has a uniquely high expression pattern, while RPL8 has a relatively low expression pattern. According to recent publications, such a pattern has been identified in the early stage of human fetal astrocytes [RPL7 and RPL8 may be quite different from the other two glioma subtypes [EGR1 [EIF3C [HNRNPH1 [C1orf61 [CYP51A1 [CDR1 [Ten rules were formulated to contribute to the identification of diffuse astrocytoma involving multiple functional genes. To validate the efficacy and accuracy of such rules, we summarized the expression pattern of various related sequencing datasets. Due to the limitation of article length, analyzing each rule individually is impossible. Therefore, we chose three optimal rules for further analysis: rule 3, rule 4, and rule 5. These three rules are involved in 9 genes, each sharing a high expression pattern of  pattern . The higtrocytes . Considesubtypes . Similares [EGR1 , EIF3C [1 [EIF3C , HNRNPH1[HNRNPH1 , C1orf61[C1orf61 , CYP51A1[CYP51A1 , and CDRA1 [CDR1 , have alHSPA1B and MARCKS, together with the low expression of RPSAP58 and PRDX1, may indicate that a patient may suffer from glioblastoma. HSPA1B is highly expressed in glioblastoma and is related to the pharmacological effects of erlotinib [MARCKS is a prognosis reporter for glioblastoma and contributes to the intracranial tumor proliferation rate [MARCKS may be a potential biomarker for the identification of glioblastoma. The remaining two downregulated genes, RPSAP58 and PRDX1, obtained similar evidences [COL20A1, CBR1, and MTRNR2L2, are upregulated, and TCF12 are downregulated [Apart from such filtered rules that contribute to the identification of diffuse astrocytoma, thirteen rules are presented for the validation on glioblastoma. We screened out rule 11 and rule 12 for detailed analysis. Rule 11 involves four functional genes, indicating that high expression of rlotinib . Meanwhiion rate . Therefovidences ,52. Likeegulated ,85. CompIn conclusion, because of the limitation of the article’s length, we cannot analyze the rules individually. However, all rules can be validated by recent publications, implying the efficacy and accuracy of these quantitative rules. Therefore, based on the single-cell sequencing data, we tried to identify the core functional markers and set up the quantitative rules for such distinction. This study may not only screen out a group of candidate biomarkers for the recognition of different tumor subtypes, but also provide us a novel tool for the exploration and recognition of tumor-associated genes.


Numerous urban villages (UVs) and frequent infectious disease outbreaks are major environmental and public health concerns in highly urbanized regions, especially in developing countries. However, the spatial and quantitative associations between UVs and infections remain little understood on a fine scale.r = 0.33, P = 0.000), the number of bus stops  and subway stations , and road density . About 60% of spatial variations in the gridded DF incidence rates were interpreted by the different variables of GDP, UVs, and bus stops integrated in GWR models.In this study, the relationships between reported dengue fever (DF) epidemics during 2012–2017, gross domestic product (GDP), the traffic system , and UVs derived from high-resolution remotely sensed imagery in the central area of Guangzhou, were explored using geographically weighted regression (GWR) models based on a 1 km × 1 km grid scale. Accounting for 16.53%–18.07% of residential area and 16.84%–18.02% of population, UVs possessed 28.55%–38.24% of total reported DF cases in the core area of Guangzhou. The density of DF cases and the DF incidence rates in UVs were 1.81–3.13 and 1.82–3.06 times of that of normal construction land. Approximately 90% of the total cases were concentrated in the UVs and their buffering zones of radius ranged from 0 to 500 m. Significantly positive associations were observed between gridded DF incidence rates and UV area , as well as the vetor-borne diseases  in these regions. In this study, we demonstrated that UVs may serve as transfer stations for the transmission of DF epidemic in the regions with developed transportation, higher GDP and dense population. This is manifested as that the rates of DF incidences were significantly positively associated with UV area. Furthermore, the density of DF cases and the DF incidence rates in UVs were 1.81–3.13 and 1.82–3.06 times of that of normal construction land and about 90% of the total DF cases were concentrated in 500m radius of UVs’ buffers. And the aggregation effects of UVs on this epidemic in the central region were obviously affected by public traffic conditions at the grid level. This study is the first quantitative analysis of the spatial relationship between UVs, public transportation, road density, population density, GDP and DF epidemics, which will provide a useful reference for accurately preventing and controlling DF epidemic in urban regions with numerous UVs.Due to the rapid urbanization of China, many villages in the urban fringe are enveloped by ever-expanding cities and become so-called urban villages (UVs). UVs are widely distributed in not only the Guangzhou core areas but also the other cities in the highly urbanized region of China . UVs are commonly featured by poor sanitation, overcrowding population, absent infrastructure, and some environmental pollution due to the development is neither authorized nor planned, resulting in a high environmental suitability for some vectors (e.g.,  Aedes aegypti and Aedes albopictus mosquitoes [Dengue fever (DF) is a febrile illness caused by the dengue virus, which is further classified into four serotypes (Dengue virus 1–4), and transmitted by squitoes –5. Aftersquitoes , 7. Apprsquitoes , followiBoth domestic and foreign scholars have carried out a considerable amount of research into DF epidemics, including into factors affecting the spread and prevalence of the disease and the corresponding prevention and control measures –13. ThesAedes albopictus, the sole vector of dengue transmission in Guangzhou. However, the current quantitative relationship between UVs and DF epidemics has received very little attention.Informal urban settlements in China are described as urban villages (UVs), unique areas of high population density. Urban space has undergone dramatic transformation and reconstruction during China’s rapid urbanization, which has caused a large number of rural villages that were originally on the edge of the city to be gradually surrounded or semi-enclosed by urban land –20. A laMoreover, different factors influencing the DF epidemic have a spatial scale effect. Most of the available research has been focused on analysis at a relatively large spatial scale, such as at regional and prefecture level –28, withTherefore, this study was based on high-resolution remotely sensed imagery extraction of UVs in the central areas of Guangzhou, using epidemiological statistical methods and spatial analysis to further analyze the spatial relationship between UVs, public transportation, road density, population density, gross domestic product (GDP) and the DF epidemic according to a 1 km×1 km grid scale. The aim was to provide effective guidance for relevant government departments making targeted prevention and control measures on the DF epidemics in urban regions with numerous UVs.2. This area has a population of 5.24 million permanent residents according to the 2017 Guangzhou Statistical Yearbook and is also the economic center of Guangzhou. In 2017, the GDP of the central area reached US$151.73 billion [Aedes albopictus and to the transmission of DENV, making it a high-risk area for DF [The study area was located in the central areas of Guangzhou  and included the four districts of Liwan, YueXiu, Haizhu, and Tianhe. The regional location is shown in  billion . The chaa for DF . In addia for DF .http://www.gpsspg.com/xGeocoding/) and coordinate deviation correction to produce case data for a spatial point layer using ArcGIS 10.3  software  within 24 h . The DF software . In 2014With consideration of the high degree of urbanization of the study area, land use types for 2012 and 2017 was divided into five categories: normal construction land (NCL), UV, water, vegetation and unused land. NCL and UVs are collectively referred to herein as construction land (CL) . A totalhttp://www.resdc.cn). Road density was generated from road network vector data, including all roads in the central region of Guangzhou , and it was the ratio of the length of road in each unit (grid) to the corresponding unit’s area.The public transport system  greatly facilitates the travel of people living in the central area. Population density and GDP data in 2015 were collected to indicate population and economic status. The public transport, population density, GDP and road network vector data in this study  were allp-value because of their high statistical power [p-value represents a tendency towards clustering, which means that adjacent units have similar incidence rates, whereas a low negative value indicates a tendency towards dispersal, which means that units with high incidence rates lie next to units with low incidence rates.Spatial autocorrelation analyses are frequently utilized to explore the spatial patterns of incidence or mortality in terms of Moran’s I with z-score and/or al power –37. Moraal power . GeneralIn addition, the choice of spatial scale is the basis of spatial analysis. In many studies of infectious disease epidemiology, basic geographic units such as districts or townships/streets are often disturbed by changing administrative divisions, and the creation of regular spatial grids can effectively avoid this phenomenon . With rei = 1, 2,…, m denotes the number of spatial units in the central area of Guangzhou; i; independent variable k parameter at location i,  referred to the value of an affecting factor k  at spatial unit i, which is specific for every spatial unit; 2, on which the performance of these models could be evaluated. At the same time, the spatial autocorrelation analysis on the standardized residual (StdResid) values of these models was further employed to evaluate the explanatory performances  of the OLS and GWR models. The Moran’s I values close to zero indicated that there is no spatial autocorrelation of the StdResid values, and the results would be more reliable and then recommended for subsequent analysis.In view of the spatiotemporal heterogeneity of DF incidence rates, the DF epidemic may be affected by its potential influencing factors in different ways and to various degrees, which is appropriate to analyze using a geographically weighted regression (GWR) model. As an extension of the traditional multiple linear regression , a GWR model embeds the attributes’ spatial location into the regression parameter, yielding a local regression together with local estimates of regression coefficients. The loc2 and lower values of AICc, Sigma, and VIF were recommended. Integrating various combinations of influencing factors in the OLS/GWR models with the lowest AICc and Sigma, the highest adjusted R2, and lower VIF than 7.5, eleven univariate models and fourteen multivariate models were respectively conducted for the comparison between CL, UV/NCL, water, vegetation, public traffic, road density, population density and GDP grouped factors.By means of the exploratory regression tool, twenty-five OLS and GWR models with higher Adjusted RIn addition, we created a series of buffering zones with increasing radii based on the boundaries of the UVs, in which the incidence rates, the proportion of the DF cases, as well as its growth rates, in different years in each buffering zone were counted. Meanwhile, Pearson correlation analysis was applied to explore the relationships between DF incidences and all of the potential variables  at the significance level of 0.05 and 0.01, by which some appropriate potential variables could be accordingly considered into the GWR models.All of the above spatial analysis and modeling were completed in ArcGIS 10.3 software . Typical correlation analysis was achieved using SPSS 19.0 .2) and Yuexiu, Liwan, and Tianhe districts had 7.98, 4.06, and 8.80 km2 of UV. There were more than 450 UVs with areas varying from less than 0.001 km2 to 0.87 km2. As a result of urban renewal, the total area of UV decreased from 31.75 km2 (2012) to 31.38 km2 (2017), with a clear reduction in Liwan (about 0.12 km2 in Xinglongfang and Dongjiao communities) and Tianhe  in particular, as shown in Land-use types across the central region, including Liwan, Haizhu, Yuexiu, and Tianhe districts in Guangzhou City, typically featured impervious surfaces  according to their dominant area percentage (53.80% in 2012 and 58.12% in 2017) . Among t2 and 1.95 km2, respectively, between 2012 and 2017, while vegetation and NCL increased by 4.03 km2 and 14.50 km2, respectively. In summary, the central area of Guangzhou City mainly featured impervious surfaces, especially many widely distributed UVs.In the region, the Pearl River fork zone across Yuexiu, Liwan, and Haizhu was the most typically spatially clustered with UVs. Dongpu Town in Tianhe and the central zone of Haizhu were the other two representative zones. Unused land and water area decreased by 16.21 kmp-value < 0.001; There were a total of 20 059 local DF cases reported in the central districts, which accounted for half of the total cases in the whole Guangzhou City during the study period. Meanwhile, the distribution of DF was spatially different across this typical region. The ratio of DF cases in each infected unit to the mean value of all the infected units (RDM) varied spatially on the 1 km × 1 km scale (close to the largest UV area) in 2012, 2013, 2014, and 2017. However, the units with high RDM were mainly located around the Pearl River fork between Yuexiu, Liwan, and Haizhu districts . Meanwhi2) in the UVs was slightly higher than that of NCL in 2012 and 2017, although the population size of NCL is 4.55–4.94 times that of the UVs. As a result, the density of DF cases and the DF incidence rates in UVs were respectively 1.81–3.13 and 1.82–3.06 times that of NCL between 2012 and 2017. It can be clearly seen that UVs possessed higher values of DF cases density, incidence rates, and population density in the central region of Guangzhou City. In other words, DF cases were more likely to be found in UV areas.Between 2012 and 2017, DF patterns in the UVs differed from those of the NCL areas. As shown in r = 0.45, P = 0.015), as shown in r = 0.33, P = 0.000) in the infected units.The sizes of the DF epidemic were associated with the UVs’ area. In the UVs with recorded DF cases, the number of DF cases  was strongly associated with acreage of these UVs  than those without any bus stops or subway stations (7.74 cases per km2) (n = 19). Moreover, as given in r = 0.33, P = 0.000), number of bus stops  and subway stations , and road density .Advanced traffic conditions, especially public transportation systems (such as bus services and subway lines) facilitate contact among people living in UVs. DF case density in the units (n = 272) with either bus stops or subway stations was much higher , the lowest AICc (5305.02), the lowest Sigma (272.80), and a lower VIF value (<1.63). Moreover, according to the spatially random patterns of the StdResid values , the performance of this model was also spatially stable, although there were still a few units with absolute StdResid values > 2  integrating bus stops and UVs performed the best among all of the bivariate models. When this model further integrated either GDP or population density that possessed relatively weaker explanatory ability, the performances were increased according to the rising adjusted Rlues > 2 .In terms of the influence of the three variables  on the spatial variation of DF infection, these variables were spatially differentiated across the central region . The preWidely distributed urban settlements and serious DF epidemics are two major public concerns in Guangzhou City. In this study, we analyzed the spatial and quantitative relationship between the DF epidemic and UVs on a grid scale across the central region of Guangzhou. The interesting findings provide valuable clues to enable local environmental health authorities in targeted interventions in the prevention of this epidemic.Aedes albopictus mosquitoes with a suitable environment for survival and breeding, featuring slightly lower land surface temperature than NCL areas [The size and spatial heterogeneity of the DF epidemics were probably associated with numerous UVs widely distributed across the study region with developed public transportation , good economic status, and a dense population. Previous studies across the entire joint Guangzhou-Foshan (GF) area have found that spatially clustered DF cases in this region are associated with its higher land urbanization level, population size, road density, and economic level (GDP per capita) , 41. OurCL areas , especiaCL areas , 42. ThiCL areas , 44. ThuAedes albopictus) is far less than human mobility due to developed public transportation. Accordingly, we recommend that targeted and effective interventions should be implemented in zones with numerous UVs and public traffic stations across the central region in Guangzhou City during the DF epidemic.A convenient public traffic system meets the commuting demands of local residents, including the floating population who reside in UVs but work outside of them. Earlier studies reported that traffic conditions impose important effects on DF transmission , 41, 45,Use of generalized additive models has revealed that associations between DF infection and GDP were nonlinear at the township level across the Pearl River Delta . Our earThere were some limitations to the study. First, many more important influential factors should be further explored and included in the GWR models to interpret much more spatial variation in the DF epidemic, since less than 60% was explained at present. In particular, an appropriate variable should be acquired to comprehensively reflect both public transportation and population density so as to further interpret the remained (40% or so) spatial variation in the current study. For this point, data derived from mobile devices, metro cards and/or bus cards could be used to capture information about mode of travel and the movement of local residents, both for confirmed and suspected DF cases. This is particularly relevant to the UVs, as the effects of the public transportation system and UVs on DF transmission could be further investigated and high intercept values  decreaseS1 Table(DOC)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.


The purpose of this study is to clarify the effect of providing financial support and factors associated with smoking cessation and relapse in the Japanese smoking cessation treatment (SCT) program based on financial support.A prospective cohort study was conducted at the smoking cessation outpatients of hospitals or clinics in Suita City, Japan from May 2017 to September 2018. In all, 153 participants were recruited and received standardized treatment based on the SCT program. Participants were required to answer four questionnaires and register for the financial support program. Chi-squared test, Fisher’s exact test, non-paired t-test and log-binomial regression analysis were used to analyze the data.Of the 153 participants, 140 participants completed a 12-week treatment and the completion rate was 91.5%. There were no factors significantly associated with smoking cessation and relapse (p<0.05). However, male, cigarettes smoked per day, having present diseases, having previous abstinence, living with family, cohabitation with smokers, desire to smoke at the start of treatment, self-efficacy at the start of treatment, desire to smoke at 4 weeks and self-efficacy at 4 weeks showed statistically significant odds ratio for success of smoking cessation. Similarly at 12 weeks, male, age at smoking initiation, cigarettes smoked per day, having previous abstinence, living with family, cohabitation with smokers, desire to smoke, self-efficacy and depression disorders showed statistically significant odds ratio for smoking relapse. In addition, the rate of abstainers using varenicline was 68.60%, which was higher than abstainers using nicotine patch (55.60%) and the relapse rate of participants using nicotine patch was 100.00%, significantly higher than for relapsers using varenicline (45.80%).Further study is expected to clarify the effect of providing financial support and the factors associated with smoking cessation and relapse in the SCT program based on financial support. To reduce health problems due to smoking or passive smoking, WHO has enacted the Framework Convention on Tobacco Control (FCTC) in the World Health Assembly, 21 May 2003, and the convention gives specific recommendations for different tobacco control strategies such as developing comprehensive smoking cessation guidelines and introducing warning labels on cigarette packages2. In these strategies, one approach to promote tobacco control is to take effective measures to promote smoking cessation and offer an adequate treatment program for tobacco dependence.Tobacco use is a significant public health concern worldwide and one of the major causes of death and disability in both developed and developing countries. According to the 2017 World Health Organization (WHO) report3. In light of this troubling fact, the Japanese medical insurance system has covered the smoking cessation treatment (SCT) program for nicotine dependence since 2006. Until March 2018, more than 16400 facilities have established smoking cessation outpatients or clinics, and the treatment population has been expanded to young people under 35 years of age, regardless of the Brinkman Index. With the development of smoking cessation treatment in Japan, a large number of studies have investigated factors associated with smoking cessation and relapse in the SCT program. In addition, to improve the effects of treatment, Arakawa Ward, Tokyo was first to provide financial support for the SCT program since 2007, and thereafter a similar support program has been extended to other wards and cities. However, the effects of providing financial support and factors associated with smoking cessation and relapse in the SCT program based on financial support have not been reported. Therefore, the purpose of this study is to clarify the effects of providing financial support and factors associated with smoking cessation and relapse in the SCT program based on financial support.In Japan, tobacco use has become the leading preventable cause of mortality and morbidity, resulting in about 129 thousand deaths4 of the SCT program. Meanwhile, participants were required to answer four questionnaires at the start of treatment, at 4 weeks, at 12 weeks, and at 1 year, and register for the financial support program  within one month before or after the start of treatment. In order to earn the financial support after the treatment, three conditions must be met, as follows:A prospective cohort study was conducted at the smoking cessation outpatients of several hospitals or smoking cessation clinics in Suita City, Japan from May 2017 to September 2018. In all, 153 participants were recruited and received treatment based on the 6th standardized guidelineApplicants must complete a 12-week treatment program.Applicants are limited to 100 people if over 100 people complete this program, meanwhile over 100 people applied for the financial support.Applicants must submit relevant materials  within about one month after the treatment.The applications for financial support and the responses of four questionnaires were completed at the reception counter of the Health Center of Suita City or by mail. This study was approved by the Ethical Committee of Observation Research at the Osaka University Hospital , and the division of roles was implemented based on a joint research contract between Suita City and Osaka University.6. Briefly, the SCT program consists of a total of five sessions: first session and then follow-up sessions at 2, 4, 8 and 12 weeks after the first session. At each session, the current smoking behavior is confirmed by exhaled carbon monoxide (CO) concentration and the smoker’s self-reported smoking status. Meanwhile, patients receive medication treatment consisting of varenicline (standard use: 12 weeks) or nicotine patches (standard use: 8 weeks), and behavioral counselling from physicians and nurses.The Japanese SCT program has been described in previous studies6 and specialists’ opinions from Osaka University and the Health Center of Suita City. The first questionnaire at the start of treatment includes information on age, gender, age at smoking initiation, cigarettes smoked per day, previous abstinence, self-efficacy, cohabiter, cohabitation with smokers, passive smoking, having present diseases, strength of desire to smoke, and a CES-D score . The second questionnaire at 4 weeks includes information on smoking status, self-efficacy, strength of desire to smoke, satisfaction with smoking cessation treatment, and received instructions during the period of SCT. The third questionnaire at 12 weeks includes information on smoking status at 8 weeks and 12 weeks, self-efficacy, strength of desire to smoke, satisfaction with smoking cessation treatment, received instructions during the period of SCT, CES-D score, thoughts and feelings for financial support (free description). The fourth questionnaire at 1 year includes information on smoking status at 1 year, self-efficacy, strength of desire to smoke, received instructions during the period of SCT, CES-D score, thoughts and feelings for challenge to quit smoking (free description).Data collection involves four questionnaires at the start of treatment, at 4 weeks, at 12 weeks, and at 1 year. The four questionnaires were developed based on previous studies7.Strength of desire to smoke (craving) is evaluated by grades  based on the combination of two questions: ‘How many times did you want to smoke in the past two weeks?’ , and ‘How strongly did you want to smoke in the past two weeks?’ 7.The CES-D scale is designed to measure depressive symptomatology in the general population, including 20 short self-report items. The component mainly consists of depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep disturbance. The responses of each item are weighted by frequency of occurrence of the symptom scoring from zero to three during the past week, and the possible range of CES-D scored from zero to sixty. The higher scores indicate more symptoms and over 16 points are diagnosed as being in a mood disorder group9.Self-efficacy in the smoking cessation treatment is defined as the confidence a person had in his/her ability to quit smoking and prevent relapse after a quit attempt. In the past, various questionnaires have been used to measure self-efficacy with regard to smoking cessation. A recent meta-analysis study reported that the effect size of self-efficacy with single-item measures was stronger than multi-item measures. Therefore, the self-efficacy scale with a single-item 0–100 rating is used to evaluated participants’ confidence for smoking cessation in this study. The self-efficacy to quit smoking is asked in four questionnaires: ‘How much, as a per cent, confidence do you have to quit smoking?’, with 0% corresponding to ‘I don’t have confidence at all to quit smoking’ and 100% corresponding to ‘I absolutely have confidence to quit smoking’In this study, success of smoking cessation (abstainer) is defined as at least previous 4 weeks of smoking abstinence at the end of the SCT program (12 weeks) from the third self-reported questionnaire. Maintained cessation (non-relapser) is defined as smoking abstinence at 1 year from the fourth self-reported questionnaire. Participants who do not reply to the questionnaire or answer continuous smoking in the questionnaires are defined as failure of smoking cessation (non-abstainer) at 12 weeks and smoking relapse (relapser) at 1 year.Statistical analysis was divided into three stages. First, gender, age at smoking initiation, cigarettes smoked per day, previous abstinence, cohabiter, cohabitation with smokers, smokers at workplace or familiar places, having present diseases, strength of desire to smoke at the start of treatment, self-efficacy at the start of treatment, CES-D score at the start of treatment were presented by frequency distribution and percentage; while age, age at smoking initiation, cigarettes smoked per day, self-efficacy and CES-D score were also presented as mean and standard deviation (SD). Second, chi-squared test and non-paired t-test were used to examine the association between success of smoking cessation and age, gender, age at smoking initiation, cigarettes smoked per day, previous abstinence, cohabiter, cohabitation with smokers, smokers at workplace or familiar places, having present diseases, strength of desire to smoke at the start of treatment, self-efficacy at the start of treatment, CES-D score at the start of treatment, self-efficacy at 4 weeks, and strength of desire to smoke at 4 weeks. Subsequently, log-binomial regression analysis was used to examine factors associated with success of smoking cessation at 12 weeks. Similarly, chi-squared test and non-paired t-test were used to examine the association between smoking relapse and age, gender, age at smoking initiation, cigarettes smoked per day, previous abstinence, cohabiter, cohabitation with smokers, smokers at workplace or familiar places, having present diseases, strength of desire to smoke at 12 weeks, self-efficacy at 12 weeks, and CES-D score at 12 weeks. Subsequently, log-binomial regression analysis was used to examine factors associated with smoking relapse at 1 year. Finally, chi-squared test was used to examine the association between success of smoking cessation and smoking cessation medicine, and Fisher’s exact test was used to examine the association between smoking relapse and smoking cessation medicine. All statistical analyses were performed using IBM SPSS Statistics 25.0. Values with p<0.05 (two-tailed) were statistically significant.A total of 153 participants who were screened for eligibility were referred to Suita smoking cessation challenge services from May 2017 to September 2018. At the start of treatment, all 153 participants answered the first questionnaire. At 4 weeks, 101 participants (66.0%) answered the second questionnaire. At 12 weeks, 13 participants opted out during the period of treatment, and 140 participants (91.5%) completed the 12-week treatment. At 12 weeks, 65 participants (42.5%) answered the third questionnaire, 54 participants (35.3%) were confirmed as abstainers, and 80 participants (52.3%) applied for financial support. At 1 year, 33 participants (21.6%) answered the third questionnaire, 29 participants (19.0%) were confirmed as abstainers, and of the 54 abstainers at 12 weeks, 28 abstainers (52.3%) were confirmed as relapsers .For the 153 participants, the mean age was 53.69 years (SD=13.056). Over 70% of the participants were male. The mean age at smoking initiation was 20.59 years (SD=3.882), and nearly 80% of the participants started smoking at 20 years of age or older. The mean number of cigarettes smoked per day was 20.57 (SD=8.108), and over 60% of the participants smoked 11–20 cigarettes per day. Nearly 40% of the participants had present diseases, and over 60% had experienced previous abstinence. Over 80% of the participants were living with family, and nearly 15% were living with smokers. About 70% of participants had moderate (32.7%) and strong (35.9%) desire to smoke at the start of treatment. The mean value of self-efficacy at the start of treatment was 61.29 (SD=8.108), and over a half of participants had low self-efficacy to quit smoking (≤60%). The mean CES-D score was 9.84 (SD=8.284), and 22.9% of participants were diagnosed as being in a mood disorder group (≥16) .There were no factors statistically significantly associated with success of smoking cessation at 12 weeks (p<0.05). In the log-binomial regression analysis, male , 21–30  and >30  cigarettes smoked per day, having present diseases , having previous abstinence , living with family , cohabitation with smokers , slight , moderate  and strong  desire to smoke at the start of treatment, >60 and ≤80%  and >80 and ≤100%  self-efficacy at the start of treatment, and then moderate  and strong  desire to smoke at 4 weeks, >60 and ≤80%  and >80 and ≤100%  self-efficacy at 4 weeks showed statistically significant odds ratio for success of smoking cessation . There were no factors statistically significantly associated with smoking relapse at 12 weeks (p<0.05). In the log-binomial regression analysis, male , ≥20 years of age at smoking initiation , 11–20 cigarettes  and 21–30 cigarettes smoked per day , having previous abstinence , living with family , cohabitation with smokers , moderate  desire to smoke at 12 weeks, >60 and ≤80%  and >80 and ≤100%  self-efficacy at 12 weeks and ≥16 CES-D score at 12 weeks showed statistically significant odds ratio for smoking relapse .The association between smoking cessation medicine and smoking cessation was not statistically significant (p=0.43), while the rate of abstainers using varenicline (68.60%) was higher than abstainers using nicotine patch (55.60%) . The ass17 it is obvious that the completion of the SCT program improved the success of smoking cessation, while the completion rate was very low . The completion rate of the SCT program in our study was 91.5%, which is far higher than in these previous studies and in three previous surveys17  reported by the Japanese Ministry of Health, Labor and Welfare. This comparison implies that providing financial support may improve the completion rate of smoking cessation programs, although this study is not a randomized controlled trial concerning the association between financial support and the completion of the SCT program.To the best of our knowledge, this is the first study to discuss the effects of providing financial support and factors associated with smoking cessation and relapse, based on financial support in Japan. From many studiesIdentification of factors associated with smoking cessation and relapse can help health care workers to improve the effectiveness of efforts to manage smoking behaviors. In regard to factors associated with smoking cessation at 12 weeks, there were no factors significantly associated with success in smoking cessation. However, we found that gender, cigarettes smoked per day, having present diseases, having previous abstinences, cohabiter, cohabitation with smokers, desire to smoke, and self-efficacy showed statistically significant odds ratio for success in smoking cessation. Similarly, our study also demonstrated that there were no factors significantly associated with smoking relapse at 1 year. However, we found that gender, age at smoking initiation, cigarettes smoked per day, having previous abstinences, cohabiter, cohabitation with smokers, desire to smoke, and self-efficacy CES-D score showed statistically significant odds ratio for smoking relapse. In addition, our study demonstrated that the rate of abstainers using varenicline was 68.60%, which was higher than abstainers using nicotine patch (55.60%) at 12 weeks, while at 1 year the relapse rate of participants using nicotine patch was 100.00%, significantly higher than relapsers using varenicline (45.80%).29. This may be because females had more severe withdrawal symptoms, higher satisfaction levels for smoking, limited methods in releasing stress, more strongly anxious about weight gain due to quit smoking, more sales strategies targeting women and more smokers in the family compared to male smokers21. In general, nicotine dependence was a significant factor that prevented smoking cessation. Our study found that patients smoking 21–30 and >30 cigarettes per day found it difficult to quit smoking. This result may imply that high nicotine dependence is negatively associated with success of smoking cessation.In regard to gender associated with success in smoking cessation, our study demonstrated that males were more likely to quit smoking than females, and this result was consistent with previous studies29. This may be because smokers with present diseases, especially smoking-related diseases such as cardiovascular diseases, COPD, are more concerned about their health and more eager to quit smoking. However, previous studies29 demonstrated that having mental diseases was negatively associated with success of smoking cessation. This difference implies that smokers with different present diseases may have different smoking cessation behavior. In addition, we found that having previous abstinence, living alone and cohabitation with smokers were negatively associated with success of smoking cessation and this result is consistent with previous studies21.In our study, we found that having present diseases was positively associated with success of smoking cessation and this was consistent with previous studies32 while our study demonstrated that the rate of abstainers was 68.60%. Furthermore, with regard to the long-term effect (1 year) of varenicline treatment, previous studies demonstrated that the success rate was 46.6–68.4%28 while our study demonstrated that the success rate (non-relapsers) was 54.20%. In addition, a recent randomized clinical trial33 showed no significant differences in rates of smoking abstinence between these two treatments. However, our study demonstrated that varenicline appeared to be more effective than nicotine patch in Japan and this result is consistent with previous studies32.In regard to the short-term effect (12 weeks) of varenicline treatment, previous studies demonstrated that the rate of abstainers was 43.5–84.5%6. In Japan, four previous studies23 also demonstrated that there was a positive association between self-efficacy and the success in smoking cessation, although self-efficacy was divided into several stages based on different scores. Furthermore, our study demonstrated that participants with self-efficacy scores >80% at the first session and >60% at the second session were more likely to attain abstinence than those with low self-efficacy scores, although there was not a statistically significant association (p>0.05). These results suggest that maintaining participants’ self-efficacy at a high level is able to enhance success of smoking cessation. In addition, a review of 21 studies examining predictors of more than 6 months cessation outcome found that self-efficacy predicted relapse among both self-quitters and treated smokers34. Our study also demonstrated that self-efficacy scores >60% at 12 weeks were negatively associated with smoking relapse.To date, studies have demonstrated that self-efficacy was positively associated with success of smoking cessation among smokers who received smoking cessation interventionThere are several limitations in this study. First, the number of participants was only 153 and this may affect the efficiency of the results. Second, we only used self-report questionnaires to assess smoking status that was not biochemically verified. Third, 60.9% of participants had a present illness in our study. Therefore, these results may not be able to be applied to the general population. Fourth, the strength scale of desire to smoke was only used in Japan and the psychometric properties of this scale do not exist.This is the first study in Japan to discuss the effects of providing financial support and factors associated with smoking cessation and relapse, based on financial support. Our results suggest that providing financial support may be able to improve the completion rate of the SCT program. Male, cigarettes smoked per day, having present diseases, having previous abstinence, living with family, cohabitation with smokers, desire to smoke at the start of treatment, self-efficacy at the start of treatment, desire to smoke at 4 weeks, self-efficacy at 4 weeks showed significant odds ratio for success of smoking cessation, although there was no statistically significant association (p>0.05). Similarly, male, age at smoking initiation, cigarettes smoked per day, having previous abstinence, living with family, cohabitation with smokers, desire to smoke at the start of treatment, self-efficacy at the start of treatment, desire to smoke at 12 weeks, self-efficacy at 12 weeks and CES-D score at 12 weeks showed significant odds ratio for smoking relapse, although there was no statistically significant association (p>0.05). In addition, our study suggests that varenicline is more effective than nicotine patch in the SCT program. Further research is expected to clarify the effect of providing financial support and the factors associated with smoking cessation and relapse in the SCT program based on financial support.


There is evidence that replacing saturated fat (SFA) with polyunsaturated fat (PUFA) lowers ischemic heart disease (IHD). In order to improve the population’s diet, the World Health Organization has called for the taxation of foods that are high in SFA. We aimed to assess the potential health gains of a European fat tax by applying the SFA intake reduction that has been observed under the Danish fat tax to six other European countries. For each country, we created a fat tax scenario with a decreased SFA intake and a corresponding increase in PUFA. We compared this fat tax scenario to a reference scenario with no change in SFA intake, and to a guideline scenario with a population-wide SFA intake in line with dietary recommendations. We used DYNAMO-HIA to dynamically project the policy-attributable IHD cases of these three scenarios 10 years into the future. A fat tax would reduce prevalent IHD cases by a minimum of 500 and 300 among males and females in Denmark, respectively, up to a maximum of 5,600 and 4,000 among males and females in the UK. Thereby, the prevented IHD cases under a fat tax scenario would correspond to between 11.0%  and 29.5%  of the prevented IHD cases under a guideline scenario, which represents the maximum preventable disease burden. Henceforth, our quantification of beneficial health impacts makes the case for the policy debate on fat taxes. Cardiovascular disease (CVD), with its main forms ischemic heart disease (IHD) and stroke, is the leading cause of mortality in Europe. With 3.9 million deaths a year, it corresponds to 45% of all deaths . CurrentEven though it is recommended to replace SFA with PUFA, and to consume ≤10 percent of one’s total energy intake (%E) from SFA , the majMeanwhile, the evidence of a fat tax induced SFA intake change from a real-life setting is available. In October 2011, Denmark was the first country in the world that introduced a tax on meat, dairy products, animal fat, oils, margarine and butter blends with more than 2.3g of SFA per 100g. These products were taxed with 16 DKK  per kg of SFA . Due to This study aims to enlarge the body of evidence by modelling the health impacts of a fat tax in seven European countries, using the SFA intake reduction that has been observed under the Danish fat tax.Apart from a fat tax scenario, we modelled a reference and a guideline scenario for comparison purposes. The change in SFA intake for a fictitious person is illustrated in SFA intake by country was drawn from the European Nutrition and Health Report , which rFor the reference scenario, we smoothed the original age-group-related mean intake of SFA over age. To predict the fat-tax scenario’s age-specific mean intake of SFA, we multiplied the reference scenario’s age-specific mean intake by the age-specific SFA consumption change that was observed in Denmark after the introduction of a fat tax .For the guideline scenario, all individuals were assumed to have a SFA intake of ≤10%E.The mean SFA intake across scenarios is illustrated in Figs For the reference and fat tax scenario, we presumed a normal distribution of SFA intake , 43, andWe used net transitions, i.e. we set the age-specific SFA intake to be constant for each scenario, so that the age-specific SFA intake in the population does not change over the projection period.The relative risks of ischemic heart disease for each 5%E of lowered PUFA intake, being replaced with SFA, were taken from the GBD Study 2016 . We tranhttps://www.dynamo-hia.eu).We derived data on the population size, age-composition, projected births and mortality, as well as data on the IHD incidence, prevalence and excess mortality of Denmark, Italy, the Netherlands, Poland, Spain, Sweden and the UK from the DYNAMO-HIA database . The datWe modeled the three scenarios  10 years into the future, using DYNAMO-HIA. DYNAMO-HIA is a dynamic health impact assessment tool, which compares the effects of intervention scenarios with a changed risk factor exposure to a reference scenario with unchanged risk factor exposure. Therefore, it projects a real-life population through risk factor exposure, in this case SFA intake, and associated diseases –46. FullThe cumulative number of prevalent IHD cases in the reference scenario, the fat tax scenario as well as the guideline scenario in projection year 10 are shown in In the reference scenario, with no change in dietary intake, prevalent IHD cases would range from an estimated 86,600 among males and 64,800 among females in Denmark, followed by Sweden, the Netherlands, Spain, Poland and Italy, to an estimated 1,343,500 male and 1,026,100 female prevalent IHD cases in the UK.Compared to the reference scenario, the reduction of prevalent IHD cases under the fat tax scenario would range from 500 among males and 300 among females in Denmark, respectively, followed by Sweden, the Netherlands, Spain, Italy, and Poland, to 5,600 and 4,000 less prevalent IHD cases in males and females in the UK, respectively.Under the guideline scenario, which represents the maximum preventable disease burden, prevalent IHD cases would be reduced by a minimum of 3,200 and 2,100 among males and females in Denmark, respectively, followed by Sweden and Spain, Italy, the Netherlands, and Poland, up to 46,000 and 34,700 fewer prevalent IHD cases in the UK.Measured against the guideline scenario, this reduction in IHD cases under the fat tax scenario ranges from 11.5% and 11.0% among males and females in the Netherlands, followed by the UK, Sweden, Denmark and Poland, and Spain up to 26.4% and 29.5% among males and females in Italy.This is the first study that has applied the SFA intake reduction observed under the Danish fat tax to six other European countries in order to project the potential health impacts.Our results suggest that a fat tax would reduce prevalent IHD cases by a minimum of 500 and 300 among males and females in Denmark, respectively, up to a maximum of 5,600 and 4,000 among males and females in the UK. In most countries, a fat tax would reach between 11.0%  and 15.6%  of the prevented IHD cases under the guideline scenario, whereby the latter represents the maximum preventable disease burden. A fat tax in Spain and Italy, however, would reach 24.4%  to 29.5%  of the maximum preventable disease burden. These results for Spain and Italy can be explained by their relatively low initial SFA intake, especially in higher age groups. In these countries, SFA intake under the fat tax comes very close to the SFA intake under the guideline scenario.In our simulation, a fat tax would lead to 104 more persons  being alive in Denmark in projection year 10 . In contOur guideline scenario would lead to 812 more persons  being alive in Denmark in projection year 10 . In compThus, both scenarios in our simulation seem to underestimate results. However, the number of postponed deaths increases steadily over the projection period in our simulation  Files, aIn general, the comparability between studies modelling the health impacts from changes in SFA intake is complicated for several reasons. Firstly, modelling studies use different policy scenarios. Whereas we presume an intake reduction in line with the Danish fat tax, where products were taxed with 16 DKK per kg of SFA , others Several limitations of this health impact assessment must be acknowledged.First of all, we assumed that the SFA intake change observed under the fat tax in Denmark would occur in other countries as well. To the best of our knowledge, we have no evidence on the contrary, but the precise dietary changes will vary, depending on what food groups contribute to SFA intake in the respective country. Across the different cohorts of the European Prospective Investigation into Cancer and Nutrition (EPIC) study, dairy products, meat and meat products, as well as fats and oils  were main contributors to SFA intake, but the extent differed across EPIC cohorts . For insThe second limitation stems from the SFA intake data. SFA intake was drawn from the European Nutrition and Health Report , which wSimilarly, the third restriction refers to the epidemiological data on the population and IHD. We used the DYNAMO-HIA database, which is the only publicly available database for quantitative health impact assessment with homogenous data collection methods. The database was made publicly available in 2011 and contains trend-free incidence, prevalence and mortality data. Nevertheless, the impact of trend-free data on our results is negligible. Our aim was to compare reference, fat tax and guideline scenario with each other, and we used the same disease data in all scenarios .The fourth constraint stems from the relative risks we used. We used the GBD Study 2016’s relative risks that were applied to 195 countries and territories . To the Fifthly, we conservatively presumed no further health benefit below the recommended SFA intake goal of 10%E . HoweverFinally, a fundamental assumption in our study was that PUFA intake would increase accordingly. This assumption is in line with the dietary recommendations that SFA should be replaced with PUFA , 53, andIn conclusion, this study quantifies the magnitude of health improvements under a tax on SFA in European countries and has found a small to medium beneficial impact on health. We hope that our quantification of health impacts can further inform the policy debate on fat taxes.S1 TableOverview of studies modelling A) counterfactual saturated fat intake or B) fiscal policies on saturated fat and resulting health impacts.(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S7 Table(DOCX)Click here for additional data file.S8 Table(DOCX)Click here for additional data file.S9 Table(DOCX)Click here for additional data file.S10 Table(DOCX)Click here for additional data file.S11 Table(DOCX)Click here for additional data file.S12 Table(DOCX)Click here for additional data file.S13 Table(DOCX)Click here for additional data file.S14 Table(DOCX)Click here for additional data file.S15 Table(DOCX)Click here for additional data file.S16 Table(DOCX)Click here for additional data file.S17 Table(DOCX)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.


Vitis vinifera (L.) cultivar Godello under rain-fed and two drip irrigation systems , and under the soil surface, subsurface drip irrigation (SDI)) over three consecutive years. Irrigation tended to increase must and wine total acidity; however, it did not alter must amino acid concentrations significantly. Irrigation reduced the concentrations of acetaldehyde and methanol in Godello wines. Moreover, irrigation tended to decrease the concentrations of compounds giving fruity aromas, such as acetaldehyde (by 31% in SDI) and isoamyl acetate (by 21% in SDI), when compared to rain-fed conditions. Sensory analysis revealed slight differences between treatments. Rain-fed and SDI were the treatments showing the greatest differences. Weather conditions affected more must and wine composition than in-season effects caused by irrigation.The concentrations of amino acids and volatile compounds of a given grapevine cultivar may be modified by climate variability between years and by management practices, such as irrigation, that may alter the typicality of its wines. The current study aimed at assessing the amino acid profile of musts and wines, volatile composition and sensory profile of wines from  Wine aroma is defined by its volatile composition, which depends on many factors including grape variety, climate, soil and vineyard management, amongst others ,2. AminoVitis vinifera L.) yield and grape and wine composition, mainly on red cultivars [Irrigation management can be a tool for modulating berry growth and quality . A greatultivars ,10. Receultivars ,12,13,14In the Northwest of the Iberian Peninsula , white grapevine cultivars are predominantly grown and the volatile composition of their grapes and wines might be altered by increasing temperatures and drought events over the growing cycle. Amongst them, Godello provides monovarietal wines recognized worldwide. Volatile composition of Godello wines has already been described ,16. ReceTherefore, the aim of the current study was to assess the effects of two irrigation systems on the amino acid composition of musts and wines, and the aromatic and sensory profiles of wines from Godello during three years in Northwest Spain. This is a comprehensive approach for studying wine quality since it involves both chemical and sensory evaluations. The obtained results should be of interest to grape growers, winemakers and other wine professionals.−1) and vertically trellised on a double cordon system. Rows were oriented in the north-south direction. Soil is loamy-textured, very acidic and available water capacity is 170 mm m−1. According to the multicriteria climatic classification system [The study was carried out from 2012 to 2014 in a Godello vineyard planted in 1997 onto 110-Richter rootstock and located in A Rúa, Ourense, Spain . Vines were spaced 1.35 × 1.95 m . The treatments were: Rain-fed (R), surface (DI) and subsurface (SDI) drip irrigation, which reduces direct evaporation from soil and, therefore, more water is available for the vines. The DI pipes were installed on the vineyard row 40 cm above the soil, while SDI pipes were buried 40 cm deep into the soil. Both systems were equipped with 2 L hemitters , one emiIrrigation treatments started on June 1st and finished in mid-August in 2012; during 2013, irrigation began in July and ended by late August; however, due to the pumping system malfunctioning, irrigation started in mid-July and finished by the end of August. In summary, water was applied for 59, 46 and 34 days in 2012, 2013 and 2014, respectively, at a rate of 1.5 h per day. Average irrigation depths were 1.14 mm and 1.54 mm for DI and SDI, respectively . AgriculSeveral variables were measured over the study period for characterizing the water status, vegetative growth and yield of vines in each treatment. Both methods and results about these determinations are out of the scope of this report and have been described elsewhere ,19. HoweHarvest were performed on the same date, each year, for the three treatments. Samples of 20 kg per field replication were collected for winemaking, one tank was used for two replications; therefore, there were two wines per treatment and year. Two 250 mL must samples from each replicate were collected for determining the general attributes of musts  according to official methods after grape pressing [2 (50 mg L−1) was added to avoid oxidation. After 24 h, musts were racked and, then, fermented in 35 L stainless steel tanks. Commercial yeast  was added (20 g h L−1). Once fermentation finished, wines were racked and SO2 was added to 35 mg L−1 free sulfur dioxide. A natural clarification was performed at 4 °C for one month. Finally, wines were filtered, bottled and stored for five months at 10 °C until analysis. The main attributes of wines were determined according to the official methods [The winemaking process was the same as that reported previously . In summas added  g h L−1.Milli-Q equipment  allowed for obtaining ultra-pure water. Super-gradient High-Performance Liquid-Chromatography (HPLC) grade acetonitrile and methanol were from Scharlau . Ammonium chloride was from Merck . Individual L-α amino acids and diethylethoxymethylenemalonate were from Acros Organics . Amino acid solutions were made with HCl 0.1 N. Dichloromethane, n-pentane and anhydrous sodium sulfate were from Scharlau . Standards for volatile compounds were from Merck , Aldrich , Fluka , Alfa Aesar  and Sigma . All the standards were prepared in 50% hydroalcoholic solutions.The determination of amino acids in Godello musts and wines from each treatment was performed by HPLC according to previous works ,21, usinConcentrations of major volatile compounds were quantified by direct injection in a 7890A gas chromatograph  ,16. TerpThe ratio between concentration of an individual compound and its perception threshold was computed to obtain the odor activity value (OAV) of volatile compounds ,23.A panel of nine judges  evaluated, each year, the wines from this study. These professionals were oenologists and technicians from Galician wineries, with expertise on assessing white wines, because experienced tasters describe better what they like than consumers or trained panelists ,25. For The effects of year, irrigation treatment and their interaction on amino acids and volatile compound concentrations were assessed by analysis of variance (ANOVA). When required, mean separation was performed using the Tukey’s test. A principal component analysis (PCA) was carried out to separate must samples according to their amino acid concentrations and wines according to their volatile and sensory profiles. Statistical analyses were performed using R v3.2.2 . Data fro) was greater in 2013 than in the other studied years (A summary of the weather conditions over the study period (2012–2014) is presented in ed years .Previous studies reported data on the effects of irrigation on physiology and yield response of vines in this site ,19. In sp < 0.1) to higher acidities in musts from the irrigated treatments was observed  and valine (p = 0.06) concentrations when compared to the rain-fed control in 2012. In contrast, the effect of year was significant for aspartic and glutamic acids, asparagine, serine, histidine, threonine, γ-aminobutyric acid (GABA), tyrosine, cysteine, tryptophan, ornithine and lysine, and the sum of amino acid concentrations in Godello musts  explained 80.8% of the total variance in the dataset . SamplesIn agreement with a previous report on the cultivar Verdejo , our resAlthough previous research showed that the percentage of amino acids allowed for a differentiation of grapes according to the variety and cultivation system , regardlIn the case of wines, those from SDI showed the lowest concentrations of serine, glutamine, glycine and isoleucine, as well as the lowest sum of free amino acids . Year exVolatile compounds in the wines from the current study  were pretrans-linalool-oxide (pyran) and citronellol were higher in wines from R. In 2014, wines from SDI had higher concentrations of benzyl alcohol, ethyl lactate, isobutyric acid and the sum of short-chained fatty acids, whereas wines from R had higher concentrations of citronellol and hodiol I (The effect of the treatments differed among years. In 2012, higher concentrations of benzyl alcohol, acetoine and acetol appeared in wines from R, whereas 2-phenylethyl acetate was at lower concentrations in wines from SDI. In 2013, 1-propanol, 3-methyl-1-butanol and the sum of higher alcohols were greater in wines from DI, whereas the concentrations of hodiol I . PreviouIn this study, 19 volatile compounds appeared in wines at concentrations higher than their odor thresholds , likely No clear differences among treatments were detected for color . Aroma dWhen applying a PCA to the aroma descriptors and the families of volatile compounds quantified in Godello wines , the firUnder the climate conditions of Northwest Iberian Peninsula, irrigation had a low incidence on amino acid and volatile composition of Godello musts and wines, because of the weak level of water stress experienced by vines from veraison to harvest. Despite this, rain-fed vines produced wines with lower acidity and higher pH than those from the treatment under subsurface drip irrigation. Moreover, irrigation decreased the concentration of volatile compounds providing fruity aromas, such as acetaldehyde and isoamyl acetate, leading to slight differences in wine perception by tasters.