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Background: Diabetes is prevalent in older adults, and machine learning algorithms could help predict diabetes in this population., Objective: This study determined diabetes risk factors among older adults aged ≥60 years using machine learning algorithms and selected an optimized prediction model., Methods: This cross-sectional study was conducted on 3084 older adults aged ≥60 years in Seoul from January to November 2023. Data were collected using a mobile app (Gosufit) that measured depression, stress, anxiety, basal metabolic rate, oxygen saturation, heart rate, and average daily step count. Health coordinators recorded data on diabetes, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, percent body fat, and percent muscle. The presence of diabetes was the target variable, with various health indicators as predictors. Machine learning algorithms, including random forest, gradient boosting model, light gradient boosting model, extreme gradient boosting model, and k-nearest neighbors, were employed for analysis. The dataset was split into 70% training and 30% testing sets. Model performance was evaluated using accuracy, precision, recall, F1 score, and area under the curve (AUC). Shapley additive explanations (SHAPs) were used for model interpretability., Results: Significant predictors of diabetes included hypertension (χ²1=197.294; P<.001), hyperlipidemia (χ²1=47.671; P<.001), age (mean: diabetes group 72.66 years vs nondiabetes group 71.81 years), stress (mean: diabetes group 42.68 vs nondiabetes group 41.47; t3082=-2.858; P=.004), and heart rate (mean: diabetes group 75.05 beats/min vs nondiabetes group 73.14 beats/min; t3082=-7.948; P<.001). The extreme gradient boosting model (XGBM) demonstrated the best performance, with an accuracy of 84.88%, precision of 77.92%, recall of 66.91%, F1 score of 72.00, and AUC of 0.7957. The SHAP analysis of the top-performing XGBM revealed key predictors for diabetes: hypertension, age, percent body fat, heart rate, hyperlipidemia, basal metabolic rate, stress, and oxygen saturation. Hypertension strongly increased diabetes risk, while advanced age and elevated stress levels also showed significant associations. Hyperlipidemia and higher heart rates further heightened diabetes probability. These results highlight the importance and directional impact of specific features in predicting diabetes, providing valuable insights for risk stratification and targeted interventions., Conclusions: This study focused on modifiable risk factors, providing crucial data for establishing a system for the automated collection of health information and lifelog data from older adults using digital devices at service facilities., (©Hocheol Lee, Myung-Bae Park, Young-Joo Won. Originally published in JMIR Formative Research (https://formative.jmir.org/).)

Background: Although many studies on exposure to environmental tobacco smoke from passive smoking have been conducted, most of such studies have only focused on the chemicals produced by active combustion. The current study examined the extent to which uncombusted and packaged cigarettes in cigarette racks at retail stores diffuse airborne nicotine., Methods: Airborne nicotine samples were collected for 15 days on passive monitors mounted near the indoor cigarette racks (Point 1) and farthest point from the cigarette racks (Point 2) in tobacco retailer stores (N=95) in South Korea (5 months, data collection from January to May in 2022., Results: The average airborne nicotine level was 0.0908 ug/m 3 at Point 1 and 0.0345 ug/m 3 at Point 2. We found a positive correlation (r=0.647, p <0.001) in nicotine concentration between the two measurement points. The interior size of the target stores was positively correlated (r=0.334, p <0.001) with the within-store difference in nicotine concentration between the two measurement points. The airborne nicotine concentration at Point 1 was statistically significantly higher than at Point 2 (z=-2.326, p=0.020, effect size: 0.2215), especially at larger stores., Conclusions: Our findings indicate that packaged, unopened, and uncombusted cigarettes in cigarette racks at tobacco retailers emits airborne nicotine, which is a previously unrecognized source of nicotine exposure. This result has implications for policy considerations, such as the potential installation of ventilation systems on cigarette racks or the exploration of alternative packaging methods., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Background/purpose: Second-hand smoking (SHS) is usually examined by self-report (SR). However, there is a possibility that SR may not accurately measure SHS exposure. This study aimed to identify yearly trends and gender differences in SHS by SR and cotinine., Methods: We used data from the 2009-2018 Korea National Health and Nutrition Examination Survey (KNHANES) and included adults aged 19 years and older. We analyzed data of 47,907 respondents on SHS exposures in the past week and of 23,572 respondents who had both urine cotinine and creatinine measurements. SHS exposure was defined as those who answered 'yes' to whether or not they were exposed to smoking by SR. We performed descriptive analysis, Average annual percentage change (AAPC), and multiple regression analysis. All analyses were weighted reflecting the multi-stratified cluster sampling., Results: Exposure to SHS indoors at the work place (WSHS) (2009: 44.8%, 2018: 12.3%), indoors at home (HSHS) (2009: 14.1%, 2018: 3.9%), and indoors at public places (PSHS) (2013: 55.6%, 2018: 15.4%) decreased steadily over the years. WSHS and PSHS exposure was higher for males but HSHS was higher for females. However, the concentration of cotinine-to-creatinine ratio (Co/Cr) was higher among females regardless of SHS exposure status and environment. Multiple regression analysis showed that among males, the association between Co/Cr education level and WSHS was the strongest, and among females, the association was the strongest with HSHS. In addition, home exposure to SHS intensified the differences in Co/Cr levels between males and females., Conclusion: Our study confirmed that cotinine-induced SHS showed different results by year and gender compared to SR. In particular, Co/Cr level in females was higher than in males regardless of exposure by SR, suggesting that SR did not correctly evaluate SHS. To reflect reality more accurately, biomarkers should be monitored along with SR., Competing Interests: Declaration of competing interest None declared., (Copyright © 2023 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Background: Suicide is one of the leading causes of death among adolescents. Students from intercultural families (ICFs) are hypothesized to be vulnerable to suicide. This study aimed to identify the current status of depression and suicide in students from ICFs and the risk of suicide according to family type., Methods: Data from the Korea Youth Risk Behavior Web-based Survey (KYRBS) were used for this study. We selected 586,829 participants from 2011 to 2020. We analyzed the statistical differences between groups using the chi-square and Bonferroni tests. Last, multiple logistic regressions were performed., Results: Regarding experiencing extreme sadness/desperation and suicidal ideation, the group with both parents born outside Korea had the highest rate (37.1 % and 24.7 %, respectively), followed by the father-only, non-ICF, and mother-only groups. The both-parents group had the highest risk for suicidal plan and attempts, and for suicidal attempts after hospital visits (17.2 %, 14.9 %, and 59.5 %, respectively), followed by the father-only, mother-only, and non-ICF groups. In particular, the both-parents group had 1.74, 3.40, 4.56, and 6.44 times higher odds for suicidal ideation, suicidal plan, and suicidal attempt, and hospital visit after suicidal attempt than the non-ICF group, respectively., Conclusions: ICF students were more vulnerable to suicide than the non-ICF group, particularly the both-parents and father-only groups. Thus, adolescents from ICFs are a high-risk group for suicide and should be a top priority for intervention., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

Background: A study on coronavirus disease 2019 (COVID-19) phobia among students revealed that fear of contracting COVID-19 was associated with commuting to school and spending time with others at school. Therefore, it is the need-of-the-hour for the Korean government to identify factors affecting COVID-19 phobia among university students and to consider these factors while framing the policy direction for the process of returning to normalcy in university education. Consequently, we aimed to identify the current state of COVID-19 phobia among Korean undergraduate and graduate students and the factors affecting COVID-19 phobia., Methods: This cross-sectional survey was conducted to identify the factors affecting COVID-19 phobia among Korean undergraduate and graduate students. The survey collected 460 responses from April 5 to April 16, 2022. The questionnaire was developed based on the COVID-19 Phobia Scale (C19P-S). Multiple linear regression was performed on the C19P-S scores using five models with the following dependent variables: Model 1, total C19P-S score; Model 2, psychological subscale score; Model 3, psychosomatic subscale score; Model 4, social subscale score; and Model 5, economic subscale score. The fit of these five models was established, and a P -value of less than 0.05 ( F test) was considered statistically significant., Results: An analysis of the factors affecting the total C19P-S score led to the following findings: women significantly outscored men (difference: 4.826 points, P = 0.003); the group that favored the government's COVID-19 mitigation policy scored significantly lower than those who did not favor it (difference: 3.161 points, P = 0.037); the group that avoided crowded places scored significantly higher than the group that did not avoid crowded places (difference: 7.200 points, P < 0.001); and those living with family/friends scored significantly higher than those in other living situations (difference: 4.606 points, P = 0.021). Those in favor of the COVID-19 mitigation policy had significantly lower psychological fear than those who were against it (difference: -1.686 points, P = 0.004). Psychological fear was also significantly higher for those who avoided crowded places compared to those who did not difference: 2.641 points, P < 0.001). Fear was significantly higher in people cohabitating than those living alone (difference: 1.543 points, P = 0.043)., Conclusion: The Korean government, in their pursuit of a policy that eases COVID-19-related restrictions, will also have to spare no efforts in providing correct information to prevent the escalation of COVID-19 phobia among people with a high fear of contracting the disease. This should be done through trustworthy information sources, such as the media, public agencies, and COVID-19 professionals., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2023 The Korean Academy of Medical Sciences.)

Purpose: The purpose of this study was to identify the mental health problems and quality of life of family caregivers of people with dementia, depending on whether they live with people with dementia., Methods: The sample was divided into three groups: those without a family member with dementia, those with a family member with dementia but not living with them, and those living with a family member with dementia. Descriptive statistics, ANCOVA, and post-hoc tests were performed on key variables. We included a total of 324,078 people with at least one family member older than 60 years, whose data were extracted from the Korean Community Health Survey. Dependent variables: depressive symptoms, stress recognition, subjective health, happiness, and quality of life., Independent Variables: family member with dementia (yes/no), cohabitation type. Control variables: Sex, age, region (urban/rural), household income, and education level., Results: Depressive symptoms and stress recognition were higher in people who live with a family member with dementia. Their subjective health, happiness, and quality of life were the lowest of the three groups. Overall, the indicators for people who lived with a family member with dementia were the most negative, followed by those who did not live with their family member with dementia, and then those who did not have such a family member., Conclusions: Family caregivers living with people with dementia must be prioritized in policies regarding dementia; a program that can provide emotional support and reduce the burden of care is needed., (Copyright © 2021. Published by Elsevier B.V.)

Background: Secondhand smoke (SHS) exposure is known to have negative effects on mental as well as physical health. However, the association between SHS and mental health problems has not been assessed in non-smokers. To evaluate the association of exposure to tobacco smoke and depressive symptoms, and that of the prevalence of having depressive symptoms and urinary cotinine (UCo) concentrations in non-exposed subjects., Methods: Data was extracted from the Korea National Health and Nutrition Examination Survey (KNHANES). Depressive symptoms were determined based on a patient's overall score on the Patient Health Questionnaire (PHQ)-9, and SHS exposure was evaluated using self-reported data and UCo concentration. Overall, 13,219 non-smokers, ≥ 19 years were included in the study. Multinomial logistic regression analysis was conducted to identify factors related to depressive symptoms; independent t-test was conducted to confirm the differences in UCo concentration according to the prevalence of depression., Results: Among the non-exposure groups, 2.0% of the males and 5.6% of the females showed depressive symptoms. Lower social-economic status, higher UCo concentration, and SHS exposure increased the prevalence of depressive symptoms. The UCo concentration of females with depressive symptoms was significantly higher than those of females without depressive symptoms., Limitations: This study only demonstrated an association between SHS exposure and depression, not the causal effects, because of the cross-sectional study design., Conclusion: SHS exposure and depressive symptoms are correlated. The association was also confirmed by evaluating the UCo concentration of those who were not exposed to SHS based on self-reported data., (Copyright © 2021. Published by Elsevier B.V.)

This study aimed to estimate the secondhand smoke (SHS) exposure using urinary cotinine (UCo) to prove that the SHS exposure could not be properly assessed by self-reporting (SR). In total, 28,574 nonsmokers aged >19 years were selected from the Korean National Health and Nutrition Examination Survey data (2009-2018). First, changes in the annual concentration of UCo were analyzed, and the annual SHS exposure rates were measured based on SR and UCo from 2009 to 2018. Then, the average UCo concentration and UCo-measured SHS exposure rate were confirmed according to the subjects' characteristics. Finally, factors associated with the UCo-measured SHS exposure rate were identified based on multiple regression analysis. The findings showed that the annual UCo concentrations and self-reported SHS exposure rates dropped significantly over the past decade. In contrast, the UCo-measured SHS exposure rate indicated that >80% of nonsmokers are still exposed to SHS. Moreover, we found vulnerable groups using UCo-measured SHS exposure rate. In particular, the self-reported SHS exposure at home and in workplaces and house type was highly associated with SHS exposure. Thus, these findings indicate that the actual SHS exposure could not be properly assessed by SR and should be verified using a biomarker, such as UCo. Considering that even a short-term exposure can be harmful to health, the goal of the policy should be to keep cotinine concentration as low as possible.

Background: The use of social big data is an important emerging concern in public health. Internet search volumes are useful data that can sensitively detect trends of the public's attention during a pandemic outbreak situation., Objective: Our study aimed to analyze the public's interest in COVID-19 proliferation, identify the correlation between the proliferation of COVID-19 and interest in immunity and products that have been reported to confer an enhancement of immunity, and suggest measures for interventions that should be implemented from a health and medical point of view., Methods: To assess the level of public interest in infectious diseases during the initial days of the COVID-19 outbreak, we extracted Google search data from January 20, 2020, onward and compared them to data from March 15, 2020, which was approximately 2 months after the COVID-19 outbreak began. In order to determine whether the public became interested in the immune system, we selected coronavirus, immune, and vitamin as our final search terms., Results: The increase in the cumulative number of confirmed COVID-19 cases that occurred after January 20, 2020, had a strong positive correlation with the search volumes for the terms coronavirus (R=0.786; P<.001), immune (R=0.745; P<.001), and vitamin (R=0.778; P<.001), and the correlations between variables were all mutually statistically significant. Moreover, these correlations were confirmed on a country basis when we restricted our analyses to the United States, the United Kingdom, Italy, and Korea. Our findings revealed that increases in search volumes for the terms coronavirus and immune preceded the actual occurrences of confirmed cases., Conclusions: Our study shows that during the initial phase of the COVID-19 crisis, the public's desire and actions of strengthening their own immune systems were enhanced. Further, in the early stage of a pandemic, social media platforms have a high potential for informing the public about potentially helpful measures to prevent the spread of an infectious disease and provide relevant information about immunity, thereby increasing the public's knowledge., (©Jinhee Lee, Yunna Kwan, Jun Young Lee, Jae Il Shin, Keum Hwa Lee, Sung Hwi Hong, Young Joo Han, Andreas Kronbichler, Lee Smith, Ai Koyanagi, Louis Jacob, SungWon Choi, Ramy Abou Ghayda, Myung-Bae Park. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 18.06.2021.)

Background: Children may be exposed to tobacco products in multiple ways if their parents smoke. The risks of exposure to secondhand smoke (SHS) are well known. This study aimed to investigate the association between parental smoking and the children's cotinine level in relation to restricting home smoking, in Korea., Methods: Using the Korea National Health and Nutrition Health Examination Survey data from 2014 to 2017, we analyzed urine cotinine data of parents and their non-smoking children (n = 1,403), in whose homes parents prohibited smoking. We performed linear regression analysis by adjusting age, sex, house type, and household income to determine if parent smoking was related to the urine cotinine concentration of their children. In addition, analysis of covariance and Tukey's post-hoc tests were performed according to parent smoking pattern., Finding: Children's urine cotinine concentrations were positively associated with those of their parents. Children of smoking parents had a significantly higher urine cotinine concentration than that in the group where both parents are non-smokers (diff = 0.933, P < .0001); mothers-only smoker group (diff = 0.511, P = 0.042); and fathers-only smoker group (diff = 0.712, P < .0001). In the fathers-only smoker group, the urine cotinine concentration was significantly higher than that in the group where both parents were non-smoker (diff = 0.221, P < .0001), but not significantly different compared to the mothers-only smoker group (diff = - -0.201, P = 0.388). Children living in apartments were more likely to be exposed to smoking substances., Conclusion: This study showed a correlation between parents' and children's urine cotinine concentrations, supporting the occurrence of home smoking exposure due to the parents' smoking habit in Korea. Although avoiding indoor home smoking can decrease the children's exposure to tobacco, there is a need to identify other ways of smoking exposure and ensure appropriate monitoring and enforcement of banning smoking in the home., Competing Interests: The authors have declared that no competing interests exist.

The purpose of this study was to apply multicriteria decision making and an analytic hierarchy process (AHP) model for assessing sustainable management of hypertension and diabetes. Perception of two alternative health care priorities was also investigated. One priority was improving treatment compliance of patients with hypertension and diabetes. The other priority was strengthening the healthcare system for continuous care. Our study design to evaluate community-based intervention programs for hypertension and diabetes was developed using brainstorming, Delphi techniques, and content analysis along with literature review. We finally proposed a hierarchical structure of the AHP model with 50 third sub-criteria in six levels. By surveying this AHP questionnaire to a total of 185 community health practitioners in Korea, we found that improving treatment compliance of patients with chronic diseases should be relatively more important than strengthening the healthcare system. Further research is needed to expand survey subjects to primary care physicians and even policymakers of central government for the appropriate application of this AHP model.

Objectives: It is especially difficult for hospitality workers to avoid secondhand smoke (SHS), meaning that they are likely particularly vulnerable to the effects of SHS. The authors aimed to determine the degree to which smoke-free laws protect hospitality workers from SHS exposure, by examining biochemical markers of such exposure., Material and Methods: This was a cross-sectional study examining SHS exposure in non-smoking employees working in hospitality settings where smoking is prohibited or permitted. The following biomarkers were selected: cotinine and tobaccospecific nitrosamines, which are known to measure SHS exposure, and 2 representative carcinogens: 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK). The authors compared these biomarkers between 3 hospitality settings. A descriptive analysis was performed. In addition, they conducted 1-way and 2-way analysis of covariance (ANCOVA) to compare the biochemical markers., Results: Smoking substances were identified by smoking ban levels. In the case of hair nicotine and urine cotinine, their concentrations were lower in areas with a complete smoking ban than in both areas with a separate smoking room and no smoking ban; however, there was no statistically significant difference between these. In the case of dust NNK, its level was the lowest in areas with a complete smoking ban. To confirm the smoking ban effect by hospitality settings, the authors checked the results of the 2-way ANCOVA. In karaoke and billiard halls, the dust NNK concentrations were significantly higher in areas with no smoking ban than in areas with a separate smoking room., Conclusions: Exposure to SHS is more prevalent in places that are more lenient when it comes to smoking (e.g., Internet cafés) than in places that are not (e.g., restaurants and cafés), even when smoking is similarly prohibited in both types of places. Int J Occup Med Environ Health. 2021;34(1):53-67., (This work is available in Open Access model and licensed under a CC BY-NC 3.0 PL license.)

Background: South Korea is one of the few countries that has succeeded in flattening the curve of new COVID-19 cases and avoiding a second outbreak by implementing multiple strategies, ranging from an individual level to the population level., Objective: We aim to discuss the unique strategies and epidemiological characteristics of COVID-19 in South Korea and present a summary of policies implemented by the Korean government during the COVID-19 pandemic., Methods: We designed a cross-sectional study of epidemiological data published by the Korea Centers for Disease Control and Prevention on October 1, 2020. We analyzed detailed epidemiological information of COVID-19 cases, including the number of confirmed cases and resulting deaths., Results: As of October 1, 2020, a total of 23,889 confirmed COVID-19 cases and 415 deaths were reported in South Korea. In this paper, we present data on the epidemiological characteristics and transmission of the disease and discuss how the South Korean government, health care providers, and society responded to the COVID-19 outbreak., Conclusions: Understanding the epidemiological characteristics of COVID-19 in South Korea and the government's successful efforts in managing the spread of the disease can provide important insights to other countries dealing with the ongoing pandemic., (©Gwang Hun Jeong, Hyo Jeong Lee, Jinhee Lee, Jun Young Lee, Keum Hwa Lee, Young Joo Han, Sojung Yoon, Seohyun Ryu, Da Kyung Kim, Myung Bae Park, Jae Won Yang, Maria Effenberger, Michael Eisenhut, Sung Hwi Hong, Andreas Kronbichler, Ramy Abou Ghayda, Jae Il Shin. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 10.12.2020.)

This cross-sectional study investigated the relationships between socioeconomic factors and social capital and benign prostatic hyperplasia symptoms. The participants were 100,000 adult men who participated in the Korea Community Health Survey. The surveyors used the International Prostate Symptom Score. As regards occupation, the prevalence of benign prostatic hyperplasia was higher in men with blue-collar occupations or those who were unemployed than in those with white-collar jobs. In terms of marital status, the prevalence of benign prostatic hyperplasia was 1.319 times higher among divorced men than married men. As regards social capital, the prevalence of benign prostatic hyperplasia in men with positive attitudes towards one's community scores that reflected good, poor and very poor community scores was 1.228, 1.246 and 1.447 times higher than that of men who had very good scores respectively. The groups with good, poor, and very poor community participation scores had 1.115, 1.202 and 1.364 times higher prevalence of benign prostatic hyperplasia than the group with very good scores. Social disparities and social capital of a community were associated with the prevalence of benign prostatic hyperplasia. Thus, the use of social capital in the community setting will be effective in the management of the condition., (© 2018 Blackwell Verlag GmbH.)

Antibiotic resistance is steadily rising worldwide. Respiratory tract infections (RTIs) are common indications, mostly imprudent, for antibiotic prescriptions in outpatient setting. In Korea, antibiotic prescription rate for RTIs is still high. As physician visit and antibiotic prescribing are influenced by patient's perceptions and beliefs, we aimed to explore the general public's perspectives and practices toward RTIs and to develop the 'RTI clinical iceberg.' A cross-sectional survey was conducted in Wonju Severance Christian Hospital (WSCH) among 550 adults attending outpatient departments during January 2016. Differences in distributions between groups were examined using two-tailed Pearson χ² test. Using the Andersen's behavioral model as a conceptual framework, we constructed logistic regression models to assess factors associated with physician visit. Of 547 participants with complete questionnaires, 62.9% reported having experienced an RTI in the previous six months; 59.3% visited a physician for the illness, most commonly because the symptoms were severe or prolonged, and approximately 16% of them expected an antibiotic prescription from the visit. Perceptions of symptoms severity, the need factor, most strongly influenced physician visit. Predisposing and enabling factors such as inappropriate expectations for antibiotic for a sore throat or having national health insurance also influenced physician visit. Almost all participants who reported asking for an antibiotic were prescribed one, with a 37.1% non-adherence rate. Conclusively, public education on self-care for RTI symptoms that addresses their main concerns may reduce physician visits. Improving physician-patient relationship and informing patients about the lack of antibiotic benefit for most RTIs may also reduce antibiotic prescriptions., Competing Interests: The authors have no potential conflicts of interest to disclose.

Background: Female smoking is perceived very negatively in East Asian countries such as South Korea, Japan, and China, as well as in Islamic countries. These countries' self-reported surveys (SRs) tend to produce results that underestimate the number of smokers, owing to the social desirability response bias. The present study seeks to assess South Korea, Europe, and the Americas, by comparing data from SRs with those from urinary cotinine samples., Methods: Current smoking rates were calculated using the SRs and the urinary cotinine concentration (UCC) methods according to socioeconomic factors. In order to examine response accuracy regarding current smoking status in the SRs, participants who both completed the SRs and acquired UCC results were subject to analyses of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and difference ratio (DR) with respect to gender, age, region, economic level, household status, and the presence of chronic disease., Results: Based on self-reports, the current smoking rate among women was 7.1% (official smoking rates), while that according to the UCC was 18.2%; the rates for men were 47.8% and 55.1%, respectively. The sensitivity of males was 0.8553, the specificity 0.9768, PPV 0.9783, NPV 0.8465, and the difference ratio (DR) was 1.143. The sensitivity for females was 0.3670, the specificity 0.9956, PPV 0.9486, NPV 0.8761, and the DR was 2.6. These results exhibit a very low response alignment rate compared to males., Conclusion: This study shows that the actual female smoking rate is significantly higher than that reported officially, but also that the gap is decreasing steadily. Females exhibited a higher rate of false responses, which resulted in an underestimation of the female smoking rate.