Betel nut chewing: the prevalence and the intergenerational effect of parental behavior on adolescent students.

PURPOSE: To explore the betel nut chewing prevalence among students, analyze the probability and the odds ratio of ex-chewers and current chewers, as well as the correlation between parental behavior characteristics and those of adolescents chewing betel nut. METHODS: A cross-sectional survey was designed and 10,288 Taiwanese students answered the questionnaires in 2002. A structured questionnaire included information about betel nut chewing behavior among the adolescent students, sociodemographic data, and the betel nut chewing practice among parents or classmates. Samples were randomly chosen from each cluster of different types of schools in various areas. Three different grade levels of the first, second, and third grade (ages 16-18 years) were selected. Frequency distribution was used to analyze the prevalence among adolescent students, and Chi-square tests were used to compare the differences of betel nut chewing behavior among genders and the effect of parental behavior and socioeconomic factors. Logistic regression was used to analyze the odds ratio of the prevalence of adolescent students' betel nut chewing in the different types of schools and by gender. RESULTS: When the parents' marriage was not successful, or was of a lower social status, a higher incidence of adolescent betel nut chewing was observed. It was easy to experience betel nut chewing in adolescence if either parent chewed betel nut. The prevalence of betel nut chewing among male students was higher than female students and among vocational school students than general school students. The odds ratio of agricultural school students to general school students was highest of all the ex-chewers and current chewers from different types of schools. CONCLUSIONS: Betel nut chewing behavior is related to the effect of parental behavior on adolescent students. Apparently, it is indicated that there is a significant intergenerational effect of the parent's behavior on their children's behavior.     

嚼食槟榔地区槟榔使用现状研究

摘要:目的　为嚼食槟榔地区流行病学研究提供数据。方法　查阅近年来国内、外相关文献,对我国、东南亚及南亚、西方等嚼食槟榔地区槟榔使用现状及问题进行综述。结果　我国及东南亚及南亚地区,槟榔嚼食率较高,而戒断率较低,西方地区槟榔嚼食率相对较低,长期嚼食槟榔对口腔健康会产生影响。结论　嚼食槟榔地区不断蔓延,公众对于槟榔知晓率偏低,有关部门应采取相对措施,控制槟榔咀嚼率。     

Betel nut chewing is associated with increased risk of cardiovascular disease and all-cause mortality in Taiwanese men

BACKGROUND: Betel nut chewing is related to several kinds of cancer, metabolic syndrome, and type 2 diabetes. Whether it is associated with a greater risk of cardiovascular disease (CVD) and all-cause mortality, however, remains unclear. OBJECTIVE: We aimed to investigate the association between betel nut chewing and CVD and all-cause mortality. DESIGN: A baseline cohort of 56,116 male participants > or = 20 y old were recruited from 4 nationwide health screening centers in Taiwan in 1998 and 1999. Cox proportional hazards regression analyses were used to estimate the relative risks (RRs) of CVD and all-cause mortality for betel nut chewers during an 8-y follow-up period. RESULTS: There were 1549 deaths during the follow-up period, 309 of which were due to CVD. After adjustment for age, body mass index, diabetes, hypertension, lipids, smoking, alcohol consumption, physical activity, income, and education level, the RRs (95% CI) of CVD and all-cause mortality among the former betel nut chewers were 1.56 (1.02, 2.38) and 1.40 (1.17, 1.68), respectively, and those among current chewers were 2.02 (1.31, 3.13) and 1.40 (1.16, 1.70), respectively, compared with persons who had never chewed betel quid. Current and former betel nut chewers had a higher risk of CVD mortality (RR: 2.10; P < 0.05) than did current and former smokers. Greater frequency of betel nut chewing was associated with greater CVD and all-cause mortality. CONCLUSIONS: Betel nut chewing was independently associated with a greater risk of CVD and all-cause mortality in Taiwanese men. Regular screening for betel nut chewing history may help prevent excess deaths in the future. An anti-betel nut chewing program is urgently warranted for current chewers.     

Betel nut chewing and related factors in adolescent students in Taiwan

OBJECTIVE: To investigate the prevalence of betel nut chewing and related factors among adolescent students in general, manufacturing, commercial, agricultural and medical technology schools in Taiwan. To make suggestions regarding how health authorities can reduce the number of students taking up the habit. MATERIALS AND METHODS: A cross-sectional survey was designed, and 10,288 students answered the questionnaire. RESULTS: Significantly more male than female students were betel nut chewers. The less urbanized areas were also associated with a higher prevalence of the habit. The prevalence of the habit grew with increasing age. By analysing betel nut chewing behaviour, it was found that most students started chewing betel nuts because of curiosity, and most obtained betel nuts from their friends and classmates. Betel nut chewing behaviour is definitely related to peer pressure. Most betel nut chewers did not realize that withdrawal could lead to physiological reactions, and they were ignorant of any risk to health even though they were compulsive betel nut chewers. The health-harming behaviours of both smoking and drinking were found in many betel nut chewers, particularly smoking. CONCLUSION: This study confirmed the need for a health education programme dealing with the health risks of betel nut chewing for students at risk. The health authorities could also develop a programme for betel nut chewing among Taiwan's adolescent students, emphasizing the dangers of this habit.     

Confirmatory factor analysis and structural equation modeling of socio-cultural constructs among chamorro and non-chamorro micronesian betel nut chewers

Objectives: Betel nut chewing is embedded within the cultures of South Asia, and Southeast Asia, and the Western Pacific. The determinants of betel nut consumption are complex. Ongoing consumption of betel nut is affected by cultural, social, and drug-specific effects (i.e. dependence). This study’s first objective was to assess the psychometric properties (i.e. reliability and validity) of the socio-cultural constructs in a survey developed for betel nut chewers. The study’s second objective was to investigate the influence of socio-cultural variables on betel nut chewing behaviors among Chamorro and non-Chamorro Micronesians in Guam.

Design: The current study was a secondary analysis of a larger study (N?=?600; n?=?375 chewers and n?=?225 former chewers) that examined socio-cultural factors that influence why chewers chew betel nut, along with assessing chewing behaviors, perceptions of risks, probability of changing behaviors, and methods that could be used to reduce use or quit. The socio-cultural constructs of the survey were analyzed using confirmatory factor analysis and structural equation modeling.

Results: The socio-cultural factors were a sufficient fit with data and the instrument is reliable and valid, as indicated by various model fit indices (χ² (13)?=?18.49 with p?=?.14, TLI?=?.99, CFI?=?1.00, SRMR?=?.02, RMSEA?=?.03 with 90% CIs [.00,.07]). Cronbach’s alpha, the sign and magnitude of the factor loadings, the inter-factor correlations, and the large proportion of variance extracted for each factor, all indicate that the instrument is reliable and valid. Additionally, multivariate analyses showed that socio-cultural reasons were important contributing or chewing betel nut. Participants cited chewing because their friends and family members chewed, the behavior is embedded within their culture, and it would be considered rude and disrespectful to not chew.

Conclusion: Based on the findings, this study provides important implications pertaining to creating culturally appropriate cessation programs.     

某部队官兵嚼食槟榔健康教育干预

目的了解南海某岛礁驻防官兵嚼食槟榔现状,明确其主要原因,验证教育宣讲的干预效果,探索有效控制槟榔嚼食的具体措施。方法采用自行编制的岛礁部队官兵嚼食槟榔调查问卷,对随机抽取的南海某岛礁部队147名经槟榔危害健康教育宣讲官兵进行调查对比。结果受调查官兵槟榔嚼食率为58.5%,其中41.62%为偶尔嚼食,40.14%嚼食时间≥1年。经健康教育后1月,随访发现未嚼食槟榔者有91人(61.9%),嚼食槟榔数量减少者有44人(29.93%)。认为健康教育宣讲对本人和周围人群戒食槟榔有作用占89.11%。结论健康教育是岛礁部队官兵戒食槟榔的强有力手段之一。结合调查问卷,建议采取多样化措施,减少槟榔嚼食对官兵的影响,提高官兵身体素质和战斗力。     

Betel Nut Chewing Decreased Calcaneus Ultrasound T-Score in a Large Taiwanese Population Follow-Up Study

Chewing betel nut is common in Taiwan. Although previous studies have shown that chewing betel nuts is associated with adverse health effects, findings about the impact on bone density have been inconsistent. Therefore, the aim of this study was to investigate the correlation between betel nut chewing and calcaneus ultrasound T-score in a longitudinal study of 118,856 participants from the Taiwan Biobank. Of these participants, 27,002 were followed up with for a median of 4 years. The T-score of the calcaneus was measured in the non-dominant foot using ultrasound. Multivariable analysis showed that a history of chewing betel nut (coefficient β = −0.232; p < 0.001) was significantly associated with low baseline T-score in all participants (n = 118,856). In addition, a long duration of betel nut chewing (per 1 year; coefficient β = −0.003; p = 0.022) was significantly associated with a low baseline T-score in the participants with a history of chewing betel nut (n = 7210). Further, a long duration of betel nut chewing (per 1 year; coefficient β = −0.004; p = 0.039) was significantly associated with a low ΔT-score in the participants with a history of chewing betel nut (n = 1778) after 4 years of follow-up. In conclusion, our results showed that betel nut chewing was associated with a decrease in calcaneus ultrasound T-score, and thus, it is important to stop chewing betel nut to help prevent an increased risk of osteoporosis in the Taiwanese population.     

嚼槟榔与口腔癌关系的病例对照研究

目的 分析口腔癌发病的危险因素,并进一步探讨嚼槟榔与口腔癌的关系。 方法 采用以医院为基础的1:1病例对照研究方法,对2014年在湘潭市某综合医院确诊的口腔癌病例及同期该院其他科室就诊的非口腔疾病、非肿瘤病人共100对进行问卷调查。采用条件logistic回归对资料进行分析,计算OR值及95%CI,并分析嚼槟榔与吸烟、饮酒的交互作用。 结果 单因素条件logistic回归分析结果:吸烟(OR=3.441,95%CI:1.671～7.001,P=0.001)、饮酒(OR=3.010,95%CI:1.497～6.063,P=0.002)、嚼槟榔(OR=3.340,95%CI:1.423～7.844,P=0.006)是口腔癌的危险因素;而多因素条件logistic回归分析结果:吸烟(OR=2.700,95%CI:1.289～5.656,P=0.008)、饮酒(OR=2.257,95%CI:1.071～4.756,P=0.032)是口腔癌的危险因素,但未发现嚼槟榔(OR=2.070,95%CI:0.790～4.758,P=0.139)能独立升高口腔癌的发病风险。交互作用分析结果:嚼槟榔与吸烟(OR_相乘交互=0.696,95%CI:0.140～1.465,P=0.658)、饮酒(OR_相乘交互=1.416,95%CI:0.318～6.300,P=0.648)间不存在相乘交互作用。相加交互作用:嚼槟榔与吸烟之间不存在相加交互作用,相对超危险度比(RERI)的95%CI(-1.573～2.225),归因比(AP)的95%CI(-0.364～0.514)包括0,且交互作用指数(S)的95%CI (0.589～2.087)包括1。但嚼槟榔与饮酒之间存在相加交互作用,嚼槟榔且饮酒患口腔癌的危险性是不嚼槟榔不饮酒的5.034倍,RERI为2.263、AP为0.449、S为2.275。 结论 嚼槟榔、吸烟、饮酒都是口腔癌的主要危险因素。嚼槟榔与饮酒存在相加交互作用,可增加饮酒患口腔癌的发病风险。     

食用槟榔对口腔黏膜健康影响的现况研究

目的研究咀嚼槟榔对口腔黏膜健康异常状况的影响情况和影响因素。方法在湖南省湘潭市和常德市通过多阶段随机抽样的方法对调查对象开展咀嚼槟榔对口腔黏膜健康影响的问卷调查和口腔检查,采用SPSS13.0软件对数据进行统计分析。结果调查对象中咀嚼槟榔524人,口腔黏膜健康异常检出率为12.4%;不咀嚼槟榔521人,口腔黏膜健康异常检出率为2.5%,两组差异有统计学意义(P0.05)。口腔黏膜典型纤维化、粘膜充血、张口受限与咀嚼槟榔有统计学联系,口腔黏膜溃疡、出血、白斑、白色角化、扁平苔藓、白斑病及舌活动受限与咀嚼槟榔无统计学联系;性别、年龄、是否嚼槟榔、嚼槟榔年限和量、吸烟、饮酒为口腔黏膜健康状况的影响因素,地域分布、嗜好辣椒、刷牙习惯、嚼口香糖习惯与口腔黏膜健康状况的影响差异无统计学意义;χ2趋势检验结果显示随着咀嚼槟榔片数的增加口腔黏膜健康异常检出率有增加的趋势。多因素的非条件Logistic回归分析结果显示嚼槟榔年限(年)、嚼槟榔片数(片/d)为口腔黏膜健康的影响因素(OR=1.498和1.510)。结论长时间大量咀嚼槟榔可能损伤口腔黏膜健康。     

A population-based study of the association between betel-quid chewing and the metabolic syndrome in men

BACKGROUND: Betel-quid chewing, an established risk factor for oropharyngeal malignancy, is associated with hyperglycemia and obesity. Associations with other characteristics of the metabolic syndrome have not been reported. OBJECTIVE: This study examined associations between betel-quid chewing and the metabolic syndrome, allowing for recognized risk factors and exploring dose-response effects in a population-based study. DESIGN: Age-specific prevalence rates of the metabolic syndrome were examined in betel-quid chewing and nonchewing men (n = 19,839) recruited into the Keelung Community-based Integrated Screening program in 2001-2003. The independent effect of betel-quid chewing on metabolic syndrome risk was examined by using multiple logistic regression with control for well-recognized risk factors (eg, education, physical activity, and dietary factors) and dose-response effects were examined by using trend tests. RESULTS: The age-adjusted prevalence of the metabolic syndrome was highest in current chewers (25.13%), next highest in ex-chewers (22.04%), and lowest in nonchewers (15.73%) (P < 0.0001). Odds ratios (95% CIs) for the metabolic syndrome were 1.38 (1.19, 1.60) and 1.78 (1.53, 2.08) in ex-chewers and current chewers, respectively, adjusted for other significant correlates such as a family history of hypertension and diabetes mellitus. Meaningful odds ratios for the metabolic syndrome components ranged from 1.24 for hyperglycemia (95% CI: 1.09, 1.64) to 1.90 (95% CI: 1.66, 2.19) for hypertriacylglycerolemia. Increasing odds ratios for the metabolic syndrome with higher consumption of betel quid (whether by rate of use, duration of use, or cumulative exposure) suggest dose-response effects. CONCLUSIONS: After adjustment for well-established risk factors, our study showed independent predictive dose-response effects of betel-quid chewing for the metabolic syndrome and its components in a population-based study of men with a 15% prevalence of betel-nut chewing.     

Betel Nut Chewing Increases the Risk of Metabolic Syndrome and Its Components in a Large Taiwanese Population Follow-Up Study Category: Original Investigation

Betel nut chewing is a popular habit in Taiwan, and it is associated with adverse metabolic effects. The aim of this study was to investigate correlations between betel nut chewing with metabolic syndrome (MetS) and its components in a longitudinal study using data from the Taiwan Biobank. A total of 121,423 participants were included in the baseline study, and 27,002 received follow-up examinations after a median of 4 years. The association between betel nut chewing and MetS was analyzed using multiple logistic regression after controlling for confounders. The baseline prevalence of MetS was 22.5%. Multivariable analysis showed that a history of chewing betel nut was significantly associated with baseline MetS (odds ratio (OR) = 1.629; 95% confidence interval (CI) = 1.535 to 1.730, p < 0.001) and five components of MetS in all participants. A long history of chewing betel nut (per 1 year; OR = 1.008; 95% CI = 1.004 to 1.013, p < 0.001) was associated with baseline MetS, abdominal obesity, hypertriglyceridemia and low high-density lipoprotein (HDL) cholesterol. In addition, high cumulative dose (per 1 year × frequency × daily score; OR = 1.001; 95% CI = 1.001–1.002; p < 0.001) was significantly associated with baseline MetS. At the end of the follow-up, a history of chewing betel nut (OR = 1.352; 95% CI = 1.134 to 1.612, p = 0.001) was significantly associated with MetS and its components including abdominal obesity, hypertriglyceridemia and low HDL-cholesterol in the participants without baseline MetS. In addition, a longer history of betel nut chewing was associated with MetS (per 1 year; OR = 1.021; 95% CI = 1.008 to 1.035, p = 0.002), abdominal obesity and hypertriglyceridemia at follow-up. However, cumulative dose (p = 0.882) was not significantly associated with follow-up MetS. Chewing betel nut and a long history of betel nut chewing were associated with baseline MetS and its components. In the participants without MetS at baseline, chewing betel nut and a long history of chewing betel nut were associated with the development of MetS after 4 years of follow-up. However, a cumulative dose of betel nut chewing was not associated with follow-up MetS. Betel nut chewing cessation programs are important to reduce the incidence of MetS in Taiwan.     

Assessment of genetic damage among chewers of mixture containing mainly areca nut and tobacco

Chewing mixture containing areca nut and tobacco is believed to be associated with oral cancer. Habit of chewing such mixture is prevalent among South Asian countries. This study aimed to evaluate the genotoxic effect of areca nut and tobacco on human lymphocytes. Peripheral blood from 107 subjects (nonchewers, 48; chewers, 59, including 20 subjects with oral submucous fibrosis [OSMF]) analyzed by cytokinesis-block micronucleus (CBMN) and alkaline comet assay. Nuclear anomalies, namely, binucleated cells with micronuclei (BN MN), total MN, nucleoplasmic bridge, and nuclear buds were higher in chewers whereas elevation in BN MN and total MN were significant among subjects with OSMF than nonchewers. DNA damage assessed by comet assay showed increased percentage of Tail DNA, Tail moment, and Olive tail moment among chewers as well as OSMF subjects. Significant positive correlation was observed between induction of CBMN and consumption of quids per day (r = .280, P = .033). RESULTS: suggested cytotoxic and genotoxic potential of mixture containing areca nut and tobacco.     

A prospective community-population-registry based cohort study of the association between betel-quid chewing and cardiovascular disease in men in Taiwan (KCIS no. 19)

BACKGROUND: Betel-quid chewing, a recognized risk factor for oral cancer, was shown to be a contributory cause of metabolic syndrome in humans, which implies a greater likelihood of developing cardiovascular disease (CVD) among those with the betel habit. OBJECTIVE: This study investigated the effect of betel chewing on the risk of developing overt CVD. DESIGN: We used the prospective cohort data derived from a community-population-registry-based integrated screening program to quantify the effect of betel-quid chewing on the incidence of newly diagnosed CVD by classifying the study population into either exposed or nonexposed groups according to chewing status at baseline. We then followed the group free of CVD at recruitment for 2.72 y (SD=1.52 y) to learn of new cardiovascular events. Proportional hazards regression modeling was used to estimate the magnitude of the effect of betel-quid chewing on CVD. RESULTS: After control for age and education level, ever chewers had a 23% (95% CI: 11%, 37%) greater risk of developing CVD than did never chewers; ever chewers were still at greater risk of developing CVD by 24% (95% CI: 11%, 39%) after further adjustment for age, education, and other significant confounders. Significant dose-response relations were found for betel-quid chewing (P<0.05, trend test) after adjustment for other significant variables. CONCLUSION: The habit of chewing betel nut was shown to have independent dose effects to predict increases in the risk of CVD in men, with the use of a prospective community-population-registry-based cohort study.     

A Positive Relationship between Betel Nut Chewing and Significant Liver Fibrosis in NAFLD Subjects,but Not in Non-NAFLD Ones

Background: Betel nut chewing is associated with oral cancer, cardiovascular disease, liver cirrhosis, and hepatocellular carcinoma (HCC). The aim of this study was to explore the association of betel nut chewing with liver fibrosis in subjects with and without nonalcoholic fatty liver disease (NAFLD). Method: A total of 5967 subjects were enrolled. NAFLD was diagnosed with ultrasonography. Betel nut chewing was classified into non-chewing, ex-chewing, and current chewing, and cumulative dosages were calculated. The aspartate aminotransferase (AST)/platelet ratio index and NAFLD fibrosis scores (NFS) were calculated for evaluation of liver fibrosis. Results: NAFLD increased the associated risk of liver fibrosis in those with (odds ratio (OR): 5.51, 95% confidence interval (CI): 3.09–9.80) and without betel nut chewing (OR: 2.33, 95% CI: 1.64–3.29). In subjects without NAFLD, betel nut chewing was not associated with liver fibrosis (OR: 1.12, 95% CI: 0.44–2.86). In subjects with NAFLD, cumulative betel nut chewing and ex- and current chewing were positively associated with NFS and significant liver fibrosis. Conclusions: In subjects with NAFLD, betel nut chewing, even ex-chewing, was associated with a higher risk of liver fibrosis, where higher cumulative levels were found to increase the risk of significant liver fibrosis. However, the associated risk of liver fibrosis due to betel nut chewing was insignificant in subjects without NAFLD.     

Chewing and spitting in eating disorders and its relationship to binge eating

OBJECTIVE: This study examined (i) the frequency of chewing and spitting and (ii) its association with other pathological eating behaviors in eating-disordered inpatients. We hypothesized a positive association between chewing and spitting and binge eating given the phenomenological similarities between these disordered eating behaviors. METHOD: Frequent chewers/spitters were compared with those who did not regularly engage in this behavior with regard to diagnosis, psychometric test results, and associated eating pathology. RESULTS: Chewing and spitting was not associated with elevated bingeing. Rather, frequent chewers/spitters exhibited higher levels of restrictive eating behaviors and the behavior was more prevalent in younger patients. DISCUSSION: Contrary to our predictions, chewing and spitting is more closely associated with restrictive than with binge behaviors. This suggests that most individuals chew and spit small portions of food. The behavior is frequent, occurs across diagnostic groups, and may be associated with greater psychopathology. Future studies should clarify the amount of food consumed during chew/spit episodes and the presence of a sense of loss of control.     

湖南地区食用槟榔流行病学研究

目的探讨湖南地区居民咀嚼槟榔的原因和安全性,为槟榔的开发提供科学依据。方法采用多阶段抽样方法进行湖南省城乡居民咀嚼槟榔情况调查,运用国家规定的方法开展槟榔加工前后化学成分的检测及毒理学试验。结果湖南省居民咀嚼槟榔率为38.40%,其中城区为42.65%,乡村为34.12%;咀嚼槟榔的年限城区5年以下占24.72%,乡村5年以下占46.91%;日咀嚼槟榔数量的中位数城区为23.6 g,乡村为22.8 g;过瘾、提神醒脑和交际需要是居民咀嚼槟榔的前三位原因;检测17种槟榔成分,镉、锡、铅、总砷、柠檬烯、薄荷醇、香兰素加工前后无变化,加工后含量增加的有水份、脂肪和乙基麦芽酚3种,含量减少的有铁、粗纤维、锌、锰、铜、粗多糖和槟榔碱7种。毒理学实验证明,槟榔干果为无毒级,无遗传毒性和亚慢性毒作用。结论湖南地区城乡居民咀嚼槟榔已成为一种生活嗜好,食用槟榔对人体健康的影响仍有待于进一步研究。     

Betel Nut Chewing in Hawai‘i: Is it Becoming a Public Health Problem? Historical and Socio-Cultural Considerations

This article examines the socio-cultural significance of betel nut use among Micronesians, in light of the recent migration of Micronesians to Hawai‘i. The different ways of chewing betel nut are the result of historical changes within Micronesia over time due to Spanish and US colonialism as well as the introduction of tobacco. These divergent ways of chewing may have different risks or impacts on health and it remains to be seen whether or not betel nut will become a significant public health problem in Hawai‘i.     

Areca nut chewing and mortality in an elderly cohort study

Compared with the well-documented association with betel-related cancer, little is known about the long-term effect of areca nut chewing on other fatal diseases. The authors' analyses were based on a population-based cohort study in Taiwan, including 4,049 participants aged 60 years or older enrolled in 1989 and 2,462 participants aged 50-66 years enrolled in 1996. Information regarding betel quid chewing and covariates was collected at baseline and was updated at subsequent interviews. Proportional hazards analysis was performed to determine the effect of chewing on all-cause and cause-specific deaths. During a mean follow-up of 9.5 years, 2,309 deaths occurred. Ever chewers were at higher risk of only total (hazard ratio = 1.19, 95% confidence interval: 1.05, 1.35) and cerebrovascular (hazard ratio = 1.66, 95% confidence interval: 1.19, 2.30) deaths. Furthermore, increased chewing-years or quid-years appeared to be associated with increased mortality risk (linear trend: p = 0.02 for total mortality and p = 0.001 for cerebrovascular mortality). The authors found that, although betel quid chewing resulted in a statistically significant increase in the risk of total and cerebrovascular deaths in the elderly population, the associations were weak and should be interpreted with caution. Further studies are needed to confirm these findings and to better understand the possible mechanisms of death.     

Risk of betel quid chewing on the development of liver cirrhosis: a community-based case-control study

PURPOSE: The role of betel quid on the development of liver cirrhosis is unclear; we thus designed a community-based case-control study to evaluate the association between betel quid chewing and liver cirrhosis. METHODS: A total of 42 cases of liver cirrhosis and 165 matched controls were included for analysis. Questionnaires were administered to obtain histories of betel quid chewing, alcohol consumption, smoking, and family history of liver disease. Hepatitis B surface antigen and anti-hepatitis C antibody were also determined by immunoassay. RESULTS: Individuals with more betel quid chewing (more than 55 quid-years vs. less than 55 quid-years and never-chewers, matched odds ratio [OR(m)] = 2.2; 95% confidence interval [CI]: 1.0-5.0) had higher risks for liver cirrhosis. The combined effects on liver cirrhosis by betel quid chewing and the number of other risk factors, including hepatitis B virus (HBV) infection, smoking, and alcohol drinking, were also observed. When individuals with less betel quid chewing (less than 55 quid-years and never-chewers) and with no other risk factors used as a reference, betel quid chewers expressing greater betel quid chewing (more than 55 quid-years) and more risk factors of HBV infection, cigarette smoking, and habitual alcohol drinking expressed a greater risk of liver cirrhosis (OR(m) = 70.8; 95% CI: 4.0-1260.1). CONCLUSIONS: Our results suggest that betel quid chewing may play an important role in the development of hepatic cirrhosis. Larger study and cohort studies would be necessary to provide further evidence regarding this finding.     

Population Burden of Betel Quid Abuse and Its Relation to Oral Premalignant Disorders in South,Southeast, and East Asia: An Asian Betel-Quid Consortium Study

Objectives. We investigated the population burden of betel quid abuse and its related impact on oral premalignant disorders (OPDs) in South, Southeast, and East Asia.Methods. The Asian Betel-Quid Consortium conducted a multistage sampling of 8922 representative participants from Taiwan, Mainland China, Malaysia, Indonesia, Nepal, and Sri Lanka. Participants received an interviewer-administered survey and were examined for oral mucosal disorders.Results. The prevalence of betel quid abuse was 0.8% to 46.3% across 6 Asian populations. The abuse frequency was over 40.5% for current chewers, with the highest proportion in Nepalese and Southeast Asian chewers (76.9%−99.6%). Tobacco-added betel quid conferred higher abuse rates (74.4%−99.6%) among Malaysian, Indonesian, and Sri Lankan men than did tobacco-free betel quid (21.8%−89.1%). Gender, lower education level, younger age at chewing initiation, and clustering of familial betel quid use significantly contributed to higher abuse rates. Indonesian betel quid abusers showed the highest prevalence of OPDs and had a greater risk of OPDs than did nonabusers.Conclusions. Betel quid abuse is high in regions of Asia where it is customarily practiced, and such abuse correlates highly with OPDs. By recognizing abuse-associated factors, health policies and preventive frameworks can be effectively constructed to combat these oral preneoplasms.The chewing of betel quid, a combination of areca nut, betel leaf, slaked lime, and region-dependent flavoring ingredients, is a uniquely Asian, culturally derived lifestyle habit. Bred from ancient tradition, its use is socially accepted in all groups, including women and young children, although other substance use such as tobacco smoking is deemed objectionable.1,2 Chemical composition studies have showed that areca nut includes psychoactive alkaloids, of which arecoline contributes the most quantity.3 By raising epinephrine and norepinephrine plus modulation of cholinergic and monoamine transmission, areca nut exerts neurobiological effects on the sympathetic and parasympathetic nervous systems.3–5 In human studies, tolerance and withdrawal symptoms have been clearly detected in regular betel quid chewers.6–8 Such a pharmacological profile is comparable with nicotine, a well-known substance that leads to abuse and dependence. In recent decades, successful marketing of commercially manufactured betel quid has dramatically increased its accessibility and widespread use throughout Asia.9 An increased availability indicates that betel quid may be abused throughout different cultures, but the extent is unknown.Studies on the natural history of oral cancer suggest that several oral premalignant disorders (OPDs), including oral lichen planus (OLP), oral submucous fibrosis (OSF), oral leukoplakia (OL) and oral erythroplasia, precede the development of this neoplasm.10 In Asia, the prevalence of oral precancerous conditions and lesions was estimated to be 1.7% to 11.7% in western India,11 4.4% to 12.7% in southern Taiwan,12,13 0.1% to 4.7% in the Hunan province of Mainland China,14 1.4% in Malaysia,15 and 6.7% in the central Sri Lanka.16 Although there is evidence to support that chronic consumption of betel quid products, with or without added tobacco, is a central etiological agent for OPD and neoplasms of the oral cavity, pharynx, esophagus and larynx,10,17–23 no data are available concerning the oral precancerous consequences among betel quid abusers.To study the health effects of betel quid consumption in Asian populations and mobilize outreach activities in disease prevention, in 2008, the Center of Excellence for Environmental Medicine at Kaohsiung Medical University in Kaohsiung, Taiwan, in consultation with the World Health Organization (WHO) Collaborating Centre for Oral Cancer in the United Kingdom, launched an international collaborative project that constitutes the Asian Betel-quid Consortium (ABC) study. Six large research centers from East Asia (Kaohsiung Medical University, Taiwan, and Central South University, Changsha, Mainland China), Southeast Asia (Airlangga University, Surabaya, Indonesia and University of Malaya, Kuala Lumpur, Malaysia), and South Asia (University of Peradeniya, Peradeniya, Sri Lanka and Kathmandu University, Kavrepalanchwok, Nepal) participated in this investigation. Because of varying practices and particular marketing of betel quid products in those countries (detailed explanations shown in Table A, available as a supplement to the online version of this article at http://www/ajph.org), present study actions are promisingly warranted. The purposes of this report are twofold: (1) to present the current population burden of betel quid abuse and the factors associated with this behavior in the investigated Asian communities, and (2) to evaluate the impact of betel quid abuse on oral premalignant disorders.