A qualitative study on tobacco smoking and betel quid use among Burmese refugees in Australia

The association between betel quid use and oral potentially malignant and malignant disorders in Southeast Asian and Pacific regions: a systematic review and meta-analysis with GRADE evidence profile

Background

Betel quid (BQ) chewing is a prevalent habit in the Asian and Pacific regions. It is deeply intertwined within cultural customs, and has been reported to result in oral potentially malignant disorders (OPMDs) and malignant disorders (MDs).

Objective

We aim to present a summative and broad overview of the burden that BQ chewing has imposed on the residents of the Southeast Asian, Pacific, and Australasian regions, allowing us to quantify the level of impact it is currently causing on the risk of people developing oral cancer.

Methods

This scoping review and meta-analysis screened databases such as PubMed, MEDLINE, and Google Scholar for publications that investigated the association between BQ and OPMDs and MDs. The search strategy involved MeSH headings relating to BQ, OPMDs, and MDs, and a search for results during the period between January 2010 and June 2023 within the set geographical boundaries of the Southeast Asian and Pacific regions. This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement for Scoping Reviews (PRISMA-ScR). R software was used to screen outliers. The included studies were further analysed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Results

Nine articles (n = 19,312 participants) presented odds ratio outcomes from 11 regionally different study groups. We indicated a strong correlation between BQ chewing and the increased risk of OMPDs and MDs. The risk was quantified through meta-analyses with an odds ratio (OR) of 8.18 (5.27-12.72) and an increased OR of 9.93 (7.36-13.39) when the outlier was removed. BQ chewing was further identified within various Australian communities and discovered to be produced locally in North Queensland.

Discussion

A meta-analysis of two outcomes revealed substantial heterogeneity and minor evidence of publication bias, thus the association effect was included with and without these articles. The overall GRADE quality of evidence ranged from moderate to very high and highlighted five studies with a high level of imprecision.

Conclusion

The lingering high prevalence of BQ in the Southeast Asia and Pacific regions, as well as its rising acceptance among non-ethnic Australians, is alarming and requires prompt and rigorous intervention to prevent the risk of oral cancer.

Systematic Review Registration

PROSPERO (CRD42023429694).

A systematic review of qualitative research on substance use among refugees

AIMS

To evaluate qualitative research on substance use and substance use disorders (SUDs) among refugees in terms of practitioners' and substance users' attitudes, beliefs and experiences.

METHODS

Six medical, allied health and social sciences databases (EBSCO, PubMed, ScienceDirect, Web of Science, Scholar and the Cochrane Library) were systematically searched in a time frame between January and April 2021 to identify original peer-reviewed articles describing qualitative findings related to substance use among refugees (alcohol, illicit drugs, tobacco and prescription drugs). Study selection, critical appraisal and detailed extraction were performed via the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Systematic Reviews (PRISMA) (2018). Three independent reviewers selected the relevant abstracts and articles. Synthesis of the evidence identified prominent themes relating to the context and consequences of substance use.

RESULTS

Twenty-six studies were included in this review. Twenty-three studies applied qualitative methods and three applied mixed methods. Synthesis of the evidence from the included studies resulted in four main findings: there is a considerable susceptibility of refugees to substance use and SUDs; the harmful consequences of substance use are complicated by the social insecurities of refugees; there are rather high barriers to treatment and health facilities for refugees in many host countries; and there is a strong need to improve effective access to treatment, interventions and prevention approaches.

CONCLUSIONS

Refugees are at high risk for substance use and substance use disorders and often face high barriers to treatment and interventions in host countries.

Health disparities among Burmese diaspora: an integrative review

Tens of thousands of displaced Burmese ethnic minorities have endured various adversities for over six decades but are largely underserved. This study aimed to illuminate the health impacts of their misfortunes and unmet areas of concern. Using a holistic lens, we conducted an integrative review of 47 papers spanning the years 2004 to 2022 from diverse data sources. The results revealed widespread multimorbidity, triggered mainly by displacement. The diaspora's problematic health conditions were worse than their host country's general population. There was a strong indication that the diaspora's unfortunate health trajectory is determined early in life. Ongoing human rights violations and grossly inadequate health care interventions deepened pre-existing health conditions. Noteworthy emerging treatment initiatives, including integrative health care, were underutilized. The persisting health and intervention needs among the diaspora warrant advanced studies to facilitate much-needed resource mobilization and collaboration among stakeholders to promote health equity.

Funding

There was no financial support for this manuscript.

Metabolism of the areca alkaloids - toxic and psychoactive constituents of the areca (betel) nut

Areca nut (AN) is consumed by millions of people for its therapeutic and psychoactive effects, making it one of the most widely self-administered psychoactive substances in the world. Even so, AN use/abuse is associated with myriad oral and systemic side effects, affecting most organ systems in the body. Alkaloids abundant in the nut (e.g. arecoline, arecaidine, guvacoline, and guvacine), collectively called the areca alkaloids, are presumably responsible for the major pharmacological effects experienced by users, with arecoline being the most abundant alkaloid with notable toxicological properties. However, the mechanisms of arecoline and other areca alkaloid elimination in humans remain poorly documented. Therefore, the purpose of this review is to provide an in-depth review of areca alkaloid pharmacokinetics (PK) in biological systems, and discuss mechanisms of metabolism by presenting information found in the literature. Also, the toxicological relevance of the known and purported metabolic steps will be reviewed. In brief, several areca alkaloids contain a labile methyl ester group and are susceptible to hydrolysis, although the human esterase responsible remains presumptive. Other notable mechanisms include N-oxidation, glutathionylation, nitrosamine conversion, and carbon-carbon double-bond reduction. These metabolic conversions result in toxic and sometimes less-toxic derivatives. Arecoline and arecaidine undergo extensive metabolism while far less is known about guvacine and guvacoline. Metabolism information may help predict drug interactions with human pharmaceuticals with overlapping elimination pathways. Altogether, this review provides a first-of-its-kind comprehensive analysis of AN alkaloid metabolism, adds perspective on new mechanisms of metabolism, and highlights the need for future metabolism work in the field.

Non-communicable diseases risk factors among the forcefully displaced Rohingya population in Bangladesh

Rohingya refugees of Ukhiya, Cox's bazar are an unaccounted group of people who form the largest cluster of refugees worldwide. Non-communicable disease (NCD) alone causes 70% of worldwide deaths every year therefore, the trend of NCD among Rohingya refugees demands proper evaluation and attention. The objective of this study was to measure the NCD risk factors among a convenient sample of Rohingya refugees. This cross-sectional study was conducted among 249 Rohingya refugees living in Balukhali and Kutupalang Rohinga Camps at Ukhiya, Cox's bazaar using a survey dataset adapted from the WHO Stepwise approach to NCD Risk Factor Surveillance (STEPS). Data was collected through face-to-face interviews with a structured questionnaire. Anthropometric and biochemical measurements were done by trained medical assistants. Descriptive analysis was applied as appropriate for categorical variables. A Chi-square test and a student t test were performed to compare the categories. In general, the findings of NCD risk factors as per STEPS survey was 53.4% for tobacco use including smokeless tobacco, 2.8% for alcohol consumption, 23.7% for inadequate vegetable and fruit intake, 34.5% for taking extra salt, 89.6% for insufficient physical activity, 44.5%for confirmed hypertension, 16.9% for overweight, 1.2% for obesity and 0.8% for high blood sugar. Some modifiable non-communicable disease risk factors such as physical inactivity, tobacco smoking, extra salt with food, and hypertension are present among the Rohinga refugees in Bangladesh. These findings were timely and essential to support the formulation and implementation of NCD-related policies among the Rohingya refugees as a priority sub-population.

Areca Nut Chewing: Initiation, Addiction, and Harmful Effects Emphasizing the Barriers and Importance of Cessation

Areca nut is a highly addictive substance with carcinogenic properties and causes many harmful effects to the human body. Alkaloids are the major chemicals found in areca nut, and their mechanism of action has been studied for several years. About 600 million people around the world use areca nut, and its usage is higher in Asian countries. Areca nut chewers get used to the habit mainly due to social influence, stress, or lack of awareness. Some studies have reported a dependence syndrome related to areca nut chewing. Even though there are many ongoing research studies regarding tobacco addiction, less concern has been given to the areca nut addiction. There are only few studies related to areca nut cessation, and even those few cessation programs are mainly designed using tobacco cessation methodology. Sociocultural influence, behavioral factors, and accessibility are the main barriers to cessation. Behavior changing interventions proved to be more effective in areca nut cessation, but recently studies on pharmacological therapies are also emerging.

Tradition Gone Mobile: An Exploration of #Betelnut on Instagram

Background: As a psychoactive substance that spans borders and cultures, researchers estimate that 600 million people use the areca nut. Despite its historical and geographical significance, betel nut use has received far less research attention than other stimulants such as tobacco, coffee or tea. Scholars have observed that social media platforms have significant effects on the promotion and use of addictive substances. Objectives: Our study investigates user practices and activities on a sample of Instagram posts tagged #betelnut dating back to 2011. Methods: Using social media analytics and hashtag network analysis, we examined user practices and activities on a sample of over 7800 Instagram posts tagged #betelnut dated between July 2011 to February 2019 that were collected in early 2019. Results: Findings determined that #betelnut is a growing topical hashtag on Instagram with content that drives social engagement. Importance: Co-occurring hashtags with #betelnut reflect regional language and cultural naming conventions that center around the Indian subcontinent and Melanesia. The importance of future work in this area is highlighted.

Betel Quid Use and Oral Cancer in a High-Risk Refugee Community in the USA: The Effectiveness of an Awareness Initiative

Betel nut (BN) is a psychoactive oral carcinogen that is commonly used among Asian communities. This study aims to investigate BN usage patterns and the effectiveness of a visually guided educational initiative in a high-risk refugee population. All adult patients presenting to a private practice clinic, free community clinic, or health fair in the refugee community of Clarkston, Georgia during days when survey staff were present were approached for the study. Participants were first categorized into a familiar and unfamiliar cohort depending on participant-reported familiarity with BN. Depending on familiarity, subjects were then administered a pre-intervention test surveying health awareness for BN and usage patterns where relevant; subsequently, a visually guided educational brochure was reviewed, and a post-intervention test was administered. Results were statistically analyzed (STATA 12). Forty-eight participants were surveyed for the familiar cohort and 25 for the unfamiliar cohort. Among the familiar cohort, South and Southeast Asians comprised 91% of participants. On frequency of use, 42.8% reported social, 28.6% reported usage during celebrations only, and 28.6% reported daily. The most common reasons for use were for taste (40.9%), enjoyment (38.6%), and addiction (25%). Among the familiar cohort, 75% believed BN was harmful for health compared to 8% among the unfamiliar (p < 0.0001). In the familiar cohort, 52.3% believed BN alone could cause cancer compared to 4% among the unfamiliar (p < 0.0001). Following the educational intervention, 100% of participants believed BN mastication is harmful in both cohorts (p < 0.01), while 87.5% of participants in both cohorts recognized that BN alone could cause cancer (p < 0.0007). This study illustrates gaps in understanding regarding oral cancer and the health consequences of chronic BN mastication, as well as the efficacy of a visually guided educational brochure to improve participant knowledge among a high-risk refugee population.

A qualitative study of attitudes to and perceptions of betel quid consumption and its oral health implications in Taiwan

OBJECTIVES

Betel quid (BQ) chewing is extremely prominent in South and Southeast Asia because it considered by users to be of social, cultural and religious importance. BQ chewing has been recognized as a risk factor for oral premalignant lesions and oral cancer. Because BQ chewing has become a severe health risk in Taiwan, the development of prevention and cessation programmes is essential. The purpose of this study was to explore the attitudes and perceptions associated with BQ consumption and its oral health implications in an attempt to inform the development of health promotion initiatives and BQ cessation efforts in Taiwan, where the dental profession could have a pivotal role in preventing and controlling BQ use among persons at risk.

METHODS

This qualitative study used data gathered from focus groups and individual interviews. A convenience sample of 41 adults from Jhushan and Lugu Townships (Nantou County) and Taichung City, Taiwan, participated in this study (27 men, 14 women; 31 Han, 10 aboriginals from the Paiwan tribe; mean age 40.3, SD 9.2 years).

RESULTS

Among the seven themes that emerged from the original study, five (Initiation, Health Risk Perception, Health Consequences, Withdrawal Symptoms and Help from Healthcare Providers) had oral/dental implications.

CONCLUSIONS

Our study highlights research areas relevant to further investigation, such as incorporating brief BQ prevention and cessation counselling when early oral and dental signs associated with BQ consumption are detected. Undertaking behavioural interventions in dental settings might help to reduce the prevalence of BQ chewing in Taiwan.

Cardiovascular Disease-related Health Beliefs and Lifestyle Issues Among Karen Refugees Resettled in the United States From the Thai-Myanmar (Burma) Border

Objectives

Refugees resettled in the US may be at risk for cardiovascular disease (CVD). However, little is known about CVD-related issues among Karen refugees who have migrated to the US from the Thai-Myanmar border. The purpose of this study was to examine CVD-related health beliefs and lifestyle issues among Karen refugees resettled in the US.

Methods

Karen refugees resettled in the US from the Thai-Myanmar border (n=195) participated in a survey study on health beliefs related to CVD, salt intake, physical activity (PA), and smoking in the fall of 2016.

Results

A high-salt diet, physical inactivity, and smoking were major lifestyle problems. Participants who adhered to a low-salt diet considered themselves to be susceptible to CVD. Most participants did not engage in regular PA. Regular PA was associated with less perceived susceptibility to CVD and greater perceived benefits of a healthy lifestyle for decreasing the likelihood of CVD.

Conclusions

Each refugee population may require individualized strategies to promote PA and a healthy diet. Future studies should develop health education programs that are specifically designed for Karen refugees and evaluate such programs. In addition to health education programs on healthy lifestyle choices, tobacco cessation programs seem to be necessary for Karen refugees. At the same time, it is important to foster strategies to increase the utilization of preventive care among this population by promoting free or reduced-fee resources in the community to further promote their health.

Epidemiology of Substance Use among Forced Migrants: A Global Systematic Review

INTRODUCTION

Forced migration is occurring at unprecedented levels. Forced migrants may be at risk for substance use for reasons including coping with traumatic experiences, co-morbid mental health disorders, acculturation challenges and social and economic inequality. This paper aimed to systematically review the literature examining substance use among forced migrants, and identify priority areas for intervention and future research.

METHODS

Seven medical, allied health and social science databases were searched from inception to September 2015 in accordance with PRISMA guidelines to identify original peer-reviewed articles describing any findings relating to alcohol and/or illicit drug use among refugees, internally displaced people (IDPs), asylum seekers, people displaced by disasters and deportees. A descriptive synthesis of evidence from quantitative studies was conducted, focusing primarily on studies which used validated measures of substance use. Synthesis of evidence from qualitative studies focused on identifying prominent themes relating to the contexts and consequences of substance use. Critical Appraisal Skills Programme (CASP) checklists were used to assess methodological quality of included studies.

RESULTS

Forty-four quantitative (82% cross-sectional), 16 qualitative and three mixed-methods studies were included. Ten studies were rated as high methodological quality (16%), 39 as moderate quality (62%) and 14 as low quality (22%). The majority of research was conducted among refugees, IDPs and asylum seekers (n = 55, 87%), predominantly in high-income settings. The highest-quality prevalence estimates of hazardous/harmful alcohol use ranged from 17%-36% in camp settings and 4%-7% in community settings. Few studies collected validated measures of illicit drug use. Seven studies compared substance use among forced migrants to other migrant or native-born samples. Among eight studies which conducted multivariable analysis, male sex, trauma exposure and symptoms of mental illness were commonly identified correlates of substance use.

CONCLUSION

Our understanding of substance use among forced migrants remains limited, particularly regarding persons displaced due to disasters, development and deportation. Despite a growing body of work among refugee-background populations, few studies include refugees in low and middle-income countries, where over 80% of the global refugee population resides. Findings suggest a need to integrate substance use prevention and treatment into services offered to forced migrants, particularly in camp settings. Efforts to develop and evaluate interventions to reduce substance use and related harms are needed.