Factors affecting commencement and cessation of betel quid chewing behaviour in Malaysian adults

The antidiabetic drug pioglitazone ameliorates betel-nut-induced carcinogenesis in mice by restoring normal lipid metabolism, reducing oxidative stress, and inducing apoptosis

CONTEXT

Oral administration (2 mg mL-1) of aqueous extract of betel nut (AEBN) for 24 weeks induced oncogenic alterations in the liver of female Swiss Albino mice concomitant with aberrant lipid metabolism, overactivation of Akt/mTOR signaling, and loss of apoptosis.

AIM

This study was designed to investigate the potential of repurposing the antidiabetic drug pioglitazone for alleviating AEBN-induced carcinogenesis.

METHODS

Sera of animals were evaluated for lipid profile and free fatty acid levels. Liver tissues were investigated for oxidative stress, histopathology, and expression of proteins involved in lipid metabolism and oncogenesis by western blotting. Apoptosis was determined using TUNEL assay.

RESULTS

Coadministration of pioglitazone (10 mg kg-1 b.w) with AEBN for 8 weeks restored normal lipid profile and AMPK/ACC signaling, reduced FASN and HMGCR expressions and oxidative stress, and actively induced Akt/mTOR-mediated apoptosis in the liver.

CONCLUSIONS

Pioglitazone can effectively alleviate AEBN-induced carcinogenesis in mice.

Systematic review of determinants and interventions of areca nut cessation: curbing a public health menace

BACKGROUND

Areca nut (AN) is a proven human carcinogen and a global public health menace. There is yet no review providing comprehensive information on the determinants and interventions available for cessation of AN. This systematic review was aimed at summarizing the available literature on drivers and interventions for cessation of AN chewing habit and to highlight the research lacunae.

METHODS

A systematic literature search (from 1990 till March 2021) was conducted for studies on AN cessation. Relevant data were extracted independently by two authors.

RESULTS

A total of 16 studies were included, which highlighted the influence of socio-cultural factors, addictive nature of AN and withdrawal symptoms as barriers to quitting. However, the knowledge of ill-effects of AN use on health, absence of concurrent alcohol use or smoking and family pressure were associated with likelihood of AN cessation. The interventions utilized for AN cessation have been behavioural in majority of the studies except for one where antidepressants were used for this purpose.

CONCLUSIONS

The current review emphasizes the imperative need of appropriate cessation strategies for AN chewing habit including enhancing awareness of the harmful effects and research into additional behavioural and pharmacologic cessation therapies to control this significant public health problem.

Prevalence, Habit Pattern, and Awareness on Harmful Effects of Tobacco/Areca Nut Use among Patients Visiting a Tertiary Care Center in Sri Lanka

Background The carcinogenicity of tobacco and areca nut is well established worldwide. Areca nut is the fourth most common psychoactive substance identified recently. The effects of areca nut on the autonomic nervous system make the users dependent on the habit which has been an emerging health issue among Sri Lankan adults and adolescents. This study aimed to evaluate the prevalence and patterns of these risk habits among the patients attending a tertiary care center in Sri Lanka, and their awareness of the harmful effects of the habit.

Method A hospital-based cross-sectional study was conducted among 512 patients using an interviewer-administered questionnaire.

Results The sample consisted of 167 (33%) tobacco consumers. The average age of the initiation of tobacco consumption was 23.66 years (standard deviation ± 8.04). Age (p = 0.001), gender (p = 0.001), income (p = 0.005), and educational level (p = 0.001) are significantly associated with tobacco consumption. There is a strong likelihood for tobacco consumers to consume areca nut (odds ratio [OR] 30.58, 95% confidence interval [CI] 17.05–54.88) and alcohol (OR 11.16, 95% CI 6.91–17.98) at any stage in their lives. The majority of the tobacco consumers (61%) were smokeless tobacco users. Areca nut consumers are 0.44 times more likely to know its carcinogenic effects than nonconsumers (95% CI 0.28–0.69). Tobacco consumers are more likely to be aware of the harmful effects of tobacco consumption than nonconsumers (OR 1.11, 95% CI 0.45–2.74). Sixty percent have made at least one attempt to quit the habit. Sixty-two percent of the unsuccessful quitters reported the reason as “addiction.”

Conclusion Prevalence of smokeless tobacco consumption prevails at a high level among Sri Lankans. Tobacco and areca nut users are more likely to be aware of its harmful effects than the nonconsumers but unable to quit the habit due to the psychoactive properties of tobacco and areca nut.

Behavioral and Psychosocial Risk Factors that Lead Individuals to Initiate and/or Maintain Betel Quid Chewing in Developed and Developing Countries: A Systematic Review

BACKGROUND

Betel quid (BQ) is the fourth most commonly used psychoactive substance and its use is highly prevalent among southeast Asian countries due to the influence of psychosocial, behavioral, and environmental factors. As a result, even young children and women are becoming addicted and find it difficult to achieve long-term abstinence. Systematic research addressing the influence of behavioral and psychosocial factors on BQ chewing is scarce, hence pointing to the need for understanding the interplay of these factors to develop tailored intervention strategies for BQ cessation.

OBJECTIVE

The objective of this systematic review is to assess various behavioral and psychosocial risk factors from pre-existing literature that lead individuals to initiate and/or maintain BQ chewing in developed and developing countries.

MATERIALS AND METHODS

The electronic retrieval systems and databases PUBMED [MEDLINE], EMBASE, SCOPUS, WEB OF SCIENCE, GOOGLE SCHOLAR, and SCIENCE DIRECT were searched independently by two authors for relevant articles from January 2011 to July 2021 using combinations of keywords. Primary studies published in English focusing on the behavioral and psychosocial risk factors for BQ chewing were included.

RESULTS

Out of the initial 264 articles searched, 12 articles met the selection criteria. Included studies addressed the influence of behavioral and psychosocial factors toward the initiation and/or maintenance of BQ chewing. Included studies reported that dependent BQ was not able to quit BQ chewing due to habituation, addiction, and withdrawal symptoms. Few social BQ chewers in Southeast Asian countries were not willing to initiate quitting as they considered AN as an important social and cultural identifier and claimed that they could not resist chewing in a peer group, and it has become part of their social life.

CONCLUSION

In the future, studies should take into consideration behavioral and psychosocial risk factors, which are major barriers toward successful quitting. These factors should be integrated into areca nut cessation guidelines, and there is a need to develop more comprehensive culture-specific intervention approaches to achieve long-term abstinence.

Betel quid chewing and its prevalence and determinants: data from Myanmar Demographic Health and Survey of 2015-2016

BACKGROUND

Although betel quid chewing with tobacco use is one of the major behavioral risk factors for chronic diseases, the prevalence is rather on the increase in Myanmar. This study determined prevalence of betel quid chewing at the national and subnational levels and its associations with tobacco and sociodemographic factors.

METHODS

This study is a secondary data analysis of Myanmar demographic health survey 2015-2016 with a total of 11 773 women and 4251 men aged 18-49 years. Chi-square tests and multivariable logistic regression tests were performed.

RESULTS

Prevalence of betel quid chewing was 61.8% in men and 19.5% in women and by regions it ranged from 34 to 82.2% and from 5-8 to 52.9%, respectively. The prevalence of the concurrent use with tobacco was 25.8 and 2.3%, respectively. Women with older age, low education and low wealth and occupation and living with spouse were associated with betel quid chewing, while low education, living with spouse and Myanmar speaker were associated with men. Tobacco use was inversely and positively associated with betel quid chewing in men and women, respectively (P-interaction <0.0001).

CONCLUSION

Implementation of culturally sensitive intervention and policies including effective community awareness campaigns for anti-betel quid chewing is strongly recommended in Myanmar.

Altered Spontaneous Brain Activity in Betel Quid Dependence Chewers: A Resting-State Functional MRI Study With Percent Amplitude of Fluctuation

OBJECTIVE

This study aimed to investigate brain spontaneous neural activity changes in betel quid dependence (BQD) chewers using the percent amplitude of fluctuation (PerAF) method.

METHODS

This study included 48 BQD chewers. The healthy control (HC) group comprised 35 volunteers who were matched with BQD chewers in age, gender, and educational status. All subjects underwent resting-state functional magnetic resonance imaging (rs-fMRI) and neuropsychological tests. The PerAF method was used to identify BQD-related regional brain activity changes. An independent samples t-test was used to evaluate the PerAF difference across two groups. The association between PerAF changes and clinical features such as BQD scores, duration of BQD, Hamilton Depression Rating Scale-24 item (HAMD-24), and Hamilton Anxiety Rating Scale-14 item (HAMA-14) was evaluated by using Spearman's correlation analysis. It assessed the ability of the PerAF method to distinguish between BQD chewers and HCs using a receiver operating characteristic (ROC) curve.

RESULTS

Compared to the control group, BQD chewers showed decreased PerAF in right anterior cingulate cortex (ACC), right middle frontal gyrus (MFG), right insula, right precuneus, left putamen, left supramarginal gyrus (SMG), and left cerebellum and increased PerAF in right orbitofrontal and left superior temporal gyrus (STG) [P < 0.05, Gaussian random field (GRF) corrected]. PerAF values of the right MFG and right ACC had a significant negative relationship with the duration of BQD (P < 0.05). The average values of PerAF in the left putamen, left cerebellum, and left STG showed significant discriminatory power in distinguishing BQD chewers from HCs, with relatively prime area under the curve (AUC) values.

CONCLUSION

Our findings suggested that betel quid chewing is associated with spontaneous neural activity alterations in the impulsivity areas (MFG and ACC), cognitive (MFG, ACC, precuneus, and the cerebellum), and reward (orbitofrontal, putamen, and insula) systems, which may be correlated with neuropathological mechanisms of BQD. Also, PerAF may be useful as a potential sensitive biomarker for identifying spontaneous brain activity changes in BQD chewers.

Reduction in and Preventive Effects for Oral-Cancer Risk with Antidepressant Treatment

Areca nut (AN) was identified as carcinogenic to humans. Around 600 million people globally use AN in some form, yet no effective therapeutic drug is available to overcome AN addiction. This preclinical study examines the effects of antidepressants on AN use with animal models. We produced AN powder and dissolved it into drinking water, training 55 C57BL/6 mice in free self-selection to drink AN water or normal water. Then, the mice were randomly divided into four groups. Selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), and tricyclic antidepressants (TCAs) were given as three treatment groups and one placebo group for four weeks. In the follow-up period, the preference and amount of free selection of AN and normal water, and oral pathological change were evaluated. There was a significant decrease in preference for AN drinking during the first four weeks, and the 36th week after drug withdrawal in the MAOI and SSRI groups (all p < 0.05). The drug-reducing effect of AN water in the 1–4-week period was significant in the MAOI group (p < 0.0001) and was also significant in the 3–4-week period in the SSRI group (p = 0.03). The TCA group did not show a decrease effect. At the endpoint (60 weeks), oral mucosal fibrosis (OSF) levels and risk in the SSRI (p = 0.0081) and MAOI (p = 0.01) groups were significantly lower than those in the control group. Antidepressant drugs MAOIs and SSRIs could reduce the amount of AN use and decrease the early stage of oral fibrosis in mice, but SSRIs may need to be boosted again.

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.

The Effectiveness of Betel Quid Cessation among Workers through the Adoption of the Five Action Areas of the Ottawa Charter

This study aimed to increase workers' awareness of betel quid cessation. Methods: Using community and workplace resources, a workplace health promotion program was developed in accordance with the five action areas of the Ottawa Charter. Questionnaires were administered to examine the changes in the knowledge and attitudes of 714 workers in different occupations before and three months after the intervention. Results: Regardless of subjects' pre-intervention chewing status, their knowledge and attitude scores relating to betel quid cessation increased significantly after the intervention. The effect of occupation was significant on the post-intervention knowledge and attitude scores among chewers. Furthermore, 16 (11.6%) of the 138 study subjects who chewed betel quid before the intervention and had no willingness to quit, did quit betel quid chewing following the intervention. The factors contributing to an unwillingness to quit among chewers with no intention to quit before the intervention were examined. Workers in the electronic material manufacturing industry had a greater willingness to quit compared to those in the metal, machinery, and related trades (odds ratio [OR] = 0.15; 95% confidence interval [CI] = 0.02-0.94). Travel attendants, tour guides, cleaners, and helpers were the least willing to quit (OR = 21.29; 95% CI = 2.51-180.81). Conclusions: This study promoted workers' awareness of betel quid cessation by adopting the five action areas of the Ottawa Charter framework, the effectiveness of the intervention varied in different occupations. Workers with a high-income and better education level had a higher awareness of betel quid cessation.

Vildagliptin, a dipeptidyl peptidase-4 inhibitor, reduces betel-nut induced carcinogenesis in female mice

AIM

Betel-nut, a popular masticatory among Southeast Asian populations is a class I carcinogen, previously associated with dyslipidemia and aberrant lipid metabolism, and is reported to be used more frequently by females, than males. This study investigates the potential of repurposing the anti-diabetic drug, vildagliptin, a dipeptidyl peptidase-4 inhibitor, for alleviating the oncogenic condition in female Swiss Albino mice administered an aqueous extract of betel-nut (AEBN) orally (2 mg ml^-1) for 24 weeks.

MAIN METHODS

Tissues were investigated by histopathological, immunohistochemical and apoptosis assays. Biochemical analyses of oxidative stress markers and lipid profile were performed using different tissues and sera. The expressions of different proteins involved in lipid metabolism and oncogenic pathways were evaluated by Western blotting.

KEY FINDINGS

AEBN induced carcinogenesis primarily in the liver by significantly impairing AMPK signaling, inducing oxidative stress, activating Akt/mTOR signaling, increasing Ki-67 immunoreactivity and cyclin D1 expression, and significantly diminishing apoptosis. Co-administration of AEBN with vildagliptin (10 mg kg^-1 body weight) for 8 weeks reduced liver dysplasia, and significantly decreased free palmitic acid, increased free oleic acid, normalized lipid profile, decreased oxidative stress, cyclin D1 expression, Ki-67 immunoreactivity, and Bcl2 expression, and increased the ratio of apoptotic/non-apoptotic cells. Mechanistically, vildagliptin elicited these physiological and molecular alterations by restoring normal AMPK signaling and reducing the cellular expressions of FASN and HMGCR, restoring AMPK-dependent phosphorylation of p53 at Ser-15 and reducing Akt/mTOR signaling.

SIGNIFICANCE

These results indicate that vildagliptin may alleviate betel-nut induced carcinogenesis in the liver of female mice.

Cytotoxic Effects of Betel Quid and Areca Nut Aqueous Extracts on Mouse Fibroblast, Human Mouth-Ordinary-Epithelium 1 and Human Oral Squamous Cell Carcinoma Cell Lines

Background:

Betel quid chewing is more common among the older generation in rural areas of Malaysia. Oral cancer in Asia has been associated with the habit of chewing betel quid and areca nut.

Objective:

This study aims to investigate the cytotoxic effects of betel quid and areca nut extracts on the fibroblast (L929), mouth-ordinary-epithelium 1 (MOE1) and oral squamous cell carcinoma (HSC-2) cell lines.

Methods:

L929, MOE1 and HSC-2 cells were treated with 0.1, 0.2 and 0.4 g/ml of betel quid and areca nut extracts for 24, 48 and 72 h. MTT assay was performed to assess the cell viability.

Results:

Both extracts, regardless of concentration, significantly reduced the cell viability of L929 compared with the control (P<0.05). Cell viability of MOE1 was significantly enhanced by all betel quid concentrations compared with the control (P<0.05). By contrast, 0.4 g/ml of areca nut extract significantly reduced the cell viability of MOE1 at 48 and 72 h of incubation. Cell viability of HSC-2 was significantly lowered by all areca nut extracts, but 0.4 g/ml of betel quid significantly increased the cell viability of HSC-2 (P<0.05).

Conclusion:

Areca nut extract is cytotoxic to L929 and HSC-2, whereas the lower concentrations of areca nut extract significantly increased the cell viability of MOE1 compared to the higher concentration and control group. Although betel quid extract is cytotoxic to L929, the same effect is not observed in MOE1 and HSC-2 cell lines. Further investigations are needed to clarify the mechanism of action.

Rationale and design of a randomized, controlled, superiority trial on areca nut/betel quid cessation: The Betel Nut Intervention Trial (BENIT)

Background

Areca nut (AN) is the seed endosperm of the Areca catechu L. palm and a Group 1 carcinogen chewed by 10–20% of the world population. AN is often chewed with Piper betle L. leaf, slaked lime, and tobacco to form a betel quid (BQ). The negative health effects associated with AN/BQ consumption warrant the need for an evidence-based cessation program. However, systematic research on AN/BQ cessation is rare.

Methods/design

The Betel Nut Intervention Trial (BENIT; trial #NCT02942745) is a randomized controlled trial designed to test the efficacy of an intensive AN/BQ cessation program. The trial is ongoing in Guam and Saipan with adult chewers who include tobacco in their BQ. Enrolled participants are assessed for their primary (chewing status) and secondary (saliva bio-verification) outcome at baseline, 22 days, and 6 months. Participants randomized into the control arm receive an educational booklet while those randomized into the intervention arm receive the educational booklet and a 22-day cessation program modeled after a smoking cessation program and led by trained facilitators. Information on chewing behavior (history, reasons for chewing, and AN/BQ composition and dependency) are collected. The intervention effectiveness is assessed using the logistic mixed model to compare cessation status between randomization groups.

Discussion

AN/BQ chewing affects a large population of people, many of whom live in low and moderate income countries in the Asia-Pacific region. Although the BENIT focuses on chewers in Guam and Saipan, it has the potential for greater regional and global importance.

Investigating Betel Nut Use, Antecedents and Consequences: A Review of Literature

Background: Betel nut use is a public health issue in the Asia-Pacific region that is often neglected. To control betel nut use, understanding of the adverse effects of betel nut use and evidence-based policies and strategies is necessary. Objectives: This narrative review aims to characterize the current situation on betel nut use at a global level regarding the epidemiology, pharmacology and toxicology, health effects, treatment options, policies and strategies. Methods: We found 139 existing literature published between 1970-2019 on the Web of Science database and other technical documents to collate the most relevant information on betel nut use. Data were categorized into appropriate themes. Results: The literature demonstrates that there is a lack of up to date statistics on betel nut use. There is limited research on the effect of policies and strategies to control betel nut use. Conclusion: Betel nut-chewing countries should focus on understanding which populations chew betel nut and implement appropriate policies, educational and cessation programs to help control betel nut use.

Barriers to Quitting Areca Nut Consumption and Joining a Cessation Program as Perceived by Chewer and Nonchewer Populations in Guam

Background: Areca nut (AN) is a carcinogenic substance consumed by roughly 600 million individuals worldwide with increasing popularity in Guam. In response, a cessation program was developed and implemented in Guam and Saipan. However, to improve its delivery, it is necessary to understand the reasons influencing recruitment and participation, such as why a chewer may not want to quit or join a cessation program. Objective: To explore barriers inhibiting chewers from quitting AN chewing and from participating in a cessation program. Methods: Nine individual and group discussions were facilitated with a convenience sample of 17 chewers and nonchewers in Guam in 2017. The mean age of the participants was 36.4 years. Recurring themes relating to reasons for not quitting and not joining a cessation program were extracted. Results: Results produced three general categories-Sociocultural, Behavioral, and Accessible. Each category encompasses different attributes concerning reasons not to quit chewing (e.g. addiction, enabling community, or belief that AN is harmless), and reasons influencing lack of participation in a cessation program (e.g. time, transportation, or relatability). Conclusions: Current findings suggest chewers are unaware of the harmful effects of AN. Also, they may not comprehend the purpose of a cessation program. In addition, the likelihood of chewers participating in a cessation program is influenced by their level of comfort with the program and personnel, and whether a program addresses their time and transportation limitations.

Prevalence and Correlates of Betel Quid Chewing among Bhutanese Adults

Background: Chewing of betel quid, popularly known as doma khamdo, is prevalent in Bhutan and is associated with Bhutanese customs and traditions. The objective of this paper was to determine the prevalence and explore the correlates of current betel quid use in Bhutan. Materials and methods: This is a retrospective study of secondary data from the National Health Survey 2012 (NHS 2012) of Bhutan. The outcome variable of interest was current betel quid use. The self-reported demographic characteristics were obtained using a questionnaire developed following the WHO STEPwise approach to the surveillance of non-communicable diseases (STEP). Univariate and multivariate logistic regression were performed to identify correlates for betel quid use. Results: The prevalence of current betel quid use in this study was 45.0%. The correlates associated with current betel quid use were: being female; having a primary, high school or a monastic education; being professionals in the armed forces, managers, technicians, service and sales workers, and machine operators; being current smokers; alcohol consumption; and intake of drugs. Correlates associated with decreased betel quid use were: having a diploma/certificate-level and non-formal education, and living in urban areas. Conclusion: The findings indicate that betel quid was consumed by nearly half of the Bhutanese population. Bhutan should immediately initiate national prevention programs targeting these correlates of betel quid use.

An Overview on Betel Quid and Areca Nut Practice and Control in Selected Asian and South East Asian Countries

Background: Areca nut (AN) and betel quid (BQ) chewing are ancient practices followed by an extensive proportion of the world's population. These practices are endemic in larger parts of South and Southeast Asia and selected Western Pacific countries. The prevalence of these habits varies across regions, age, gender, cultural practice, and socioeconomic status groups. Considerable variations exist between countries with respect to prevention/intervention programs, and policy guidelines of BQ usage. Objectives: (1) To provide an overview of the BQ chewing prevalence, practices, preventive interventions and policies in selected Asian and Western Pacific countries. (2) To explore the different terminologies associated with BQ use. Method: A narrative review of the current literature related to BQ, AN, and oral cancer was conducted by searching PUBMED, CINAHL, and GOOGLE databases. Results: The literature review revealed that the prevalence of BQ was found to be highest in Papua New Guinea, followed by Bangladesh, India, Pakistan, Myanmar and Sri Lanka. While, Cambodia, Malaysia, Indonesia and Taiwan had comparatively lower prevalence. Smokeless tobacco, BQ with tobacco, BQ without tobacco, AN were some of the terminologies used for BQ in various studies. Conclusions: The prevalence, and the interventional policies related to BQ and AN chewing habits varies widely among the selected countries. With the increasing awareness and association of BQ with oral cancer, there is a need to have better awareness, prevention and interventional strategies in place. We also found considerable variation in the use of terminologies associated with BQ.

Oral health-related quality of life among 11-12 year old indigenous children in Malaysia

BACKGROUND

Poor oral health among Malaysian indigenous Orang Asli (OA) children may impact on their daily performances.

AIM

To assess the oral health status, related behaviours, and oral health-related quality of life (OHRQoL) among OA children in Cameron Highlands (CH), Malaysia, and to identify the predictor(s) for poor OHRQoL.

DESIGN

This was a cross-sectional study involving 249, 11-12 year old OA children from 4 OA primary schools in CH. The children completed a self-administered questionnaire comprising information on socio-demographics, oral health-related behaviours, and the Malay Child Oral Impacts on Daily Performances (Malay Child-OIDP) index followed by an oral examination. Data were entered into the SPSS version 23.0 software. Non-parametric tests and multiple logistic regression were used for data analysis.

RESULTS

The response rate was 91.2% (n = 227/249). The prevalence of caries was 61.6% (mean DMFT = 1.36, mean dft = 1.01) and for gingivitis was 96.0%. Despite the majority reported brushing their teeth ≥ 2x/day (83.7%) with fluoride toothpaste (80.2%), more than two-thirds chewed betel nut ≥ 1/day (67.4%). Majority of the children (97.8%) had a dental check-up once a year. Nearly three-fifths (58.6%) reported experiencing oral impacts on their daily performances in the past 3 months (mean score = 5.45, SD = 8.5). Most of the impacts were of "very little" to "moderate" levels of impact intensity with 90.2% had up to 4 daily performances affected. Most of the impacts were on eating (35.2%), cleaning teeth (22.0%) and relaxing activities (15.9%). Caries in primary teeth is associated with oral impacts among the OA children.

CONCLUSIONS

The 11-12 year old OA children in Cameron Highland had high prevalence of caries and gingivitis with the majority chewed betel nut regularly. Caries in primary teeth is associated with poor OHRQoL. Future programmes should target younger age group children to promote positive oral hygiene practices, reduce caries, and improve quality of life.

Mouth self-examination as a screening tool for oral potentially malignant disorders among a high-risk Indigenous population

OBJECTIVES

To evaluate the efficacy of mouth self-examination (MSE) as a self-screening tool for detection of oral mucosal lesions among an Indigenous population in Malaysia at high risk for oral premalignant and malignant disorders.

METHODS

Two villages were selected as the sampling frame based on prevalence of tobacco and betel quid chewing habit. Respondents were asked to check their mouth for presence of lesion or abnormalities. Education on oral cancer, including MSE, was provided. Subsequently, respondents were asked to perform MSE. Finally, a clinical oral examination (COE) was done by a specialist and the presence of oral mucosal lesions was recorded.

RESULTS

Almost 64.5 percent of respondents exhibited high levels of difficulty and low mucosal visualization and retracting ability, whereas 3.0 percent demonstrated high attention level when performing MSE. Prevalence of oral mucosal lesions was 59.0 percent, whereas the prevalence of oral potentially malignant disorders (OPMDs) was 9.0 percent. Detection of oral lesions by respondents using MSE was lower than detection by the gold standard. Sensitivity and specificity of MSE for detection of all types of lesions were 8.6 and 95.0 percent respectively. When analyzing each lesion type separately, MSE was found to be most sensitive in detection of swellings (10.0 percent), and most specific in identifying white lesions (97.8 percent). For detection of OPMDs, although specificity was high (98.9 percent), sensitivity (0 percent), and +LR (0) was poor.

CONCLUSION

MSE is not an effective self-screening tool for early detection of potentially malignant lesions for this population.

Universal health insurance, health inequality and oral cancer in Taiwan

INTRODUCTION

The introduction of universal health insurance coverage aims to provide equal accessibility and affordability of health care, but whether such a policy eliminates health inequalities has not been conclusively determined. This research aims to examine the healthcare outcomes of oral cancer and determine whether the universal coverage system in Taiwan has reduced health inequality.

METHODS

Linking the databases of the National Cancer Registry with the National Mortality Registry in Taiwan, we stratified patients with oral squamous cell carcinoma by gender and income to estimate the incidence rate, cumulative incidence rate aged from 20 to 79 (CIR20-79), life expectancy, and expected years of life lost (EYLL). The difficulties with asymmetries and short follow-up periods were resolved through applying survival analysis extrapolation methods.

RESULTS

While all people showed a general improvement in life expectancy after the introduction of the NHI, the estimated change in EYLL's of the high-, middle-, and low-income female patients were found to have +0.3, -0.5 and -7 years of EYLL, respectively, indicating a reduction in health inequality. Improvements for the male patients were unremarkable. There was no drop in the CIR20-79 of oral cancer in disadvantaged groups as in those with higher incomes.

CONCLUSIONS

Universal coverage alone may not reduce health inequality across different income groups for oral cancer unless effective preventive measures are implemented for economically disadvantaged regions.

Areca nut trade, globalisation and its health impact: perspectives from India and South-east Asia

AIM:

Areca nut (AN) is consumed globally by 600 million people, and 10%-20% of the world population uses betel quid, a preparation containing areca nut. India and other South-east Asian countries are the largest consumers of AN in the world. The aim of this article is to review the economic impact and oral health effects of the consumption of AN. It will also discuss the role of dentists and auxiliary healthcare providers for increasing public awareness and the need for a strong public health policy.

METHOD:

To address the concerned area, PubMed, Scopus and Google Scholar databases were explored from the year 1965 until 2017. Studies focusing on various aspects of AN only, and articles published in English were included. Anecdotal reports, case reports and unpublished data were excluded.

RESULTS AND DISCUSSION:

This narrative review suggests India is the world's largest producer of AN along with the largest AN consuming population followed by other South-east Asian countries. AN chewing causes oral submucous fibrosis (OSF) and it is most commonly observed in people of India and South-east Asia. AN use is associated with various social and unsocial aspects. Dentists and dental auxiliaries can increase the knowledge and awareness of a health issue (OSF) among the target audience as well as the detrimental effects of AN chewing.

CONCLUSION:

There is a need for more aggressive public health measures and dentists and dental auxiliaries should be employed to bring awareness to the general public regarding AN use.

Reasons for betel quid chewing amongst dependent and non-dependent betel quid chewing adolescents: a school-based cross-sectional survey

BACKGROUND

Betel quid (BQ) chewing in children is initiated in their adolescence. It is pivotal to understand adolescents' reasons behind chewing BQ. In this study, we aimed to evaluate the reasons for BQ chewing amongst adolescents using reasons for betel quid chewing scale (RBCS) and their associated dependency on it.

METHODS

This is a cross-sectional school based survey. Out of 2200 adolescents from 26 schools of Karachi, 874 BQ chewers were assessed for their reasons of BQ chewing and dependency on it. Regression analyses were employed to report crude and adjusted (after adjusting for all reasons of BQ chewing) effect sizes with 95% confidence interval and P-value was set significant at < 0.05.

RESULTS

Students who believed that BQ chewing relaxes them (stimulation construct) were twice as likely to be dependent on BQ (OR = 2.36, 95% CI (1.20-4.65) as compared with others. Participants who thought it eases their decision making (stimulation construct), were sizably more likely to be dependent on BQ (OR = 9.65, 95% CI (4.15-22.43) than those who did not consider ease in decision making important. Adolescents who considered not chewing as rude (social/cultural construct), were thrice more likely to be dependent on BQ (OR = 2.50, 95% CI (1.11-5.63) than others.

CONCLUSIONS

Stimulation remained fundamental chewing reason followed by social/cultural trigger amongst adolescents. Any future intervention may get favorable results if it addresses ways to overcome stimulation and social/cultural barriers that are strongly associated with BQ chewing and dependency.

Effects of Damnacanthal and Nordamnacanthal on Proliferation, Apoptosis, and Migration of Oral Squamous Cell Carcinoma Cells

Cancer is one of the most common causes of death in the developed world, with one-third of people diagnosed with cancer during their lifetime. Oral cancer commonly occurs involving the buccal mucosa (cheeks), tongue, floor of the mouth and lip. It is one of the most devastating and disfiguring of malignancies. Morinda citrifolia L., commonly known as ‘noni’, belongs to the Rubiaceae family. It is native to the Pacific islands, Hawaii, Caribbean, Asia and Australia. The plant displays broad curative effects in pharmacological studies. Damnacanthal (DAM) and Nordamnacanthal (NDAM), anthraquinone compounds isolated from the roots of Morinda citrifolia L., has been used for the treatment of several chronic diseases including cancer. The objectives of this study were to evaluate cytotoxicity, morphological changes, cell death mode (apoptosis/necrosis), and cell migration induced by DAM and NDAM on the most common type of oral cancer, oral squamous cell carcinoma (OSCC)cells. Anti-proliferative effects of these compounds against OSCC cell lines were determined by MTT assay. The mode of cell death was analysed by phase contrast and fluorescent microscopy as well as flow cytometry. In addition, cell migration was assessed. The results showed that DAM and NDAM exerted cytotoxicity against OSCC cells with IC₅₀ values of 1.9 to >30 μg/ml after 72 h treatment. Maximum growth inhibition among the tested cell lines for both compounds was observed in H400 cells, and thus it was selected for further study. The study demonstrated inhibition of H400 OSCC cell proliferation, marked apoptotic morphological changes, induction of early apoptosis, and inhibition of cell migration by DAM and NDAM. Therefore, this information suggests that these compounds from noni have potential for used as anti tumor agents for oral cancer therapy.

Defining a global research and policy agenda for betel quid and areca nut

Betel quid and areca nut are known risk factors for many oral and oesophageal cancers, and their use is highly prevalent in the Asia-Pacific region. Additionally, betel quid and areca nut are associated with health effects on the cardiovascular, nervous, gastrointestinal, metabolic, respiratory, and reproductive systems. Unlike tobacco, for which the WHO Framework Convention on Tobacco Control provides evidence-based policies for reducing tobacco use, no global policy exists for the control of betel quid and areca nut use. Multidisciplinary research is needed to address this neglected global public health emergency and to mobilise efforts to control betel quid and areca nut use. In addition, future research is needed to advance our understanding of the basic biology, mechanisms, and epidemiology of betel quid and areca nut use, to advance possible prevention and cessation programmes for betel quid and areca nut users, and to design evidence-based screening and early diagnosis programmes to address the growing burden of cancers that are associated with use.

Adverse Health Effects of Betel Quid and the Risk of Oral and Pharyngeal Cancers

Global reports estimate 600 million betel quid (BQ) chewers. BQ chewing has been demonstrated not only to be a risk factor for cancers of the oral cavity and pharynx and oral potentially malignant disorders (OPMD) but also to cause other cancers and adverse health effects. Herein, we summarized the international comparison data to aid in the understanding of the close relationship between the prevalence of BQ chewing, the occurrence of oral and pharyngeal cancers, and adverse health effects. Potential biomarkers of BQ carcinogens, such as areca nut, alkaloids, and 3-methylnitrosaminopropionitrile (MNPN), are closely associated with human health toxicology. Molecular mechanisms or pathways involving autophagy, hypoxia, COX-2, NF-κB activity, and stemness are known to be induced by BQ ingredients and are very closely related to the carcinogenesis of cancers of oral and pharynx. BQ abuse-related monoamine oxidase (MAO) gene was associated with the occurrence and progress of oral and pharyngeal cancers. In summary, our review article provides important insights into the potential roles of environmental BQ (specific alkaloid biomarkers and nitrosamine products MNPN) and genetic factors (MAO) and offers a basis for studies aiming to reduce or eliminate BQ-related OPMD and oral/pharyngeal cancer incidences in the future.

Intoxication and substance use disorder to Areca catechu nut containing betel quid: A review of epidemiological evidence, pharmacological basis and social factors influencing quitting strategies

AIM

We present a systematic review of substance use disorder (SUD) to Areca catechu nut (AN) and AN containing betel quid (ANcBQ) with emphasis on dependence resulting from chewing of tobacco-free ANcBQ. We examined pharmacology of intoxication and addiction, and factors influencing quitting strategies.

METHODS

Epidemiological publications of SUD were included according to PRISMA criteria. Pharmacological publications were retrieved from the PUBMED database and websites of the WHO, United Nations, and Sigma-Aldrich.

RESULTS

Nine epidemiological studies show clear evidence of abuse and dependence in tobacco-free ANcBQ and/or ANcBQ+Tobacco chewers. Dependency is greater if ANcBQ contains tobacco. In both groups higher dependency scores were positively correlated with higher frequency of chewing. Dependency on AN+Lime is associated with altered brain morphology, resting state brain activity, neurochemistry and deterioration of working spatial memory. ANcBQ contains a complex mixture of neuroactive compounds that have the potential to act directly upon all major cerebral neurotransmitter systems. Of these compounds, only arecoline (muscarinic agonist) has been the focus of limited pharmacological investigation. In animal studies, arecoline increases dopamine transmission in the mesocorticolimbic circuit and this action may be one factor contributing to ANcBQ dependency in humans. Societal and familial acceptance of ANcBQ consumption is paramount for commencement and persistence of chewing.

CONCLUSIONS

ANcBQ SUD remains an orphan disease. The limited understanding of pharmacological basis of intoxication and SUD determines there are no pharmacological replacement therapies for ANcBQ SUD. The addictive properties of ANcBQ coupled with social acceptance of ANcBQ chewing limits the effectiveness of counseling-based quitting programs.

Genome wide profiling in oral squamous cell carcinoma identifies a four genetic marker signature of prognostic significance

BACKGROUND

Cancers of the oral cavity are primarily oral squamous cell carcinomas (OSCCs). Many of the OSCCs present at late stages with an exceptionally poor prognosis. A probable limitation in management of patients with OSCC lies in the insufficient knowledge pertaining to the linkage between copy number alterations in OSCC and oral tumourigenesis thereby resulting in an inability to deliver targeted therapy.

OBJECTIVES

The current study aimed to identify copy number alterations (CNAs) in OSCC using array comparative genomic hybridization (array CGH) and to correlate the CNAs with clinico-pathologic parameters and clinical outcomes.

MATERIALS AND METHODS

Using array CGH, genome-wide profiling was performed on 75 OSCCs. Selected genes that were harboured in the frequently amplified and deleted regions were validated using quantitative polymerase chain reaction (qPCR). Thereafter, pathway and network functional analysis were carried out using Ingenuity Pathway Analysis (IPA) software.

RESULTS

Multiple chromosomal regions including 3q, 5p, 7p, 8q, 9p, 10p, 11q were frequently amplified, while 3p and 8p chromosomal regions were frequently deleted. These findings were in confirmation with our previous study using ultra-dense array CGH. In addition, amplification of 8q, 11q, 7p and 9p and deletion of 8p chromosomal regions showed a significant correlation with clinico-pathologic parameters such as the size of the tumour, metastatic lymph nodes and pathological staging. Co-amplification of 7p, 8q, 9p and 11q regions that harbored amplified genes namely CCND1, EGFR, TPM2 and LRP12 respectively, when combined, continues to be an independent prognostic factor in OSCC.

CONCLUSION

Amplification of 3q, 5p, 7p, 8q, 9p, 10p, 11q and deletion of 3p and 8p chromosomal regions were recurrent among OSCC patients. Co-alteration of 7p, 8q, 9p and 11q was found to be associated with clinico-pathologic parameters and poor survival. These regions contain genes that play critical roles in tumourigenesis pathways.

Disrupted Resting-State Default Mode Network in Betel Quid-Dependent Individuals

Recent studies have shown that substance dependence (addiction) is accompanied with altered activity patterns of the default mode network (DMN). However, the neural correlates of the resting-state DMN and betel quid dependence (BQD)-related physiopathological characteristics still remain unclear. Resting-state functional magnetic resonance imaging images were obtained from 26 BQD individuals and 28 matched healthy control subjects. Group independent component analysis was performed to analyze the resting state images into spatially independent components. Gray matter volume was examined as covariate with voxel-based morphometry to rule out its effect on the functional results. The severity of BQD was assessed by the BQD Scale (BQDS). We observed decreased functional connectivity in anterior part of the DMN including ventral medial prefrontal cortex, orbital MPFC (OMPFC)/anterior cingulate cortex (ACC). Furthermore, the functional connectivity within the OMPFC/ACC in BQD individuals was negatively correlated with BQDS (p = 0.01, r = -0.49). We reported decreased functional connectivity within anterior part of the DMN in BQD individuals, which provides new evidence for the role of the DMN in the pathophysiology of BQD.

Taking actions to quit chewing betel nuts and starting a new life: taxi drivers' successful experiences of quitting betel nut chewing

AIMS AND OBJECTIVES

To understand taxi drivers' successful experiences of quitting betel nut chewing.

BACKGROUND

Previous studies verified that betel nut chewing significantly increases the risk of oral cancer. In Taiwan, taxi drivers work for approximately 10-13 hours per day, and 31·7-80% of them choose to chew betel nuts for their invigorating qualities, which enable them to work more hours and receive more income.

DESIGN

A qualitative research design was used.

METHODS

This study used the grounded theory method with purposive sampling to perform in-depth interviews with male taxi drivers who had successfully quit betel nut chewing for more than six months.

RESULTS

The interviewed participants were 25 taxi drivers aged 45-67 who had chewed betel nuts for an average of 30·9 years. A constant comparative analysis of the 25 interviews revealed six categories, namely the first experience of chewing betel nuts, a part of work and life, perceiving the impact of betel nuts, trying to change, acting to quit betel nut chewing and starting a new life.

CONCLUSIONS

During the cessation process, taxi drivers tended to be affected by their addiction to chewing betel nuts and the temptation of friends' invitations to chew betel nuts. However, their recognition of the physical effects of betel nut chewing and their sense of responsibility and commitment to family were the critical factors affecting their determination to quit betel nut chewing. Their willpower to not to chew betel nuts and the source of their motivation to exercise self-control also contributed to their success.

RELEVANCE TO CLINICAL PRACTICE

Healthcare personnel should understand the experiences and perceptions of betel nut chewers, strengthen their understanding of the effects of betel nut chewing on physical health during the cessation period and support their self-efficacy and quitting behaviours with the assistance of significant others.

Cell cycle arrest and mechanism of apoptosis induction in H400 oral cancer cells in response to Damnacanthal and Nordamnacanthal isolated from Morinda citrifolia

Oral cancer is the eleventh most prevalent cancer worldwide. The most prevalent oral cancer is oral squamous cell carcinoma (OSCC). Damnacanthal (DAM) and nordamnacanthal (NDAM), the anthraquinone compounds, are isolated from the root of Morinda citrifolia L. (Noni), which has been used for the treatment of several chronic diseases including cancer. The objectives of this study were to evaluate the cytotoxicity, cell death mode, cell cycle, and the molecular mechanism of apoptosis induced by DAM and NDAM on OSCC. The cytotoxic effects of these compounds against OSCC cell lines were determined by MTT assay. The cell death mode was analysed by DNA laddering and FITC-annexin V/PI flow cytometric assays. In addition, the mechanism of apoptosis induced by DAM and NDAM was detected using mitochondrial membrane potential, Cytochrome c, and caspases assays. Finally, the effect of DAM and NDAM on cell cycle phase distribution of OSCC cells was detected by flow cytometry. In the present study, DAM and NDAM showed cytotoxicity towards OSCC cell lines and the maximum growth inhibition for both compounds was observed in H400 cells with IC50 value of 1.9 and 6.8 μg/ml, respectively, after 72 h treatment. The results also demonstrated the inhibition of H400 OSCC cells proliferation, internucleosomal cleavage of DNA, activation of intrinsic apoptosis pathway, and cell cycle arrest caused by DAM and NDAM. Therefore, these findings suggest that DAM and NDAM can be potentially used as antitumor agents for oral cancer therapy.

Detection of Human Papillomavirus 16-Specific IgG and IgM Antibodies in Patient Sera: A Potential Indicator of Oral Squamous Cell Carcinoma Risk Factor

The association between human papillomavirus type 16 (HPV16) and oral cancer has been widely reported. However, detecting anti-HPV antibodies in patient sera to determine risk for oral squamous cell carcinoma (OSCC) has not been well studied. In the present investigation, a total of 206 OSCC serum samples from the Malaysian Oral Cancer Database & Tissue Bank System, with 134 control serum samples, were analyzed by enzyme-linked immunosorbant assay (ELISA) to detect HPV16-specific IgG and IgM antibodies. In addition, nested PCR analysis using comprehensive consensus primers (PGMY09/11 and GP5(+)/6(+)) was used to confirm the presence of HPV. Furthermore, we have evaluated the association of various additional causal factors (e.g., smoking, alcohol consumption, and betel quid chewing) in HPV-infected OSCC patients. Statistical analysis of the Malaysian population indicated that OSCC was more prevalent in female Indian patients that practices betel quid chewing. ELISA revealed that HPV16 IgG, which demonstrates past exposure, could be detected in 197 (95.6%) OSCC patients and HPV16-specific IgM was found in a total of 42 (20.4%) OSCC patients, indicating current exposure. Taken together, our study suggest that HPV infection may play a significant role in OSCC (OR: 13.6; 95% CI: 3.89-47.51) and HPV16-specific IgG and IgM antibodies could represent a significant indicator of risk factors in OSCC patients.

Neurochemical abnormalities in anterior cingulate cortex on betel quid dependence: a 2D (1)H MRS investigation

The effects of betel quid dependence (BQD) on biochemical changes remain largely unknown. Individuals with impaired cognitive control of behavior often reveal altered neurochemicals in Magnetic Resonance Spectroscopy Imaging (MRSI) and those changes are usually earlier than structural alteration. Here, we examined BQD individuals (n = 33) and age-, sex-, and education-matched healthy control participants (n = 32) in an 2D (1)H-MRS study to observe brain biochemical alterations in the anterior cingulated cortex (ACC) associated with the severity of BQD and duration of BQD. In the bilateral ACC, our study found NAA/Cr were lower in BQD individuals compared to the healthy controls, Cho/Cr and Glx/Cr were higher in individuals with BQD compared to the healthy group, but increase was noted for mI/Cr in BQD individuals only in the left ACC. NAA/Cr ratios of the right ACC negatively correlated with BQDS and duration, NAA/Cr ratios of the left ACC negatively correlated with duration, Glx/Cr ratios of the right ACC positively correlated with BQDS. The findings of the study support previous analyses of a role for ACC area in the mediation of BQ addiction and mechanistically explain past observations of reduced ACC grey matter in BQD patients. These data jointly point to state related abnormalities of BQ effect and provide a novel strategy of therapeutic intervention designed to normalize Glu transmission and function during treating BQ addiction.

Gray matter abnormalities associated with betel quid dependence: a voxel-based morphometry study

BACKGROUND

Betel quid dependence (BQD) patients have a cluster of cognitive, behavioral, and physiological symptoms which are associated with structural abnormalities in brain gray matter. However, so far there have neither been brain structural studies investigating the alterations related to BQD, nor studies assessing the brain structural changes with clinical indexes.

METHODS

65 subjects were recruited including 33 'pure' BQD patients and another 32 gender and age matched in the control group. T1 structural voxel-based morphometry (VBM) was performed to investigate the gray matter (GM) volume alterations. In BQD patients, Pearson correlation analysis was performed to investigate the association between GM segmentations and clinical indexes, including BQD scores, illness duration, SAS and SDS.

RESULTS

Compared with that of the control group, the VBM of GM in BQD patients exhibited a significant decrease in volume (All P values > 0.05, AlphaSim correction) in the midbrain, right anterior cingulate cortex (rACC), bilateral dorsolateral prefrontal cortex (dlPFC) and right superior temporal gyrus (STG), and also there was an increased volume in right hippocampal and right precuneus. GM volumes of the left DLPFC and right rACC showed negative correlation with the duration of BQD, meanwhile, midbrain volumes were negative correlating with BQD scores (All P values > 0.05).

CONCLUSIONS

Our findings suggested that brain structural changes were present in BQD patients, and those may be a neurobiological basis for BQD patients. These findings may provide a new insight into the pathogenesis of BQD. Also, VBM is an effective tool for in vivo investigation of gray matter alterations in patients with BQD.

Cross sectional survey on association between alcohol, betel- nut, cigarette consumption and health promoting behavior of industrial workers in Ghaziabad

BACKGROUND

The work force in industries are at risk of developing unduly high rates of health and behaviour related problems including abuse of alcohol, betel nut and cigarette (alcohol, betel nut and cigarette consumption). This study describes the relationships between alcohol, betel nut and cigarette consumption and health promoting behaviour among industrial workers.

MATERIALS AND METHODS

A cross sectional survey was conducted on workers in various industries of Ghaziabad city with concerned authority permission. A sample size of 732 workers was calculated based on pilot study. Through Simple random sampling 732 workers in 20 to 50 years age group with informed consent were interviewed through structured, pretested, validated questionnaire in vernacular language by one calibrated investigator. Data on socio demography, alcohol, betel nut and cigarette consumption pattern and health behaviour were collected. The association between health promoting behaviour and alcohol, betel nut and cigarette consumption was analysed by Logistic regression and Chi-square test through SPSS 16 at p<0.05 and 95%CI as significant.

RESULTS

Total prevalence of alcohol, betel nut and cigarette consumption in study population was 88%. The prevalence of individual alcohol, betel nut and cigarette consumption were 82%, 68% and 79% respectively. Combined alcohol, betel nut and cigarette prevalence in study population was 58%. Alcohol and cigarette users were significantly higher (p<0.001) in 30 to 40 years age group with lower level of education having poor attitude towards health promoting behaviour, poor oral hygiene practices and rare indulgence in regular physical exercise.

CONCLUSIONS

This study stimulate further research on exploring methods to prevent initiation of health risk behaviour and promote healthy behaviour with cessation help for the current alcohol, betel nut and cigarette users.

Developing a Betel Quid Cessation Program on the Island of Guam

Betel quid is a psychoactive drug preparation typically made up of a combination of areca quid, slaked lime, piper betel leaf and tobacco. It is the fourth most commonly consumed drug in the world with global use concentrated in the Asia-Pacific region (Boucher and Mannan, 2002; Warnakulasuriya and Peters, 2002). The International Agency for Research on Cancer has classified betel quid as a Group 1 carcinogen (IARC, 2004; Lin et al., 2006), and its use has been associated with oral and oropharyngeal cancer, oral lesions, oral leukoplakia, submucous fibrosis, gum disease, and cancer of the pharynx and esophagus (IARC, 2004; Oakley et al., 2005; Shah et al., 2002; Warnakulasuriya, 2002). This paper reports on the feasibility of an innovative betel quid cessation program carried on the U.S. territory of Guam, and is the first of its kind. The program is described, along with the challenges encountered during the implementation process.

The role of betel-quid chewing in smoking cessation among workers in Taiwan

BACKGROUND

Current smokers exhibit a higher rate of betel-quid chewing than non-smokers. However, little is known regarding the extent to which betel-quid chewing may affect attempts to quit smoking and smoking cessation. The aim of the present study is to examine the association between betel-quid chewing and patterns of quitting smoking. Specifically, we explore whether betel-quid chewing is associated with (1) current smokers who have never attempted to quit versus those who have attempted to quit and have failed, those who are in the process of quitting, and successful cessation smokers, and (2) current smokers who have attempted to quit and have failed versus those who have successfully quit smoking.

METHODS

A telephone survey of 7,215 workers was conducted and obtained an 88.6% response rate. In the survey, the respondents' smoking and betel-quid chewing statuses were recorded and a list of covariates was assessed.

RESULTS

After controlling for the effect of the covariates, betel-quid chewing was found to be more highly associated with current smokers who have never attempted to quit, compared to current smokers who are in the process of quitting (OR = 12.72; 95% CI = 1.05-154.26), successful cessation smokers (OR = 3.62; 95% CI = 2.32-5.65), and smokers who have attempted to quit and have failed (OR = 1.37; 95% CI = 1.06-1.77), respectively. In addition, betel-quid chewing is more highly associated with a failure to quit smoking than with successfully quitting smoking (OR = 3.46; 95% CI = 2.17-5.51).

CONCLUSION

The findings support four plausible reasons why betel-quid chewing may dissuade smokers from quitting. These reasons highlight additional avenues for potentially reducing the smoking population in workplaces, such as considering work contexts and social norms, and product sales in smoking-cessation campaigns.

The reasons for betel-quid chewing scale: assessment of factor structure, reliability, and validity

BACKGROUND

Despite the fact that betel-quid is one of the most commonly used psychoactive substances worldwide and a major risk-factor for head-and-neck cancer incidence and mortality globally, currently no standardized instrument is available to assess the reasons why individuals chew betel-quid. A measure to assess reasons for chewing betel-quid could help researchers and clinicians develop prevention and treatment strategies. In the current study, we sought to develop and evaluate a self-report instrument for assessing the reasons for chewing betel quid which contributes toward the goal of developing effective interventions to reduce betel quid chewing in vulnerable populations.

METHODS

The current study assessed the factor structure, reliability and convergent validity of the Reasons for Betel-quid Chewing Scale (RBCS), a newly developed 10 item measure adapted from several existing "reasons for smoking" scales. The measure was administered to 351 adult betel-quid chewers in Guam.

RESULTS

Confirmatory factor analysis of this measure revealed a three factor structure: reinforcement, social/cultural, and stimulation. Further tests revealed strong support for the internal consistency and convergent validity of this three factor measure.

CONCLUSION

The goal of designing an intervention to reduce betel-quid chewing necessitates an understanding of why chewers chew; the current study makes considerable contributions towards that objective.

Intention to quit betel quid: a comparison of betel quid chewers and cigarette smokers

BACKGROUND

Despite the global significance of betel quid chewing and the associated health risks, there have been no studies assessing chewers' intention to quit. Given the difficulties associated with quitting betel quid and the serious health consequences of chewing, it is important for researchers to develop interventions aimed at helping chewers quit. Betel quid chewers experience similar patterns of dependence and withdrawal symptoms as tobacco smokers, and the use of both substances causes serious adverse health effects. Therefore, it is possible that intention to quit betel quid and tobacco would also be similar. If similarities were found, researchers could look to existing tobacco cessation interventions to inform the development of betel quid cessation interventions. In the current study we sought to understand chewers' intention to quit and how it compares to smokers' intention to quit cigarettes.

METHODS

A total of 351 adult betel quid chewers from Guam were compared against 1,555 adult tobacco users from Hawaii. These comparisons were made possible because of the deliberate use of identical questionnaire items (mutatis mutandis) for betel quid chewing and cigarette smoking.

RESULTS

Smokers reported higher levels of wanting to quit, intending to quit, and wishing they have never started in the first place compared to chewers (p's<.0001). There were no differences across groups with regard to having a plan for how to quit and when to quit, with half of the samples reporting not having a plan for how or when to quit.

CONCLUSION

Both smokers and chewers want to quit and intend to quit, but do not have plans of when or how to quit. A deeper understanding of chewers' intention to quit and its similarities to smokers' intention to quit could be used to inform the development of betel quid cessation interventions.

The Betel Quid Dependence Scale: replication and extension in a Guamanian sample

BACKGROUND

Betel quid is the fourth most commonly consumed psychoactive substance in the world. The Betel Quid Dependence Scale (BQDS) is the first instrument designed specifically to measure betel quid dependence. The three factor structure of the BQDS consists of "physical and psychological urgent need," "increasing dose," and "maladaptive use." The BQDS initially was validated in a sample of male prisoner ex-chewers in Taiwan.

OBJECTIVE

To replicate and extend the original validation research on the BQDS in a sample of male and female current betel quid chewers in Guam.

METHODS

A survey containing the BQDS was administered to 300 current betel quid chewers in Guam. Participants were compensated for their time with a gift card worth $25.

RESULTS

Confirmatory factor analysis revealed an adequate fit with the hypothesized three-factor measurement model. ANOVAs and structural equations modeling revealed that betel quid dependence is associated with the inclusion of tobacco in the quid, number of chews per day, years of chewing, and education.

CONCLUSIONS

The BQDS is valid for current English-speaking male and female chewers in Guam. Overall levels of betel quid dependence were high, and most chewers included tobacco in their betel quid. The results suggest that levels of dependence for betel quid are similar to those observed for nicotine dependence. Future research should explore other important psychological and behavioral aspects of betel quid chewing such as health risk perceptions and motivation to quit chewing.

Oral cancer awareness and its determinants among a selected Malaysian population

OBJECTIVE

To assess oral cancer awareness, its associated factors and related sources of information among a selected group of Malaysians.

METHODS

A cross-sectional survey was conducted on all Malaysian ethnic groups aged ≥15 years old at eight strategically chosen shopping malls within a two week time period. Data were analysed using chi-square tests and multiple logistic regression. Significance level was set at α<0.05.

RESULTS

Most (84.2%) respondents had heard of oral cancer. Smoking was the most (92.4%) recognized high risk habit. Similar levels of awareness were seen for unhealed ulcers (57.3%) and red/white patches (58.0%) as signs of oral cancer. Age, gender, ethnicity, marital status, education, occupation and income were significantly associated with oral cancer awareness (p<0.05).

CONCLUSIONS

There was a general lack of awareness regarding the risk habits, early signs and symptoms, and the benefits of detecting this disease at an early stage. Mass media and health campaigns were the main sources of information about oral cancer. In our Malaysian population, gender and age were significantly associated with the awareness of early signs and symptoms and prevention of oral cancer, respectively.

Tobacco (kretek) smoking, betel quid chewing and risk of oral cancer in a selected Jakarta population

PURPOSE

This study aimed to determine the association between tobacco consumption (kretek) and betel quid chewing with oral cancer risk.

MATERIALS AND METHODS

A total of 81 cases of oral cancers were matched with 162 controls in this hospital-based study. Information on sociodemographic characteristics and details of risk habits (duration, frequency and type of tobacco consumption and betel quid chewing) were collected. Association between smoking and betel quid chewing with oral cancer were analysed using conditional logistic regression.

RESULTS

Slightly more than half of the cases (55.6%) were smokers where 88.9% of them smoked kretek. After adjusting for confounders, smokers have two fold increased risk, while the risk for kretek consumers and those smoking for more than 10 years was increased to almost three-fold. Prevalence of betel quid chewing among cases and controls was low (7.4% and 1.9% respectively). Chewing of at least one quid per day, and quid combination of betel leaf, areca nut, lime and tobacco conferred a 5-6 fold increased risk.

CONCLUSIONS

Smoking is positively associated with oral cancer risk. A similar direct association was also seen among betel quid chewers.

Antioxidant and cytoprotective activities of Piper betle, Areca catechu, Uncaria gambir and betel quid with and without calcium hydroxide

Background

Betel quid chewing is a popular habit in Southeast Asia. It is believed that chewing betel quid could reduce stress, strengthen teeth and maintain oral hygiene. The aim of this study was to investigate the antioxidant and cytoprotective activities of each of the ingredients of betel quid and compared with betel quid itself (with and without calcium hydroxide). The correlation of their cytoprotective and antioxidant activities with phenolic content was also determined.

Methods

Five samples (betel leaf, areca nut, gambir, betel quid and betel quid containing calcium hydroxide) were extracted in deionized distilled water for 12 hours at 37°C. Antioxidant activities were evaluated for radical scavenging activity using DPPH assay, ferric reducing activity using FRAP assay and lipid peroxidation inhibition activity using FTC assay. Total phenolic content (TPC) was determined using Folin-Ciocalteu procedure. Phenolic composition was analyzed using LC-MS/MS. Cytoprotective activity towards human gingival fibroblast cells was examined using MTT assay.

Results

Among the ingredients of betel quid, gambir demonstrated the highest antioxidant (DPPH - IC₅₀ = 6.4 ± 0.8 μg/mL, FRAP - 5717.8 ± 537.6 μmol Fe(II)/mg), total phenolic content (TPC - 1142.5 ± 106.8 μg TAE/mg) and cytoprotective (100.1 ± 4.6%) activities. Betel quid when compared with betel quid containing calcium hydroxide has higher antioxidant (DPPH - IC₅₀ =59.4 ± 4.4 μg/mL, FRAP - 1022.2 ± 235.7 μmol Fe(II)/mg), total phenolic content (TPC - 140.0 ± 22.3 μg TAE/mg), and cytoprotective (113.5 ± 15.9%) activities. However, all of the five samples showed good lipid peroxidation inhibition compared to vitamin E. LC-MS/MS analysis revealed the presence of quinic acid as the major compound of gambir and betel quid. A positive correlation was observed between TPC and radical scavenging (r = 0.972), reducing power (r = 0.981) and cytoprotective activity (r = 0.682).

Conclusions

The betel quid has higher TPC, and antioxidant and cytoprotective activities than betel quid with calcium hydroxide. The quinic acid in betel quid may play an important role in the oral health protection.

Common oncogenic mutations are infrequent in oral squamous cell carcinoma of Asian origin

OBJECTIVES

The frequency of common oncogenic mutations and TP53 was determined in Asian oral squamous cell carcinoma (OSCC).

MATERIALS AND METHODS

The OncoCarta(™) panel v1.0 assay was used to characterize oncogenic mutations. In addition, exons 4-11 of the TP53 gene were sequenced. Statistical analyses were conducted to identify associations between mutations and selected clinico-pathological characteristics and risk habits.

RESULTS

Oncogenic mutations were detected in PIK3CA (5.7%) and HRAS (2.4%). Mutations in TP53 were observed in 27.7% (31/112) of the OSCC specimens. Oncogenic mutations were found more frequently in non-smokers (p = 0.049) and TP53 truncating mutations were more common in patients with no risk habits (p = 0.019). Patients with mutations had worse overall survival compared to those with absence of mutations; and patients who harbored DNA binding domain (DBD) and L2/L3/LSH mutations showed a worse survival probability compared to those patients with wild type TP53. The majority of the oncogenic and TP53 mutations were G:C > A:T and A:T > G:C base transitions, regardless of the different risk habits.

CONCLUSION

Hotspot oncogenic mutations which are frequently present in common solid tumors are exceedingly rare in OSCC. Despite differences in risk habit exposure, the mutation frequency of PIK3CA and HRAS in Asian OSCC were similar to that reported in OSCC among Caucasians, whereas TP53 mutations rates were significantly lower. The lack of actionable hotspot mutations argue strongly for the need to comprehensively characterize gene mutations associated with OSCC for the development of new diagnostic and therapeutic tools.

Alcohol, betel-nut and cigarette consumption are negatively associated with health promoting behaviors in Taiwan: a cross-sectional study

Background

Oral cancer is the 2^nd most common cause of death due to cancer in the south-western coastal region of Taiwan; the standardized mortality of oral cancer is higher than elsewhere in the world. According to the evidence, alcohol, betel-nut and cigarette (ABC) consumption cause oral, nasopharyngeal and related cancers. This study describes the relationships between ABC consumers and health promoting behaviors among community adults living around an area with a high prevalence of oral cancer.

Methods

A population-based, cross-sectional study design was conducted in oral cancer epidemic areas in south-western coastal Taiwan in 2010, 6,203 community residents over 20 years of age participated. Demographic data, ABC habits, and health-promoting behaviors were explored. A logistic regression analyses were used to identify factors associated with ABC consumers.

Results

A high percentage of participants consumed alcohol, betel-nut and cigarettes. Betel-nut and cigarette consumers took low levels of exercise, adopted a poor diet, and had poor oral hygiene. After adjusting for potential confounders, the logistic regression model indicated that middle aged males of poor education and low economic status, who did not exercise regularly and had poor oral hygiene, were more likely to chew betel quid and smoke cigarettes.

Conclusions

It has identified that BC consumers are negatively associated with health promoting behaviors. Further research is required to understand the reasons why the subjects consume ABC, and explore ways to prevent initiation and enhance cessation of ABC habits in this population.

Betel-quid dependence and oral potentially malignant disorders in six Asian countries

BACKGROUND

Despite gradual understanding of the multidimensional health consequences of betel-quid chewing, information on the effects of dependent use is scant.

AIMS

To investigate the 12-month prevalence patterns of betel-quid dependence in six Asian populations and the impact of this dependence on oral potentially malignant disorders (OPMD).

METHOD

A multistage random sample of 8922 participants was recruited from Taiwan, mainland China, Indonesia, Malaysia, Sri Lanka and Nepal. Participants were evaluated for betel-quid dependency using DSM-IV and ICD-10 criteria and assessed clinically for oral mucosal lesions.

RESULTS

The 12-month prevalence of dependence was 2.8-39.2% across the six Asian samples, and 20.9-99.6% of those who chewed betel-quid were betel-quid dependent. Men dominated the prevalence among the east Asian samples and women dominated the prevalence in south-east Asian samples. 'Time spent chewing' and 'craving' were the central dependence domains endorsed by the Chinese and southern/south-east Asian samples respectively, whereas the Nepalese samples endorsed 'tolerance' and 'withdrawal'. Dependency was linked to age, gender, schooling years, drinking, smoking, tobacco-added betel-quid use and environmental accessibility of betel-quid. Compared with non-users, those with betel-quid dependency had higher pre-neoplastic risks (adjusted odds ratios 8.0-51.3) than people with non-dependent betel-quid use (adjusted odds ratio 4.5-5.9) in the six Asian populations.

CONCLUSIONS

By elucidating differences in domain-level symptoms of betel-quid dependency and individual and environmental factors, this study draws attention to the population-level psychiatric problems of betel-quid chewing that undermine health consequences for OPMD in six Asian communities.

Awareness and knowledge of oral cancer among university students in Malaysia

OBJECTIVES

This study aimed to assess the level of knowledge of oral cancer and its associated factors among university students in Malaysia.

METHODS

A cross sectional study was conducted among 200 university students in Malaysia. A self administered questionnaire was used to collect data. It included questions on socio- demographic data, awareness and knowledge of oral cancer.

RESULTS

Mean age of the respondents was 21.5 ± 2.5 and the age ranged from 18 to 27 years. The majority of the respondents were aware of oral cancer (92.0%) and recognized the followings as signs and symptoms of oral cancer: ulcer and oral bleeding (71.0%), followed by swelling (61.5%). A satisfactory knowledge was observed on the following risk factors; smoking (95.5%), poor oral hygiene (90.5%), family history (90.0%), alcohol (84.5%) and poor fitting dentures (83.0%). However, unsatisfactory knowledge was observed about hot/spicy food (46.5%), obesity (36.0%), old age (31.5%), dietary factor (29.0%) and smokeless tobacco (25.5%). Knowledge of oral cancer was associated significantly with age (p<0.01), year of study (p<0.01) and course of study (p<0.01).

CONCLUSION

Instead of satisfactory awareness and knowledge of oral cancer and its clinical presentations, inadequate knowledge was observed about its risk factors. There is a need to introduce oral cancer education among university students.

Factors affecting commencement and cessation of smoking behaviour in Malaysian adults

Background

Tobacco consumption peak in developed countries has passed, however, it is on the increase in many developing countries. Apart from cigarettes, consumption of local hand-rolled cigarettes such as bidi and rokok daun are prevalent in specific communities. Although factors associated with smoking initiation and cessation has been investigated elsewhere, the only available data for Malaysia is on prevalence. This study aims to investigate factors associated with smoking initiation and cessation which is imperative in designing intervention programs.

Methods

Data were collected from 11,697 adults by trained recording clerks on sociodemographic characteristics, practice of other risk habit and details of smoking such as type, duration and frequency. Smoking commencement and cessation were analyzed using the Kaplan-Meier estimates and log-rank tests. Univariate and multivariate Cox proportional hazard regression models were used to calculate the hazard rate ratios.

Results

Males had a much higher prevalence of the habit (61.7%) as compared to females (5.8%). Cessation was found to be most common among the Chinese and those regularly consuming alcoholic beverages. Kaplan-Meier plot shows that although males are more likely to start smoking, females are found to be less likely to stop. History of betel quid chewing and alcohol consumption significantly increase the likelihood of commencement (p < 0.0001), while cessation was least likely among Indians, current quid chewers and kretek users (p < 0.01).

Conclusions

Gender, ethnicity, history of quid chewing and alcohol consumption have been found to be important factors in smoking commencement; while ethnicity, betel quid chewing and type of tobacco smoked influences cessation.