Elsevier

Public Health

Volume 116, Issue 4, July 2002, Pages 195-200
Public Health

Evaluation of a self-rating screening test for areca quid abusers in Taiwan

https://doi.org/10.1038/sj.ph.1900861Get rights and content

Abstract

Areca quid chewing is a popular habit and areca is a well-known ethnopsychopharmalogic agent in southeast Asia. While the chewing habit is legal and also socially acceptable in many places of Taiwan, the public health problem of high oral cancer incidence has remained a priority on the health care list in our local health department. Helping areca quid chewers to reduce or even stop the habit will be paramount in the oral cancer prevention programme. Hence, in order to identify the appropriate strategy for stopping the chewing habit, it is important to distinguish whether an areca quid chewer has reached the level of substance abuse.

In accordance with the Diagnostic and Statistical manual of Mental disorder (fourth edition, DSM-IV), we developed a specific self-report questionnaire modified from the famous SCAN system, DSM-IV and ICD-10. The initial screening test for areca quid abusers had 52 questions. Its components included the onset age and frequency, subjective craving and feeling, social problems, physical problems, oral symptoms, psychological and abstinence-related problems, the motivation and capacity to abstain, and demographic data. The answers were divided into ‘Yes’ or ‘No’. One hundred and twenty-five areca quid users (53 men, 72 women) were recruited. The abusers tended to have older age, less education, and higher daily consumption of areca quid. There were no differences on motivation to quit chewing (abstinence) between abusers and non-abusers. There were no statistical differences on tobacco-smoking and alcohol-drinking behavior. Based on the statistical analysis of receiver operation characteristic (ROC) curves, 11 questions were chosen for the Self-report Screening Test for Areca quid Abuser (SSTAA). An areca quid chewer's answers with a score of 4 or more in these 11 questions would be considered an areca quid abuser. The modified process of SSTAA is performed for the evaluation of the native culture-related substance user. At this current stage, the SSTAA developed from the study is the first instrument for screening areca quid abuser.

Introduction

Areca quid chewing is a popular habit in many southeast Asian areas, including India, Indochina, Taiwan, southern China, the islands of the South Pacific, the north and northwest of Australia and east Africa.1, 2 Chewing areca quid is similar to smoking cigarettes or other well-known ethnopsychopharmalogic agents (including Asian karg, poppy and pituri, Peruvian coca, Indian hemp and American tobacco etc.) that are culture-related substances and abused by certain people. Many native culture-related substances, eg coca, hemp and tobacco in America are pharmacological stimulators as is areca/betel chewing in Asia. The geographical area covered by the areca/betel-chewing custom appears to be a large crescentic region to the north and northwest of Australia, Tanzania, Madagascar in east Africa and the Indo-Pakistan subcontinent, Sri Lanka in east Asia as well as southeast Asia.3 However, the contents of areca quid have less-known psychoactive properties, and rather produce a sense of well-being, release, euphoric state and change of consciousness.1, 4 According to Von Euler5 and Goodman,3 areca quid has markedly parasympathomimetic activity and peripheral muscarinic–nicotic effect of arecoline, a tertiary amine, and less potent cholinergic agonist and an inhibitor of gamma-amino butyric acid (GABA) uptake of arecaidine, hydrolytic agent of arecoline chewing with lime. Their peripheral physical reactions of parasympathetic activity of areca quid chewing have the main symptoms via vagus nervus, micronerve of blood vessels, including lower blood pressure, dilated blood vessels, decreased heart rate, facial flush, salivation, and bowel hypoactivity.1, 6

The central nervous response during areca quid chewing has no significant effect upon simple visual choice-reaction time, digit span, time on target on the pursuit rotor (eye–hand coordination).1, 7 However, areca quid chewing does produce some EEG changes consistent with alert response, lesser degree calming affect, and facilitation in choice-reaction time.1 Chewing overall increases the level of three sympathetic-related catecholamines: nor-epinephrine, epinephrine, and dopamine or their contents have reached statistically significant differences. The reactions included cardioacceleratory response, increase in heart rate, alteration of skin response, and a warm sensation of the body were noted, but its sympathetic reaction is weaker than its parasympathetic effect under areca/betel chewing.6, 7 On the other hand, the other compounds in areca/betel quid, inflorescence of Piper Betle Linn., give a refreshing pleasant odor. It contains aromatic substances, such as safrole, hydroxychavicol, isoeugenol and eugenol.1, 8, 9 They are strong stimulators to release catecholamine from chromaffin cells in vitro. Therefore, it enhances the sympathetic reaction during areca/betel quid chewing, users claim that chewing areca/betel quids reduces tension and irritability, combats hunger and fatigue, and creates alertness and a euphoric feeling. So it induces the operators of large vehicles, farmers and laborers to chew areca/betel quids. These people consider areca/betel quid chewing as an institutionalized tension-reducing and pleasure-promoting agent. In Taiwan, the areca/betel quid chewing behavior involves youngsters, low-education and low-social class groups. Hence, areca/betel quid abuse is a more severe, obvious and persistent substance-abuse than tobacco and alcohol. In some parts of Taiwan, chewing areca/betel quid is not only legal, but also socially acceptable and encouraged. The consumption of areca/betel quid has been steadily increasing for the past 15 years.1 An estimated 2.5 million Taiwan residents, including 17% of men and 1% of women, chew areca quid regularly.10

There are three major types of quid in Taiwan. ‘Lao-hwa quid’, which is commonly seen in urban areas, is made by putting a piece of inflorescence of Piper Betle Linn. with slaked lime and some local flavoring into an unripe areca fruit. The second, betel quid, is made by wrapping an unripe areca fruit and slaked lime paste with a piece of betel leaf, and is often seen in rural and aboriginal areas. The third type of quid, stem quid, is also considered as an areca quid. It is similar to the ‘lao-hwa quid’ except for the piece of inflorescence of Piper Betle Linn., which is replaced by a piece of stem of Piper Betle Linn.

Chewing areca/betel quid is highly correlated with the increasing risk of oral cancer10 and oral pre-cancerous lesions, and the decreasing onset age of oral cancer.11 From the Taiwan government's official records of mortality due to cancer, oral cancer was one of the top 10 in the year 2000. The major prevention strategies in the health department of Taiwan include the promotion of early diagnosis for pre-cancerous lesions as well as efforts towards prevention of areca/betel quid chewing.

In terms of find strategies of stopping the areca/betel quid chewing habit, it is important to identify whether a chewer is an abuser or not. The screening procedure usually required a psychiatrist. However, in Taiwan the number of psychiatrists is insufficient to perform clinical assessments for all of areca/betel quid chewers. Hence, the development of a self-report screening test for areca/betel quid abusers is important. Although areca/betel quid chewing is also a popular habit in many countries of southeast Asia,1, 2 such a self-report screening test for areca/betel quid abusers had not been explored. The purpose of this study was to introduce a Self-report Screening Test for Areca quid Abusers (SSTAA), which was modified from the famous SCAN SYSTEM (Schedules for Clinical Assessment in Neuropsychiatry, 1995) for clinic practice.

Section snippets

Methods

The initial screening questions were developed based on the SCAN (Version 2, Glossary, Schedules for Clinical Assessment in Neuropsychiatry, World Health Organisation, 1995), ICD-10 (Clinical descriptions and diagnostic guidelines: The ICD-10 Classification of Mental and Behavioural disorder, WHO, 1992), DSM-IV (DSM-IV Diagnostic and Statistical Manual of Mental disorders, American Psychiatric Association, 1994). These questions were divided into three components, which included the Present

Results

The demographic characteristics and the consumption of areca/betel quid between the abuser and non-abuser groups are compared in Table 1, Table 2. The abusers tended to have older age, less education, and had a higher daily consumption of areca/betel quid. The proportion of ‘yes’ answers between the abuser and non-abuser for the top 20 questions with higher absolute differences are shown in Table 3. For question no. 2 ‘Do you like to chew areca/betel quid?’, 82% of abusers answered ‘yes’

Discussion

According to DSM-IV, published by the American Psychiatric Association, substance dependence and abuse is a maladaptive pattern of substance use, leading to clinically significant impairment or distress. Diagnostic main criteria of substance dependence illustrates the obvious tolerance, withdrawal syndrome and psychosocial dysfunction and disability. Psychiatrists consider ‘any abnormal substance-chewing behavior’ as the field of ‘substance use disorder’ on DSM IV. They regard the plant-related

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    Chen et al. devised the Self-Reported Screening Test for Identifying an Areca Quid Abuser among the Taiwanese. They selected 11 questions for self-rating abuse and a score of 4 or more in these 11 questions identified an areca nut/betel quid abuser.7 In a literature search that we conducted, we did not find any reports that looked at the effect of habit control (i.e., cessation of areca nut habit alone) as a primary intervention.

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