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

Globally, approximately 600 million people chew betel quid (BQ). Three fourth of its consumption is concentrated in the Pacific Islands, South Asian, and Southeast Asian countries [1]. This habit commences at a very early age of nearly 13 years thus rendering adolescents as a high risk group [2]. After alcohol, caffeine, and nicotine; betel quid is yet another substance used worldwide [3‐5]. Betel quid has a known relaxing and stimulant effect by acting on autonomic nervous system [6]. The formulation of betel quid depends on a variety of factors which may include cultural background of a country, regional backdrop, personal likings and availability of specific ingredients. It is typically made up of betel leaf, betel/areca nut, slaked lime with or without tobacco [7]. The frequently available products in Pakistan are; paan masala, paan (betel nut with betel leaf with or without tobacco), chaaliya, supari, gutka (which also has synthetic flavored scent), other forms of smokeless tobacco which have betel nut in it, cardamom, catechu and/or lime [4].

Though the use of betel quid has a proven association with oral cancers and potentially malignant lesions like oral sub mucus fibrosis, and leukoplakia [8], and betel quid has been classified as a Group 1 carcinogen by the International Agency for Research on Cancer [7, 9]; yet most researches so far have been focusing on its prevalence and genetic aspects [10, 11]. And a very limited work has been done on it psychological and behavioral component. It is vital to understand the reasons behind chewing these products so to develop interventions that may help to cease the habit and minimize related disease burden [12]. Social sciences studies suggest that human behaviors are incentive driven [13], such as they may chew betel nut as they like the way it makes them feel or they like the taste. After chronic use, they become dependent on it due to arecoline [14], nicotine [15] and also tobacco components. There may be several functional, behavioral, ethnic and communal motives behind substance abuse and limited work has been done in its pursuance. A study on cab drivers was conducted which suggested similar reasons of chewing as of smoking [16]. Followed by which a standardized instrument to record reasons for BQ chewing was tested by Little et al. [12] in 2014. Both the studies focused on adult population. To date, ascertainment of the reasons for BQ chewing by a standard instrument in adolescents has not been assessed. We aimed to determine reasons of BQ chewing in adolescents by using Reasons for Betel Quid Chewing Scale (RBCS) along with identifying the reasons that affect the dependency on BQ which will be measured by betel quid dependency scale (BQDS).

In this study, the stimulation construct was found to be the most significantly marked rationale for chewing BQ. The significant findings of stimulation factor amongst BQ users (who were BQ dependent) included that BQ relaxed them and helped them in making decisions. This was followed by social/cultural factor where students considered it to be rude not to chew if their friends or family members were chewing BQ. The least frequently endorsed RBCS factor was reinforcement factor which suggested that children liked the taste of the BQ and they wanted something in their mouths always to chew.

The ‘stimulation’ (BQ in any form relaxed individuals in this study and eased their decision making) was the major reason of BQ chewing amongst dependent individuals and was coherent with study on reasons of smoking amongst adolescents may be because of nicotine [28] or combined effect of both nicotine and arecoline [15]. In our study, BQ relaxed adolescents and this made them six times more dependent on it than those who were non-dependent. This was a profound finding in other studies on motives behind smoking in both adults and adolescents [29, 30]. Focus on stimulation factor in future interventions for BQ use cessation and reduction in addiction may play a phenomenal role. For instance, the cognitive-behavioral therapy (CBT) approach to help smokers in quitting [31], may be modified and customized for BQ use cessation.

The second most commonly endorsed factor amongst dependent group was ‘social/cultural construct’ of RBCS. In current study, this suggested that a substantial chewing in adolescents was prompted by the company of a friend or a family member who chewed BQ and, when children thought it was rude if they did not chew. This was a signpost that amongst adolescents it was very important to initiate and then subsequently increase the use of BQ to be accepted as a member of the friend circle thus becoming a part of greater pursuit of societal connections. This finding was comprehensible with other studies on smoker adolescents [28] and BQ chewing adults [12, 32] as well as teenagers [33]. As a resultant effect, future interventions can be designed which may include strategies to cope with these societal norms, together with how to stay away from these chewing habits and yet be a part of the group. Also, smoking cessation interventions which were social-influence based and which proved to be effective in adolescents, can also be adapted to alter BQ chewing patterns [12].

The third and last important construct of RBCS was ‘reinforcement’ which was uniformly endorsed by both dependent and non-dependent groups in the scale (RBCS) thus suggesting that the initiation of habit is triggered by the taste of the BQ formulations. Like teenagers from other study marked pleasure from smoking as their motivational factor to initiate smoking [28], similarly adolescents of this study promoted the taste of BQ as a chewing trigger.

As per our knowledge, this is the first ever study to focus on the reasons of betel quid chewing in adolescents in a large representative sample of Pakistani schools; alongside, comparing the difference in reasons of BQ chewing between dependent and non-dependent groups. RBCS is first time ever used in this study for adolescents while earlier it was only used in adults [12, 16].

The limitations of this study include self-reported data whose quality may have been compromised by over or understatement of the participants regarding their perceived reasons of chewing BQ. Another limitation of such surveys may include recall bias but it might not have influenced our study, as these were reasons of why they chew BQ and there was nothing substantial to recall about past exposures. The effect of tobacco in betel quid can confound the effect of areca nut but since in our study only 1.3% individuals used BQ with tobacco this is unlikely to have any considerable effect on the overall findings of this study.

Stimulation was the major construct of the RBCS that was fundamental chewing reason amongst the dependent chewing group followed by which was social/cultural trigger that initiated and augmented the chewing habit amongst adolescents. Any future intervention which focuses on stimulation and social/cultural reasons of BQ chewing, may get favorable results in ceasing the BQ chewing habit amongst adolescents thereby reducing related disease burden.