Validation of the Areca (Betel) Nut State-Added Questionnaire in the Guam Behavioral Risk Factor Surveillance System (BRFSS)

Approximately 600 million people worldwide chew areca nut, also known as betel nut. It is the fourth most widely used addictive substance after nicotine, ethanol, and caffeine. Many Asians and Pacific Islanders chew betel nut, though preferences differ across populations. Guam, a U.S. territory, is composed predominantly of Asian and Pacific Islander ethnic groups. The Betel Nut State-Added Questionnaire was included in the 2007 Guam BRFSS to capture prevalence and variability in chewing preferences, and to explore emerging associations of chewing with chronic diseases including oral cancer, diabetes, and cardiovascular disease. Eighty-two adult (≥ 18 years old) betel nut chewers (42 males; 40 females) in Guam were recruited to validate the questionnaire against four weekly betel nut recalls. Concordance between the instruments was measured with simple Cohen's kappa using SASŪ (Version 9.1). Betel nut comparisons were made on variety (red/white); maturity (unripe/ripe); the addition of the Piper leaf, slaked lime, and tobacco (yes/no); and ingestion (yes/no). The state-added questionnaire was effective in measuring most of the variables with kappas of 0.65-0.93, with slight sex differences. The Piper leaf question had the lowest kappas (0.11 males; 0.57 females). The occasional use of the Piper leaf among the men tended to underestimate their use on the questionnaire, while women did not. The state-added questionnaire is a valid instrument for measuring the aforementioned betel nut variables, and with slight modifications to the Piper leaf question can be used in surveys to monitor trends and inform targeted intervention/prevention programs.