Making the case for clearly defining tobacco use in areca (betel) nut chewers

Introduction: Areca (betel) nut chewing is a habit practiced traditionally in Asia and the Pacific, although preferences may differ across populations. The nut may be chewed by itself, or with other ingredients such as betel leaf, slaked lime, and tobacco. A tool was recently developed to measure chewing practices among chewers in Micronesia. The tool was used to identify any key differences in chewing patterns in the Mariana Islands, Micronesia.

Methods: A cross-sectional study of 300 betel nut chewers (157 males; 143 females) ≥18 years old was conducted in Guam and Saipan in the Mariana Islands between January 2011and June 2012.  Information on demographics and betel nut use were collected. Latent class analysis was used to identify patterns of betel nut chewers, and classes of chewers were compared on selected variables.

Results: The mean age of betel nut chewers was 37 ± 13 years old, and the majority (52%) was males. A few (7%) had post-secondary education and about one-third (32%) was married. Two distinct classes of chewers were identified. Compared to Class 1, a significantly higher proportion of Class 2 chewers (n=222; 74%) chewed betel nut with smokeless tobacco (87% versus 14%). However, compared to Class 2, a significantly higher proportion of Class 1 chewers smoked cigarettes (59% versus 42%).  

Conclusion: The source of tobacco use among betel nut chewers differs in this population. To prevent misclassification and increase the validity of betel nut-associated disease risk in future epidemiologic studies, the type of tobacco use must be clearly specified.