Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Predictors of betel quid chewing behavior and cessation patterns in Taiwan aborigines

  • Chin-Feng Lin1, 2, 3,
  • Jung-Der Wang1,
  • Ping-Ho Chen4,
  • Shun-Jen Chang5,
  • Yi-Hsin Yang6, 7 and
  • Ying-Chin Ko4, 5Email author
BMC Public Health20066:271

DOI: 10.1186/1471-2458-6-271

Received: 27 March 2006

Accepted: 03 November 2006

Published: 03 November 2006

Abstract

Background

Betel quid, chewed by about 600 million people worldwide, is one of the most widely used addictive substances. Cessation factors in betel quid chewers are unknown. The present study explores prevalence and the quit rate of betel quid chewing in Taiwan aborigines. Our goal was to delineate potential predictors of chewing cessation.

Methods

A stratified random community-based survey was designed for the entire aborigines communities in Taiwan. A total of 7144 participants were included between June 2003 and May 2004 in this study. Information on sociodemographic characteristics, such as gender, age, obesity, education years, marital status, ethnicity, and habits of betel quid chewing, smoking and drinking was collected by trained interviewers.

Results

The prevalence of betel quid chewers was 46.1%. Betel quid chewing was closely associated with obesity (OR = 1.61; 95% CI: 1.40–1.85). Betel quid chewers were most likely to use alcohol and cigarettes together. Quit rate of betel quid chewers was 7.6%. Betel quid chewers who did not drink alcohol were more likely to quit (OR = 1.89; 95% CI: 1.43–2.50). Alcohol use is a significant factor related to cessation of betel quid chewing, but smoking is not.

Conclusion

Taiwan aborigines have a high prevalence of betel quid chewers and a low quit rate. Alcohol use is strongly association with betel quid chewing. Efforts to reduce habitual alcohol consumption might be of benefit in cessation of betel quid chewing.

Background

Betel quid consumption is an addictive habit with psychoactive properties, used by an estimated 600 million people worldwide [14]. This practice is widespread in Taiwan, with approximately two million habitual users (10% of population) [5]. In 2004, the International Agency for Research on Cancer (IARC) declared chewing of betel quid, by itself, to be a Group 1 carcinogen and the areca nut to be, correspondingly, a Group 1 carcinogen [6]. Chewing betel quid independently contributes to the risk of oropharyngeal cancer [79], oral mucosal lesions [10], oral leukoplakia [11], oral submucous fibrosis (OSF) [11], liver cirrhosis [12], hepatocellular carcinoma (HCC) [13], diabetes mellitus [14] and adverse outcomes with use during pregnancy [15, 16]. These pertinent health risks highlight the need for cessation of betel quid chewing. Indeed, betel quid chewing is a recognized public health problem in Taiwan; active strategies are necessary to reduce use.

Several factors influence betel quid chewing, including predisposition associated with ethnicity, demographic and psychosocial factors, its accessibility and public policy. Taiwan aborigines have an extensive history of betel quid use. Their habits are dictated by different social and cultural behaviors in both genders. The life expectancy of Taiwan aborigines is one decade lower than the general population [17] and the mortality rate and prevalence of chronic diseases, such as liver cirrhosis, oral cancer and renal failure, are two-to five-folds higher than rest of the Taiwanese population [18]. The estimated prevalence of betel quid chewing in Taiwan aborigines is comparably higher than rest of Taiwanese population (42% for Taiwan aborigines; 6% for Taiwanese population)[5]. Despite studies to investigate the high prevalence of betel quid chewing in Taiwan aborigines, contributing factors and quit patterns between former and current chewers have not been documented. This report provides the first description of prevalence and patterns of cessation in Taiwan aborigines.

Methods

Design

A large-scale survey of substance use (betel quid, alcohol and cigarette) among Taiwan aborigines was completed. Data was obtained by interviewing participants in their communities between June 2003 and May 2004.

Approximately 86% of Taiwanese are descended from Han Chinese, whose ancestors migrated 400 years ago from Fukkien and Canton provinces [19]. Taiwan aborigines constitute approximately 2% of the population, rarely mix with Han Chinese and reside in isolated mountainous areas with their own language, customs and social organizations. Genetically, they are markedly different from Han Chinese [20]. There are twelve aborigines tribes in Taiwan and most live in fifty isolated communities. Very few Han Chinese live in aborigines communities unless they work in the community or married aborigines. Due to random sampling, about 9% of participants are Han Chinese. They provide a comparison between aborigines and non-aborigines, because they lived in the same community. A random sampling approach was used with these fifty communities, stratified by gender and age group (>= 18 years). According to our previous study, the prevalence of betel quid chewing is approximately 20%. We randomly selected 150 to 200 persons via a household registry system in each community, obtaining 95% confidence interval (CI) within ± 3% [5]. The prevalence of betel quid chewing is between 1% and 50% in some areas, obtaining the prevalence of 95% CI between ± 1% and 5% [5]. The prevalence of betel quid chewing in Taiwan aborigines males and females is 42.1% and 19.2% respectively, among three tribes [5]. Each participant completed an interview questionnaire with trained nurses, fulfilling our target population of 9124 persons. Questionnaire contents included demographic characteristics, body morphology (height and weight), past and current histories of betel chewing, and cigarette and alcohol use. This study was approved by the Medical Associations for Indigenous People in Taiwan (No. 930010) and agreed by Department of Health, Executive Yuan (No. 0933500309).

Data analysis

Dependent variables

Separate analyses were conducted for betel quid chewing behavior and chewing cessation. The dichotomous dependent variable, betel quid chewing behavior, was coded as betel quid chewers (chewed at least once a week, irrespective of quantity) or never chewers (those who never chewed). The other dependent variable, betel quid chewing cessation, was coded as former chewers (those who quit chewing at least one year prior the survey) or current chewers (continual chewing habit). In addition, betel quid chewers included former chewers and current chewers.

Independent variables

Potential explanatory (independent) variables included gender, age, obesity, education, age commenced chewing (years), quids per day, marital status, ethnicity, alcohol consumption, and cigarette smoking. Taiwan aborigines status was classed into three groups, "Taiwan aborigines" when both parents were Taiwan aborigines, "mixed Taiwan aborigines" when one parent was Taiwan aborigines, and "non-Taiwan aborigines" when both parents were not Taiwan aborigines. Body mass index (BMI) was calculated as body weight in kilograms divided by square of body height in meters. Obesity was defined by BMI ≥ 27.8 kg/m2 for men and ≥ 27.3 kg/m2 for women. Continuous variables, including age, education years, age commenced chewing, numbers chewed per day, were divided into two categories, above and below the median cut-off.

Statistical analyses

Data were entered into a spreadsheet and analyzed using Statistic Analysis Software (SAS release 8.2, Cary, NC, USA). Missing data were excluded. Crude odds ratios (OR) with 95% CI were calculated. To control for potential confounding effects, statistically significant ORs were subsequently examined in the multiple logistic regression model to obtain adjusted OR (aOR). P value less than 0.05 or a range of 95% CI that did not include unity, were considered statistically significant.

Results

A total of 7326 participants completed our questionnaires from aborigines population of 9124. The response rate was 80.3% (7326/9124). All participants were over 18 years of age (mean 45.3 ± 17.0 years). Factors associated with a betel quid chewing habit are shown in Table 1. The prevalence of betel quid chewers (current and former chewers) was 46.1% of total subjects (3291/7144), with the males (53.2%, 2033/3824) higher than females (37.9%, 1258/3320) p < 0.05. After adjustment for all factors with a logistic regression model, factors most associated with betel chewing were male, obesity, less education, married status, Taiwan aborigines, mixed-Taiwan aborigines, drinking alcohol and smoking cigarettes (p < 0.05). It was noteworthy that the adjusted OR stratified by age showed that older group (>= 45 years) was less likely to have chewing habits.
Table 1

Sociodemographic characteristics and betel quid chewing behaviors (N = 7144)

 

Betel quid chewers (N = 3291)

Never chewers (N = 3853)

ORb (95% CI)

aORc (95% CI)

 

N

(%)a

N

(%)a

  

Gender*

      

   Male

2033

(53.2)

1791

(46.8)

1.86 (1.69–2.05) †

1.14 (1.01–1.30) †

   Female

1258

(37.9)

2062

(62.1)

1.00

1.0

Age (years)*

      

   >=45

1582

(48.0)

1716

(52.0)

1.15 (1.05–1.27) †

0.84(0.72–0.97) †

   <45

1709

(44.4)

2137

(55.6)

1.00

1.0

Obesity*

      

   Yes

800

(55.8)

633

(44.2)

1.63 (1.45–1.84) †

1.61 (1.40–1.85) †

   No

2491

(43.6)

3220

(56.4)

1.00

1.0

Education (years)*

      

   <=6

1709

(52.8)

1531

(47.3)

1.64 (1.49–1.80) †

2.02 (1.75–2.34) †

   >6

1582

(40.5)

2322

(59.5)

1.00

1.0

Marital status*

      

   Married

2661

(49.1)

2762

(50.9)

1.69 (1.51–1.89) †

1.51 (1.30–1.75) †

   Single

602

(36.3)

1057

(63.7)

1.00

1.0

Ethnicity*

      

   Taiwan aborigines

3018

(49.7)

3059

(50.3)

5.30 (4.28–6.56) †

3.83 (3.01–4.89) †

   Mixed-Taiwan aborigines

128

(43.1)

169

(56.9)

4.07 (2.98–5.54) †

3.01 (2.09–4.34) †

   Non-Taiwan aborigines

106

(15.7)

569

(84.3)

1.00

1.0

Alcohol consumption*

      

   Yes

2480

(66.9)

1225

(33.1)

7.05 (6.33–7.84) †

4.50 (4.00–5.07) †

   No

731

(22.3)

2545

(77.7)

1.00

1.0

Cigarette smoking*

      

   Yes

1821

(66.8)

906

(33.2)

4.28 (3.86–4.74) †

3.03 (2.66–3.45) †

   No

1363

(32.0)

2899

(68.0)

1.00

1.0

* Significant difference in prevalence of betel quid chewing by Chi-square analysis (p < 0.05).

† Significant difference by logistic regression model (p < 0.05).

a May not total 100% due to rounding.

b Odds ratios (OR) refer to risk of betel quid chewers (including former chewers and current chewers) versus never chewers according to each variable. OR > 1 indicates a higher likelihood of being a betel quid chewer.

c aOR: adjusted odds ratio for sex, age (years), obesity, education (years), marital status, ethnicity, alcohol consumption, and cigarette smoking by logistic regression model; 95% CI: 95% confidence interval.

Table 2 depicts the distribution of demographic characteristics, comparing former chewers to current chewers. The 251 former chewers account for 7.6% in betel quid chewers (251/3291). The quit rate for males is 8.2% (167/2033) and 6.7% (84/1258) for females. In the unadjusted analysis, the crude OR showed those who were older, non-Taiwan aborigines, chewing a smaller amount of quids per day (quids <= 10) and consuming no alcohol to be most likely to quit their chewing habits. Adjusting associations with logistic regression, those older than 45 years and with no alcohol consumption habits had a significantly higher quit rate (p < 0.05). However, the Taiwan aborigines were still less likely to quit chewing habits.
Table 2

Demographic characteristics in the cessation of betel quid chewing. (N = 3291)

 

Betel quid chewers

  
 

Former chewers (N = 251)

Current chewers (N = 3040)

ORb (95% CI)

aORc (95% CI)

 

N

(%)a

N

(%)a

  

Gender

      

   Male

167

(8.2)

1866

(91.8)

1.25(0.95–1.64)

-

   Female

84

(6.7)

1174

(93.3)

1.00

 

Age (yrs)*

      

   >=45

157

(9.9)

1425

(90.1)

1.89(1.45–2.47) †

1.84(1.40–2.42) †

   <45

94

(5.5)

1615

(94.5)

1.00

1.00

Obesity

      

   Yes

58

(7.3)

742

(92.8)

0.93(0.69–1.26)

-

   No

193

(7.8)

2298

(92.3)

1.00

 

Education (years)

      

   <=6

137

(8.0)

1572

(92.0)

1.12(0.87–1.45)

-

   >6

114

(7.2)

1468

(92.8)

1.00

 

Age commenced chewing (years)

      

   >=20

166

(8.0)

1923

(92.1)

1.13(0.87–1.49)

-

   <20

85

(7.1)

1117

(92.9)

1.00

 

Quids per day*

      

   <=10

134

(8.8)

1397

(91.3)

1.34(1.04–1.74) †

1.24(0.95–1.62)

   >10

117

(6.7)

1643

(93.4)

1.00

1.00

Marital status

      

   Married

213

(8.0)

2448

(92.0)

1.33(0.93–1.91)

-

   Single

37

(6.2)

565

(93.9)

1.00

 

Ethnicity*

      

   Taiwan aborigines

218

(7.2)

2800

(92.8)

0.36(0.21–0.60) †

0.40(0.24–0.68) †

   Mixed-Taiwan aborigines

9

(7.0)

119

(93.0)

0.35(0.15–0.80) †

0.47(0.20–1.11)

   Non-Taiwan aborigines

19

(17.9)

87

(82.1)

1.00

1.00

Alcohol consumption*

      

   No

91

(12.5)

640

(87.6)

2.10(1.60–2.76) †

1.89(1.43–2.50) †

   Yes

157

(6.3)

2323

(93.7)

1.00

1.00

Cigarette smoking

      

   No

97

(7.1)

1266

(92.9)

0.89(0.68–1.16)

-

   Yes

145

(8.0)

1676

(92.0)

1.00

 

* Significant difference in the prevalence of former and current chewers by Chi-square analysis (p < 0.05)

† Significant difference by logistic regression model (P < 0.05).

a May not total 100% due to rounding.

b Odds ratios (OR) refer to the risk of former chewers versus current chewers according to each variable. OR > 1 indicates a higher likelihood of being a former chewer (quit chewing).

c aOR: adjusted odds ratio for age (years), quids per day, ethnicity and alcohol consumption by logistic regression model; 95% CI: 95% confidence interval.

Prevalence of current chewers by ethnicity and gender (Table 3), compared to total subjects was 42.6% (3040/7144) and of current betel quid chewers, males and females were 48.8% and 35.4%, respectively. Ethnicity was classified into five groups: both parents are Taiwan aborigines, only father is Taiwan aborigines, only mother is Taiwan aborigines, non-Taiwan aborigines, and others. The highest prevalence of current male chewers was in those whose mother was Taiwan aborigines (55.7%; 64/115). In females, the highest prevalence was among those whose both parents were Taiwan aborigines (39.3%; 1115/2834). The quit rate of betel quid chewing by ethnicity and sex is summarized in Table 4. Excluding others, the highest quit rate (18.5%) was seen in non-Taiwan aborigines males. In contrast, the lowest quit rate was 3.5% among females whose mother is Taiwan aborigines.
Table 3

Prevalence rate of current betel quid chewers (N = 3040) by ethnicity and by gender

 

Prevalence rate of current betel quid chewers (%)

 

Males

Females

Ethnicity

  

   Both parents are Taiwan aborigines

1685/3243 (52.0)

1115/2834 (39.3)

   Only father is Taiwan aborigines

22/52 (42.3)

5/36 (13.9)

   Only mother is Taiwan aborigines

64/115 (55.7)

28/94 (29.8)

   Non-Taiwan aborigines

75/360 (20.8)

12/315 (3.8)

   Others

20/54 (37.0)

14/31 (45.2)

Subtotal

1866/3824 (48.8)

1174/3320 (35.4)

Total

3040/7144 (42.7)

Table 4

Quit rate of betel quid chewers (N = 3291) by ethnicity and by gender

 

Quit rate of betel quid chewers (%)

 

Males

Females

Ethnicity

  

   Both parents are Taiwan aborigines

138/1823 (7.6)

80/1195 (6.7)

   Only father is Taiwan aborigines

1/23 (4.4)

1/6 (16.7)

   Only mother is Taiwan aborigines

6/70 (8.6)

1/29 (3.5)

   Non-Taiwan aborigines

17/92 (18.5)

2/14 (14.3)

   Others

5/25 (20)

0/14 (0)

Subtotal

167/2033 (8.2)

84/1258 (6.7)

Total

251/3291 (7.6)

Independent effects of alcohol consumption, cigarette smoking and betel quid chewing on cessation were evaluated by stratifying alcohol and cigarette use across the behavior of betel quid chewing (Table 5). For the nondrinker and nonsmoker who chewed betel quid before, the likelihood of cessation increased 1.76-fold over those who drink and smoke. Likelihood was also significantly increased for betel quid chewers who did not drink, but had smoking habits (OR = 2.19; 95% CI: 1.48 – 3.26). After controlling for other factors, similar cessation patterns were observed in the betel quid chewers who had no drinking habits, but did smoke (aOR = 1.99; 95% CI: 1.32 – 2.99).
Table 5

Effects of alcohol consumption and cigarette smoking on cessation

  

Betel quid chewers

  
  

Former chewers (N = 239)

Current chewers (N = 2882)

OR(95%CI)a

aOR(95%CI)b

Alcohol

No

     
 

Cigarette

No

51

390

1.76(1.24–2.50) †

1.25(0.86–1.83)

 

Cigarette

Yes

38

233

2.19(1.48–3.26) †

1.99(1.32–2.99) †

Alcohol

Yes

     
 

Cigarette

No

45

847

0.72(0.50–1.02)

0.59(0.40–1.86) †

 

Cigarette

Yes

105

1412

1.00

1.00

† Significant difference by logistic regression model (p < 0.05).

a Odds ratios (OR) refer to the risk of former chewers versus current chewers according to each variable. OR > 1 indicates a higher likelihood of being a former chewer (quit chewing).

b aOR: adjusted odds ratio for age (years), quids per day, and ethnicity by logistic regression model; 95% CI: 95% confidence interval.

Discussion

Research into betel quid chewing and cessation factors is limited. In this large survey, the sociodemographic factors in betel quid chewing behavior and cessation patterns in Taiwan aborigines were examined. Compared to those who never chewed, betel quid chewers were more likely to be male, obese, of lower education, married, Taiwan aborigines or mixed Taiwan aborigines, a drinker and smoker. On the contrary, subjects who were older were less likely to be betel quid chewers.

This study is more reliable than past studies in determining prevalence and betel chewing association factors in Taiwan aborigines, because a randomized and systematic surveillance-style approach was adopted to recruit participants from their own communities.

There were more betel quid chewers among males than females in this study (aOR = 1.14; 95% CI: 1.01–1.30). This might be explained by the higher prevalence of chewing in Taiwanese males [5]. Taiwan aborigines have a higher prevalence of betel quid chewing than Han Chinese [5] and are more likely to be betel quid chewers than non-Taiwan aborigines (aOR = 3.83; 95% CI: 3.01–4.89). In Taiwan, betel quid chewing is widespread; chewers are frequently alcohol drinkers and smokers. After adjusting for other factors, the prevalence of drinking and smoking habits was significantly higher in betel quid chewers than in those who never chewed.

Another important finding is that betel quid chewing is closely associated with obesity. Obesity is a recognized risk factor for chronic diseases, such as diabetes mellitus, cardiovascular diseases, and hypertension. According to previous studies, betel quid chewing can increase body mass index (BMI) or contribute to obesity [2123] by the betel quid constituents (alkaloid, arecoline and arecaidine) as inhibitors of γ-aminobutyric acid (GABA) receptor [4, 24].

The present study is the first estimation of quit rates for betel quid chewing among Taiwan aborigines. Our findings indicate that cessation probability increases with older age group, non-Taiwan aborigines, and those who do not drink. Interestingly, another survey on smoking behavior showed a significantly positive association between smoking cessation and increased age [25]. We observed that former chewers comprise 7.6% of total users. Within this, Taiwan aborigines (7.2%) and mixed Taiwan aborigines (7.0%) had a lower quit rate than non-Taiwan aborigines (17.9%, p < 0.05). Apart from the Taiwan aborigines heritage, age group and use of betel quid with alcohol influenced the quit rate. Our study suggested that young Taiwan aborigines or mixed-Taiwan aborigines, who were also alcohol drinkers, found it more difficult to abstain from betel quid chewing. Dr. Wen et al. noted the combined effects of cigarette smoking and betel quid chewing in Han Chinese [26] and suggested that betel quid chewing should not to be considered as an isolated issue. Our results have shown the combined effect of betel quid chewing and alcohol consumption also existed in Taiwan aborigines. Therefore, cessation should be viewed conjointly with alcohol consumption.

Clearly, the highest prevalence of both chewing and of quitting chewing was seen in Taiwan aborigines males whose mother was Taiwan aborigines (Table 3 and Table 4). However, in Taiwan aborigines females, this consistent association was not obvious. We suggest that the likelihood of being a current or former chewer was higher in Taiwan aborigines males whose mother is Taiwan aborigines.

Our multivariate analyses noted that alcohol consumption was an independent factor in cessation (Table 5). For the nondrinkers and nonsmokers who chewed betel quid before, their cessation rate was higher than in those who had drinking and smoking habits. Nondrinkers with cigarette smoking had the highest cessation behavior, compared to those who have drinking and smoking habits, even after adjusting for covariates (OR = 1.99; 95% CI = 1.32–2.99). The cessation discrepancy between betel quid chewers with and without alcohol implies that alcohol not consumption have an additional effect on cessation [5]. The main outcome of our study is that efforts to encourage cessation of betel quid chewing will need to include efforts to reduce habitual alcohol consumption. In contrast, reducing cigarette smoking also serves as an important step in reducing betel quid chewing [26].

Conclusion

Taiwan aborigines have a high prevalence of betel quid chewing and a low quit rate. Betel quid chewing independently contributes to the likelihood of obesity. Alcohol usage is strongly related to betel quid chewing. Efforts to reduce betel quid chewing might benefit from a combined approach targeting both these habits.

Declarations

Acknowledgements

This study was supported by grants from Department of Health, Executive Yuan, Taiwan, R.O.C. (No. 0933500309). We are grateful to Dr. Allen Min-Jen Ko for correcting our manuscript.

Authors’ Affiliations

(1)
Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University, College of Public Health and Department of Internal Medicine, National Taiwan University Hospital
(2)
Department of Health, Executive Yuan
(3)
Department of Public Health, Taipei Medical University
(4)
Division of Environmental Health and Occupational Medicine, National Health Research Institutes
(5)
Department of Public Health, Faculty of Medicine, College of Medicine, Kaohsiung Medical University
(6)
Graduate Institute of Oral Health Sciences, College of Dental Medicine, Kaohsiung Medical University
(7)
Statistical Analysis Laboratory, Department of Clinical Research, Kaohsiung Medical University Chung-Ho Memorial Hospital

References

  1. Chu NS: Effects of Betel chewing on the central and autonomic nervous systems. Journal of Biomedical Science. 2001, 8 (3): 229-236. 10.1007/BF02256596.View ArticlePubMedGoogle Scholar
  2. Gupta PC, Warnakulasuriya S: Global epidemiology of areca nut usage. Addiction Biology. 2002, 7 (1): 77-83. 10.1080/13556210020091437.View ArticlePubMedGoogle Scholar
  3. Chen MJ, Yang YH, Shieh TY: Evaluation of a self-rating screening test for areca quid abusers in Taiwan. Public Health. 2002, 116 (4): 195-200.View ArticlePubMedGoogle Scholar
  4. Boucher BJ, Mannan N: Metabolic effects of the consumption of Areca catechu. Addiction Biology. 2002, 7 (1): 103-110. 10.1080/13556210120091464.View ArticlePubMedGoogle Scholar
  5. Ko YC, Chiang TA, Chang SJ, Hsieh SF: Prevalence of betel quid chewing habit in Taiwan and related sociodemographic factors. Journal of Oral Pathological Medicine. 1992, 21 (6): 261-264. 10.1111/j.1600-0714.1992.tb01007.x.View ArticleGoogle Scholar
  6. IARC: Betel-quid and areca-nut chewing and some areca-nut-derived nitrosamines, IARC Monographs on the evaluation of carcinogenic risks to humans. 2004, 85: 11-18.Google Scholar
  7. Ko YC, Huang YL, Lee CH, Chen MJ, Lin LM, Tsai CC: Betel quid chewing, cigarette smoking and alcohol consumption related to oral cancer in Taiwan. Journal of Oral Pathological Medicine. 1995, 24 (10): 450-453. 10.1111/j.1600-0714.1995.tb01132.x.View ArticleGoogle Scholar
  8. Lu CT, Yen YY, Ho CS, Ko YC, Tsai CC, Hsieh CC, Lan SJ: A case-control study of oral cancer in Changhua County, Taiwan. Journal of Oral Pathological Medicine. 1996, 25 (5): 245-248. 10.1111/j.1600-0714.1996.tb01379.x.View ArticleGoogle Scholar
  9. Lee KW, Kuo WR, Tsai SM, Wu DC, Wang WM, Fang FM, Chiang FY, Ho KY, Wang LF, Tai CF, Kao EL, Chou SH, Lee CH, Chai CY, Ko YC: Different impact from betel quid, alcohol and cigarette: risk factors for pharyngeal and laryngeal cancer. International Journal of Cancer. 2005, 117 (5): 831-836. 10.1002/ijc.21237.View ArticlePubMedGoogle Scholar
  10. Yang YH, Lee HY, Tung S, Shieh TY: Epidemiological survey of oral submucous fibrosis and leukoplakia in aborigines of Taiwan. Journal of Oral Pathological Medicine. 2001, 30 (4): 213-219. 10.1034/j.1600-0714.2001.300404.x.View ArticleGoogle Scholar
  11. Lee CH, Ko YC, Huang HL, Chao YY, Tsai CC, Shieh TY, Lin LM: The precancer risk of betel quid chewing, tobacco use and alcohol consumption in oral leukoplakia and oral submucous fibrosis in southern Taiwan. British Journal of Cancer. 2003, 88 (3): 366-372. 10.1038/sj.bjc.6600727.View ArticlePubMedPubMed CentralGoogle Scholar
  12. Tsai JF, Jeng JE, Chuang LY, Ho MS, Ko YC, Lin ZY, Hsieh MY, Chen SC, Chuang WL, Wang LY, Yu ML, Dai CY, Ho C: Habitual betel quid chewing as a risk factor for cirrhosis: a case-control study. Medicine (Baltimore). 2003, 82 (5): 365-372.View ArticleGoogle Scholar
  13. Tsai JF, Jeng JE, Chuang LY, Ho MS, Ko YC, Lin ZY, Hsieh MY, Chen SC, Chuang WL, Wang LY, Yu ML, Dai CY: Habitual betel quid chewing and risk for hepatocellular carcinoma complicating cirrhosis. Medicine (Baltimore). 2004, 83 (3): 176-187.View ArticleGoogle Scholar
  14. Tung TH, Chiu YH, Chen LS, Wu HM, Boucher BJ, Chen TH: A population-based study of the association between areca nut chewing and type 2 diabetes mellitus in men (Keelung Community-based Integrated Screening programme No. 2). Diabetologia. 2004, 47 (10): 1776-1781. 10.1007/s00125-004-1532-2.View ArticlePubMedGoogle Scholar
  15. Yang MS, Chang FT, Chen SS, Lee CH, Ko YC: Betel quid chewing and risk of adverse pregnancy outcomes among aborigines in southern Taiwan. Public Health. 1999, 113 (4): 189-192. 10.1016/S0033-3506(99)00152-3.View ArticlePubMedGoogle Scholar
  16. Yang MJ, Chung TC, Yang MJ, Hsu TY, Ko YC: Betel quid chewing and risk of adverse birth outcomes among aborigines in eastern Taiwan. Journal Toxicology and Environmental Health Part A. 2001, 64 (6): 465-472. 10.1080/152873901753215920.View ArticleGoogle Scholar
  17. Ko YC, Liu BH, Hsieh SF: [Issues on aboriginal health in Taiwan]. The Kaohsiung Journal of Medical Sciences. 1994, 10 (7): 337-351.Google Scholar
  18. Ko YC, Liu BH, Hsieh SF, Wang TN: [Cancer mortality analysis among aborigines in Taiwan]. The Kaohsiung Journal of Medical Sciences. 1994, 10 (7): 379-391.Google Scholar
  19. Department of Population. Consensus 1990: Census report of the Republic of China in Taiwan. Taipei, ROC. 1992
  20. Bellwood P: The Austronesian dispersal and the origin of languages. Sci Am. 1991, 265: 70-75.View ArticleGoogle Scholar
  21. Mannan N, Boucher BJ, Evans SJ: Increased waist size and weight in relation to consumption of Areca catechu (betel-nut); a risk factor for increased glycaemia in Asians in east London. British Journal of Nutrition. 2000, 83 (3): 267-275.PubMedGoogle Scholar
  22. Strickland SS, Duffield AE: Anthropometric status and resting metabolic rate in users of the areca nut and smokers of tobacco in rural Sarawak. Annals of Human Biology. 1997, 24 (5): 453-474. 10.1080/03014469700005212.View ArticlePubMedGoogle Scholar
  23. Chang WC, Hsiao CF, Chang HY, Lan TY, Hsiung CA, Shih YT, Tai TY: Betel nut chewing and other risk factors associated with obesity among Taiwanese male adults. Int J Obes (Lond). 2006, 30 (2): 359-363. 10.1038/sj.ijo.0803053.View ArticleGoogle Scholar
  24. Johnston GA, Krogsgaard-Larsen P, Stephanson A: Betel nut constituents as inhibitors of gamma-aminobutyric acid uptake. Nature. 1975, 258 (5536): 627-628. 10.1038/258627a0.View ArticlePubMedGoogle Scholar
  25. Manzoli L, Di Giovanni P, Dragani V, Ferrandino MG, Morano JP, Rauti I, Schioppa F, Romano F, Staniscia T: Smoking behaviour, cessation attempts and the influence of parental smoking in older adult women: a cross-sectional analysis from Italy. Public Health. 2005, 119 (8): 670-678. 10.1016/j.puhe.2004.12.005.View ArticlePubMedGoogle Scholar
  26. Wen CP, Tsai SP, Cheng TY, Chen CJ, Levy DT, Yang HJ, Eriksen MP: Uncovering the relation between betel quid chewing and cigarette smoking in Taiwan. Tobacco Control. 2005, 14 Suppl 1: i16-22. 10.1136/tc.2004.008003.View ArticlePubMedGoogle Scholar
  27. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/6/271/prepub

Copyright

© Lin et al; licensee BioMed Central Ltd. 2006

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Advertisement