The findings indicate a high prevalence of ABC consumption among adult community residents around areas with a high incidence of oral cancer. Regular users of betel quit and cigarettes are associated with low social economic status and adopting a less health promoting lifestyle. ABC consumption was also significantly associated with males.
High prevalence of ABC consumption among adult residents around high oral cancer areas
This study did not use random sampling, but a significantly higher percentage of ABC consumption, compared with national data, was identified. The prevalence of ABC consumption was identified in 35%, 17%, and 26% of participants, respectively. In addition, when considering the gender difference, males that regularly consumed ABC were 53.2%, 32.7% and 50.2%, respectively. These numbers were higher than the nation-wide percentages among both genders. In males aged over 18 years, the prevalence of current ABC behavior was 18.8, 13.0 and 35.0%, respectively . These differences may be due to location and professions. Most people who live in south-western coastal Yunlin County are farmers and fishermen. Based on the finding of Lee et al. , the highest prevalence of betel quid chewing and cigarette smoking in Taiwan is in agriculture or fisheries. This study also found that 14% regularly consumed both betel quid and cigarettes, and 9% consumed A, B and C regularly. This finding is similar to Ko et al. , which shows that, despite the Taiwan government conducting several strategies during the last two decades, problems persist.
To compare these habits with other countries, Ghani et al.  reported that in Malaysian adults 8.2% were betel quid chewers, a habit that was more prevalent among females. Females >40 years old with Indian ethnicity and a history of smoking were likely to develop a quid chewing habit. Despite betel nut and cigarette consumption, the prevalence of alcohol consumption is similar to Germany and South Korea. Donath et al.  found higher alcohol consumption in rural than urban areas in Germany, and Chung et al.  found that of the males, 90% are likely to drink excess alcohol in South Korea.
The age of starting to use ABC was very young - 12 years old for drinking alcohol, 13 for betel nut chewing and 10 for smoking cigarettes. Moreover, many betel nut users become cigarette smokers and alcohol drinkers. In the last 10 years, the Taiwan government incorporated several strategies to reduce the prevalence of ABC consumption, including legislation to increase the price or tax . However, it is unknown why western coastal adults living around areas with high incidence of oral cancer partake of these 3 unhealthy habits. Do they know the etiology and mechanism(s) of oral cancer associated with ABC? Do the health and education policies penetrate into rural areas and the socially economic disadvantaged community residents? This may suggest that to understand more fully the complexity of consumption of ABC; investigators need to develop and use sensitive measures that can capture the multidimensional aspects of ABC behavior in these areas.
Participants who chewed betel-nut and consumed cigarettes tended to be male, less well educated, middle-aged, with poor economic status and an unhealthy life style (Table 2). These findings are similar to the results of Shieh et al.  who described the prevalence of chewing betel-nut and cigarette smoking in the general population 18 or more years of age in Chiayi city, a south-western coastal city of Taiwan. Based on this finding, the researchers will develop culturally and linguistically competent health education materials for this group in the future.
This study shows an inconsistent finding in the logistic regression model that alcohol users tend to have a better education, higher economic status, adopt more physical activity and receive regular dental check-ups. This phenomenon could be due to the questionnaire not including measuring and quantifying alcohol type, such as the brands of wine they drank, although beer is popular nation-wide with the percentage of alcohol being below 5%. Small volumes of alcohol may have positive effects on health . The consequence could explain the false higher figure of alcohol consumption in this study. Therefore, we suggest a further study to consider the issue of health literacy and adequate ABC information, culture-oriented educational material or adapted language-sensitive pamphlets, and that it should take the alcohol type into account for middle aged community residents in regions with a high prevalence of oral cancer.
More specific health promotion programs are necessary initiated in the western coastal rural areas
Comparing the data with nationwide statistics, participants exercised (56.5 vs. 48%) and used dental floss (55.4 vs. 39%) less often than the general population . Betel nut and cigarette users also used dental floss significantly less (9.0%) and took less exercise (14.5%) than those without these 2 habits (Table 2). Oral health and exercise are recognized as important health-related behavior conducive to good mental and physical well-being [7, 13]. Experts recommend brushing teeth often or at least twice a day, flossing teeth daily and regularly attending dental check-ups every 6 months . Professional oral health resource and access to dental services are limited in rural areas. Therefore, community nurses should conduct health promoting programs related to the low cost, but effectiveness, of oral hygiene and physical activity through community-based health development, specifically for the social economic minority and males in rural areas.
In March 1995, Taiwan’s national health insurance (NHI) program was set up with the goal of providing high quality, affordable healthcare to all (NHI covers 99% of the population) . However, in the last 5 years, financial difficulties and conflicts between government and the public led to the NHI program becoming unstable. Enhancing health promoting programs might reduce the health-related incidence of chronic disease. Furthermore, national statistics showed that life expectancy in Yunlin County is 3 years less in males compared with Taiwan population (73.4 vs. 76.1 years) . It is common for men to die at a younger age than women worldwide , but the average is 6 years in Taiwan (76.1 vs. 82.6 years) .
Several studies have indicated that it is not only the male gender that is associated with these 3 kinds of behavior [22, 25], but that socioeconomic inequalities are important [10, 26, 27], with poor education, low economic status and living in rural areas being associated with ABC use [21, 26]. Our findings indicate that 4.5% (122) of alcohol, 13.4% (360) of betel nut, and 13.3% (357) of cigarette users reported abstinence for >1 year. Therefore, it is possible to initiate health promoting programs to reduce the prevalence of ABC behaviors if the appropriate and cultivated culture-tailed strategies are used. Physical inactivity is a modifiable risk factor for several chronic conditions and a leading cause of premature mortality. An increasing proportion of adults worldwide do not engage in a level of physical activity sufficient to prevent or alleviate these adverse effects . It is time, therefore, that we had nurse-led primary healthcare with an emphasis on health promoting strategies for disadvantaged people living in high behaviour-related cancer areas.
A few limitations must be considered when interpreting our findings. First, the cross-sectional nature of the data poses a limitation and prevents the inference of causal relationships. Second, self-reporting often underestimates true alcohol intake; and because there were more women participants in this study, the prevalence of ABC users might have been an underestimate. Third, several unaccounted factors (i.e., exposure to media messages about tobacco or alcohol or betel-nut, price or cost of ABC, psychiatric disorders, and use of other substances) could have affected the residents’ ABC behavior.