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Areca Nut Dependence Scale Thaddeus A. Herzog, Ph.D.

University of Hawai‘i Cancer Center Honolulu, Hawai‘i, USA

Presentation Structure

• Guam survey data on betel nut dependence, reasons for chewing, and motivation to quit chewing

• Multi-country survey research on betel nut dependence

• Randomized betel nut cessation trial

• Future agenda

Guam Survey Research

• Funded by first NCI U54 partnership between University of Hawai‘i Cancer Center (UHCC) and University of Guam (UOG) • NCI’s Center to Reduce Cancer Health Disparities (CRCHD) matches Minority

Institutions with NCI-designated Cancer Centers

• UHCC-UOG partnership: 20 faculty members in fields including epidemiology, pharmacokinetics, cancer biology, and behavioral research

• Pilot project (2010-2015): “Sociocultural Factors Affecting Betel Nut Chewing among Pacific Islanders on Guam” • Survey betel quid chewers and ex-chewers

• Co-Leader: Kelle Murphy, Ph.D. (UOG)

Betel Quid Dependence Scale

• Researchers in Taiwan published Betel Quid Dependence Scale in 2012 • Lee, C.Y., Chang, C.S., Shieh, T.Y., Chang, Y.Y., 2012. Development and validation

of a self-rating scale for betel quid chewers based on a male-prisoner population in Taiwan: the Betel Quid Dependence Scale. Drug and Alcohol Dependence 121, 18-22.

• We were able to verify that the scale was valid for Guam chewers

• Dependence associated with: chews per day, years as a chewer, and adding tobacco

Betel Quid Dependence Scale: Guam (continued)

Percentage and rank of BQDS Items: Factor 1

Item % Rank

Factor 1: Physical and Psychological Urgent Need

1. Can’t go on without betel nut/quid 62.4 5

2. Difficulty concentrating after reducing use 56.7 10

3. Experienced depression or drowsiness 52.0 11

4. Strong craving after reducing/stopping chew 73.3 1

5. Spend time to find when not available 64.1 3

6. Travel great distance to find when not available 58.3 9

7. Felt agitated, irritated, or anxious after reducing 59.8 8

Herzog, T.A., Murphy, K.L., Little, M.A., Suguitan, G.S., Pokhrel, P., Kawamoto, C.T., 2014. The Betel Quid Dependence Scale: replication and extension in a Guamanian sample. Drug and Alcohol Dependence 138, 154-160. PubMed PMID: 24629627; PubMed Central PMCID: PMC4010585.



Item % Rank

Factor 2: Increasing Dose

8. Trouble stopping once started chewing 66.7 2

9. Ever chewed non-stop 61.2 7

10. Increased the amount of use after first use 63.8 4

11. Felt the need to increase amount of use periodically 52.2 12

12. Often chewed betel nut/quid more than expected 61.6 6




Item % Rank

Factor 3: Maladaptive Use

13. Continue chewing after teeth loosen or wiggle 39.3 14

14. Continue chewing if you had sensitive teeth 43.1 13

15. Continue chewing if experienced mouth ulcers 25.5 15

16. Reduced or given up activities because of chewing 17.0 16



Betel Quid Ingredients by Ethnicity (Guam)

Ingredients

Ethnicity

Chamorro Chuukese Palauan Yapese Other Totals

Betel Nut alone 29 1 1 0 1 32

Quid without tobacco 31 12 5 1 8 57

Quid with tobacco 38 78 66 17 12 211

Totals 98 91 72 18 21 300

Notes: Ns reported in the table. X2 = 93.84, df = 8, p<.0001



Figure 1. Three-factor betel nut

dependence measurement model. Note.

Ellipses represent latent constructs and

rectangles represent measured variables.

Standardized parameter estimates are

presented. All parameters are significant

at p<.001. Model fit indices: X2 = 238.89,

df = 101, p<.0001; RMSEA = 0.07, 90%

CI = 0.06, 0.08; CFI = 0.98; WRMR =

1.21.



Figure 2. Structural equation model validating betel nut dependence. Note. Ellipses represent latent constructs and rectangles represent measured variables. Standardized parameter estimates are presented. This model controlled for age, gender, and education, but none of the paths were significant. Non-significant paths and covariance are not shown for graphical simplicity. Significance: *p<.05, **p<.0001. Model fit indices: X2 = 403.92, df = 218, p<.0001, RMSEA = 0.05, 0.06, CFI = 0.98, WRMR = 1.04.


Reasons for Chewing Scale

RFCS items Mean S.D. r Factor loadings

Reinforcement Construct 1.78 1.40

1. I like the taste 1.95 1.51 .92 .75

2. I like to have something in my mouth at all times 1.58 1.52 .92 .94

Social/Cultural Construct 1.26 1.08

3. All of my friends chew 1.63 1.42 .81 .78

4. My family members chew 1.74 1.37 .78 .73

5. It’s rude not to chew .88 1.35 .83 .63

6. People will not respect me if I don’t chew .73 1.27 .81 .62

Stimulation Construct 2.24 1.30

7. It relaxes me 2.54 1.41 .84 .66

8. It gives me energy 2.51 1.52 .88 .74

9. It helps me make decisions 1.68 1.64 .81 .79

10. I like the way it makes me feel 2.18 1.54 .86 .85

r = corrected item-total correlation. α = Cronbach’s alpha. Factor loadings are standardized. Response options ranged from 0-4.

Little, M.A., Pokhrel, P., Murphy, K.L., Kawamoto, C.T., Suguitan, G.S., Herzog, T.A., 2014. The reasons for betel-quid chewing scale: assessment of factor structure, reliability, and validity. BMC Oral Health 14, 62. PubMed PMID: 24889863; PubMed Central PMCID: PMC4059468.

Betel Nut and Tobacco

0

10

20

30

40

Nodefinitely

not

Noprobably

not

Don't know Yesprobably

Yesdefinitely

Do you want to quit?

0

10

20

30

40

50

none 1-5 times 6-10 times >10 times

How many times have you attempted to quit

chewing/smoking* in your life?

* Smokers were asked how many times they had quit smoking

for 24 hours or more.

010203040

Nodefinitely

not

Noprobably

not

Don't know Yesprobably

Yesdefinitely

Do you have a plan for how to quit?

010203040

Nodefinitely

not

Noprobably

not

Don'tknow

Yesprobably

Yesdefinitely

Do you have a plan for when you will quit?

Chewers

Smokers

Multi-Country Study

• Walter Patrick, M.D.

• Data Analysis by Ann Lee, Ph.D. (KMU)

• Asia-Pacific Academic Consortium for Public Health (APACPH)

• University of Malaya (Malaysia) • 954 chewers

• University of Peradeniya (Sri Lanka)

• University of Jaffna (Sri Lanka) • 404 chewers

• Kaohsiung Medical University (Taiwan) • 289 chewers

Multi-Country Study: Sample Characteristics

Malaysia (N=954) Taiwan (N=289) Sri Lanka (N=404)

Gender: Male 15.3% 51.6% 94.3%

Age 54.40 (13.30) 46.37 (15.43) 44.31 (11.41)

Commencement Age 25.39 (12.77) 25.62 (9.27) 33.67 (10.23)

Type Chewed: Hard 77.6% 66.9% 66.3%

Add Tobacco to Quid 76.2% 0.0% 57.9%

BQDS Score 7.61 (6.01) 3.76 (4.45) 3.01 (3.32)

Multi-Country Study: BQ Dependence Scale

Variables N Mean±SD P

Gender

Male 667 4.10±4.70 <0.0005

Female 924 6.96±5.89

Type

Soft 420 4.92±4.68 <0.0005

Hard 1144 6.09±5.90

Add tobacco to quid

Yes 925 7.08±5.82 <0.005

No 669 3.94±4.72

Multi-Country Study: BQDS (continued)

Variables N Mean±SD p LSD post comparison

Country

Malaysia 908 7.61±6.01 <0.005 Malaysia > Taiwan

Taiwan 283 3.75±4.45 Malaysia > Sri Lanka

Sri Lanka 404 3.01±3.32

Multi-Country Study: Multiple Regression, BQDS

Variables B S.E. Β t p-value

Intercept -0.998 0.306 -3.265 0.001

RBCS* 0.458 0.023 0.467 19.746 <0.0005

Duration (years) 0.039 0.008 0.120 5.076 <0.0005

Tobacco additive 1.477 0.292 0.130 5.060 <0.0005

Malaysia 1.376 0.319 0.122 4.318 <0.0005

Taiwan 1.520 0.407 0.103 3.734 <0.0005

Adjusted R-square = 0.370 Non-significant factors included: gender, type, medicinal use of betel quid *RBCS: Reasons for Betel-Quid Chewing Scale (Little et al., 2014) score

Intervention: Feasibility Study (U54)

• Project Leaders • Thaddeus Herzog, Ph.D. (UHCC) • John Moss, Ph.D. (UOG)

• N=17 participants in Guam, attended all 5 intervention sessions

• 11 (65%) self-identified as “ex-chewers” at completion of intervention (22 days)

• 15 (100%) self-identified as “ex-chewers” at 1-month follow-up

• 94% rated program as “very helpful”

• 82% would recommend program to a friend

• No bio-verification

BENIT: The Betel Nut Intervention Trial • Funding

• National Institutes of Health/National Cancer Institute 2 U54 CA143727-06A1 • New U54

• Project Leaders • Thaddeus A. Herzog, Ph.D. (UHCC) • Yvette C. Paulino, Ph.D. (UOG) • Adrian Franke, Ph.D. (UHCC)

• Specific Aims: • To test the efficacy of an intensive group-based betel nut cessation program • To quantitatively determine the efficacy of the group-based betel nut

cessation intervention trial using bio-verification

Study Design

324 Betel Nut Chewers

Guam (n=162) Saipan (n=162)

Intervention

(n=81)

Control

(n=81)

Intervention

(n=81)

Control

(n=81)

Intervention Booklet (Quitting Betel Nut)

+ Intensive Betel Nut Cessation Program

Control Booklet (Quitting Betel Nut)

Study Design: Booklet

Study Design: Intervention Sessions Session Day Session Topics

1 1 • Introduction, informed consent, ground rules • Negative health effects of betel nut chewing • Self-monitoring • Triggers • Betel nut fading

• Baseline survey • Saliva collection

2 8 • Lifestyle change to support quitting • “Excuses” for not chewing (from feasibility study)

3 15 • QUIT DAY • Coping strategies to prevent relapse • Maximizing social support for non-chewing

4 18 • Reinforce negative health effects of chewing (from feasibility study)

• Additional strategies for coping with urges to chew

5 22 • Managing thoughts that can lead to relapse • Follow-up survey • Saliva collection

182 • Six-month follow-up (individual visit) • Six-month survey • Saliva collection

Assessments

• Baseline (i.e., first group session)

• Week 3 (i.e., last group session)

• Month 6

Preliminary Results

• 60 participants enrolled in Guam and Saipan thus far (all Pacific Islanders)

• Preliminary cessation outcomes: 46% vs 6% Intervention vs Control at 3-week follow-up

• Saliva collected for bio-verification and additional research

Betel Nut Research Agenda

• Systemic research on betel nut cessation

• Interdisciplinary betel nut researchers at UHCC and UOG: epidemiology, pharmacokinetics, cancer biology

• International collaborations

Collaborators

• Rosnah Zain

• Amin Jalaludin

• Tien-Yu Shieh

• Chen-Yi Lee

• Prasad Amaratunga

• Pallav Pokhrel

• Melissa Little

• Crissy Kawamoto

• Kelle Murphy

• Gil Suguitan

• Yvette Paulino

• Adrian Franke

• John Moss

• Yong-Yuan Chang

• Surenthirakumaran Rajendira

• Walter Patrick

Mahalo!

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