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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.

  • Betel Quid Dependence Scale: Guam (continued)

    Percentage and rank of BQDS Items: Factor 2

    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

    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.

  • Betel Quid Dependence Scale: Guam (continued)

    Percentage and rank of BQDS Items: Factor 3

    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

    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.

  • Betel Quid Dependence Scale: Guam (continued)

    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

  • Betel Quid Dependence Scale: Guam (continued)

    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

  • Betel Quid Dependence Scale: Guam (continued)

    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

  • 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

    No definitely

    not

    No probably

    not

    Don't know Yes probably

    Yes definitely

    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.

    0 10 20 30 40

    No definitely

    not

    No probably

    not

    Don't know Yes probably

    Yes definitely

    Do you have a plan for how to quit?

    0 10 20 30 40

    No definitely

    not

    No probably

    not

    Don't know

    Yes probably

    Yes definitely

    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

  • Multi-Country Study: BQDS (continued)

    Variables N Mean±SD p LSD post comparison

    Country

    Malaysia 908 7.61±6.01 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

  • 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

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