betel quid chewing in dagon (east) townshipeast... · 7/15/2014 3 recent epidemiological studies...

7/15/2014

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Betel Quid Chewing

in Dagon (East) Township

Ko Ko Zaw1, Mya Ohnmar1, Moh Moh Hlaing1, Swe Swe Win2,

Maung Maung Than Htike 3, Phyu Phyu Aye4, Mg Mg Myint1,

Sein Shwe2 & Moe Thida Htwe2

1Department of Medical Research (Lower Myanmar), 2University of Dental Medicine (Yangon), 3International Health Division, Ministry of Health,

4Department of Health

Introduction

600 million people (10% of the world’s population)

chew betel quid worldwide.

(A review of human carcinogens–Part E. Lancet Oncol 2009;10:1033–34)

Betel quid chewing has been common in Southeast

Asia and Asia Pacific Region including Myanmar for a

long time.

Prevalence of betel quid chewing varies

from 5% in Karachi, Pakistan

through 49% in Sarawak, Indonesia

up to 80% in parts of India

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Introduction (contd.)

Betel quid use - multiple impacts on health.

Areca nut forms nitrosamines in the saliva of chewers

which induces oral pre-neoplastic disorders with a high

propensity to progress to cancer.

Areca nut, with/without added tobacco, is a cause of

oral cancer

pharyngeal cancer &

esophageal cancers

(IARC. Betel-quid and areca-nut chewing and some areca-nut derived nitrosamines. 2004.)

Areca nut with added tobacco cause pancreatic

tumours, too.

(IARC. A review of human carcinogens. 2012)

There is also limited evidence that areca nut causes

liver cancer.

(A review of human carcinogens–Part E. Lancet Oncol 2009;10:1033–34)


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Recent epidemiological studies show that betel quid

use is associated with a higher risk of:

obesity,

metabolic syndromes,

cardiovascular disease,

type 2 diabetes

chronic kidney disease,

low birth weight and

cirrhosis of the liver.


(Chien-Hung Lee et al. Intercountry prevalences and practices of betel-quid use in south, southeast and eastern

Asia regions and associated oral preneoplastic disorders .Int J Cancer, 2011 Oct 1;129(7):1741-51.)

In Myanmar, prevalence of smoking is getting lower

(22% in 2009) but that of smokeless tobacco use,

mostly in betel quid, is still high in Myanmar (30%).

The majority of these smokeless tobacco users used it

in a form of betel quid.

In Myanmar, oral cancer, a serious consequence of

betel chewing, stood at the 6th among male caners

and 10th among female cancers, contributing 3.5% of

the whole body cancers, according to cancer

registries of Yangon and Mandalay General

Hospitals.


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Community-based surveys on betel chewing and oral

health were scare and outdated in Myanmar and

updateted epidemiological information on these

issues is needed.

So this study tried to help fill this information gap to

some extent.


Objectives

The study aims to assess betel quid chewing practice

and its relation to oral pre-cancerous lesions in adult

population in Dagon (East) township.

The study has the following specific objectives:

To determine the prevalence of betel quid chewing

in adult population of Dagon (East) township.

To describe the characteristics of betel quid

chewing practice

To assess its relation to oral pre-cancerous lesions

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Methodology

Study Design: cross-sectional design

Study Place: Dagon (East) township, Yangon Region

Study Population: persons aged 18 years and above of both sexes

Excluded - very ill persons and mentally ill persons.

Methodology (contd.)

Sample Size Determination

Using the formula for one sample proportion with the following assumptions:

Alpha error is set at 5%, so, ‘z’ statistics is 1.96;

P was conservatively estimated at 50% ( the exact prevalence of betel quid chewing in Myanmar is unknown)

Margin of error (e) is 5%;

Rate of refusal to participate is10%.

Required sample size was 428 persons.

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Sampling procedure

Four hundred and twenty two households were

selected from Ward 133: one hundred and twenty

two households were selected from Sit-Pin village.

One eligible person was selected from each

selected household.


Data collection

Data collection was done in April, 2013.

By using a pretested structured questionnaire, 11

trained interviewers from DMR(Lower Myanmar)

collected from the respondents the following data

on:

socioeconomic characteristics

betel quid chewing practice

alcohol drinking

smoking

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Data collection

Photos showing

field data collection


Data collection

5 oral examination teams comprising 13 dental

surgeons and 8 dental house surgeons from

University of Dental Medicine (Yangon) made oral

examination on every respondent.

Toluidine blue staining and oral brush biopsy

were done on the respondents with visible oral

lesions.

When these oral lesions were positive by Toluidine

blue stain and/or oral brush biopsy, these were

regarded as potentially malignant.

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Data collection

Photos showing oral examination


Data collection

Photo showing

Toluidine blue staining

Photo showing

oral brush biopsy specimen

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Data management and analysis

Prevalence of betel quid chewing was calculated

by age and sex.

Characteristics of betel quid chewing practice were

described for men and women and both sexes.

Prevalence of oral potentially malignant disorders

was determined by major health risk behaviours.

Multiple logistic regression was performed to

determine the independent effect of health risk

behaviours on oral pre-cancers, controlling for

possible confounders.


Ethical considerations

The proposal was approved for ethical clearance

by the Ethical Review Committee of the Department

of Medical Research (Lower Myanmar).

Informed consent was obtained from the

respondents for interview and oral examination.

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542 persons aged 18 years and above participated

in the survey.

Results

Age and sex distribution of the respondents

Age

Male Female Total

18-24 years 28 [5.17%] 31 [5.72%] 59 [10.89%]

24-44 years 92 [16.97%] 128 [23.62%] 220 [40.59%]

45-64 years 78 [14.39%] 125 [23.06%] 203 [37.45%]

65+ years

23 [4.24%]

37 [6.83%]

60 [11.09%]

Total 221 [40.77%]

321 [59.23%]

542 [100%]

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Prevalence of current betel quid chewing

among the respondents by sex and age

Sex and age Pop.

Chewers of b etel quid

without tobacco with tobacco total

Male 221 7 [3.2%]

[95%CI= 1.2 to 6.4% ]

153 [69.2%]

[95%CI=62.7 to75 .2%]

160 [72.4%]

[95%CI=66 to 78.2%]

18-24 years 28 2 [7.1%] 19 [67.9%] 21 [75%]

24-44 years 92 1 [1.1%] 74 [80.4%] 75 [81.5%]

45-64 years 78 4 [5.1%] 49 [62.8%] 53 [68.0%]

65+ years 23 0 [0%] 11 [47.8%] 11 [ 48.8%]

Female 321 37 [11.5%]

[95%CI=8.2 to 15.5%]

87 [27.1%]

[95%CI= 22.3 to 32.3% ]

124 [38.6%]

[95%CI= 33.3 to 4.2% ]

18-24 years 31 2 [6.5%] 2 [6.5%] 4 [12.9%]

24-44 years 128 13 [10.2%] 38 [29.7%] 51 [39.8%]

45-64 years 125 17 [13.6 %] 41 [32.8%] 58 [46.4%]

65+ years 37 5 [13.5%] 6 [16.2%] 11 [29.7%]

Total 542 44 [8.1%]

[95%CI= 6 to10.7% ]

240 [44.3%]

[95%CI= 40 to 48.6% ]

284 [52.4%]

[95%CI= 48 to 56.7% ]

18-24 years 59 4 [6.8%] 21 [35.6%] 25 [42.4%]

24-44 y ears 200 14 [6.4%] 112 [10.9%] 126 [57.3%]

45-64 years 203 21 [10.3%] 90 [44.3%] 111 [54.7%]

65+ years 60 5 [8.3%] 17 [28.3%] 22 [36.7%]

Prevalence of current betel quid chewing

among the respondents by sex and age

Sex and age Pop.

Chewers of b etel quid

without tobacco with tobacco total

Male 221 7 [3.2%]

[95%CI= 1.2 to 6.4% ]

153 [69.2%]

[95%CI=62.7 to75 .2%]

160 [72.4%]

[95%CI=66 to 78.2%]

18-24 years 28 2 [7.1%] 19 [67.9%] 21 [75%]

24-44 years 92 1 [1.1%] 74 [80.4%] 75 [81.5%]

45-64 years 78 4 [5.1%] 49 [62.8%] 53 [68.0%]

65+ years 23 0 [0%] 11 [47.8%] 11 [ 48.8%]

Female 321 37 [11.5%]

[95%CI=8.2 to 15.5%]

87 [27.1%]

[95%CI= 22.3 to 32.3% ]

124 [38.6%]

[95%CI= 33.3 to 4.2% ]

18-24 years 31 2 [6.5%] 2 [6.5%] 4 [12.9%]

24-44 years 128 13 [10.2%] 38 [29.7%] 51 [39.8%]

45-64 years 125 17 [13.6 %] 41 [32.8%] 58 [46.4%]

65+ years 37 5 [13.5%] 6 [16.2%] 11 [29.7%]

Total 542 44 [8.1%]

[95%CI= 6 to10.7% ]

240 [44.3%]

[95%CI= 40 to 48.6% ]

284 [52.4%]

[95%CI= 48 to 56.7% ]

18-24 years 59 4 [6.8%] 21 [35.6%] 25 [42.4%]

24-44 y ears 200 14 [6.4%] 112 [10.9%] 126 [57.3%]

45-64 years 203 21 [10.3%] 90 [44.3%] 111 [54.7%]

65+ years 60 5 [8.3%] 17 [28.3%] 22 [36.7%]

Overall prevalence = 52.4%

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Prevalence of current betel quid chewing by sex

72.4%

38.6%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

Male (n=221) Female (n=321)

Curr

en

t b

ete

l ch

ew

ers

Prevalence of current betel quid chewing by age

75.0%

81.5%

68.0%

48.8%

12.9%

39.8%

46.4%

29.7%

Male 18-24years

(n=28)

24-44years

(n=92)

45-64years

(n=78)

65+years

(n=23)

Female 18-24years

(n=31)

24-44years

(n=128)

45-64years

(n=128)

65+years

(n=37)

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Prevalence of current betel quid chewing by age

75.0%

81.5%

68.0%

48.8%

12.9%

39.8%

46.4%

29.7%

Male 18-24years

(n=28)

24-44years

(n=92)

45-64years

(n=78)

65+years

(n=23)

Female 18-24years

(n=31)

24-44years

(n=128)

45-64years

(n=128)

65+years

(n=37)

Addition of tobacco to betel quid

Among 284 current chewers,

240 (85%) added tobacco to

betel quid.

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62.9%

30.8%

19.6%15.4%

7.5% 7.1%4.2% 3.3% 2.1%

Kinds of tobacco consumed with betel quids among chewers of betel quid with tobacco (n=240) *

*Multiple responses

Photo showing some kinds of tobacco

added to betel quids

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Boxplot showing age at which betel quid chew started

10

25

61Oldest age

Median age

Earliest age

(N=284, the respondents who currently chewed betel quids)

years

years

years

0

10

75

Boxplot showing duration of betel quid chewing

Longest duration

Median duration

Shortest duration

years

years

year


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1

8

100

Boxplot showing number of betel quids chewed per day

Highest number

Median number

Lowest number

quids

quids

quid


Ways of dealing with betel quid juice among the

respondents who currently chewed betel quids

Swallow (2.8%)

Spit out (88.7%)

Both swallow and spit

out (8.5%)


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Ways of discarding betel quid among the

respondents who currently chewed betel quids

Way of discarding

used betel quid*

Male

(n=160) Female

(n=124) Total

(n=284)

- Spit out onto the

ground/building corner

- Spit out to plastic bags or

other containers

-Spit out to dustbin/dump

116 [72.5%]

41 [25.6%]

16 [10.0%]

78 [63.9%]

46 [37.7%]

3 [2.5%]

194 [68.8%]

87 [30.9%]

19 [6.7%]

*Multiple responses

Reasons for chewing betel quid among the respondents

who currently chewed betel quids* (N=284)

35.1% 34.4%

14.5%

9.9% 9.6%

5.0%

To ease an soursensation in the

mouth

Addiction tochewing betel

quids

To be alert To beconcentrated

To make breathssweet

To quit smoking

*Multiple responses

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Out of 542 persons, 25 persons (4.6%) turned out to

have visible oral lesions (ulcer or patch) which tested

positive for Toludine blue staining and/or oral brush

biopsy (95%CI=3.0 to 6.7).

These oral lesions were regarded as potentially

malignant (precancerous).

Prevalence of oral potentially malignant lesions

Prevalence and unadjusted risk of oral precancer

by three major lifestyles

Pop. Oral potentially malignant lesions

Number Percent [95% CI] Crude Odds Ratio

Betel quid chewing habit

Non-chewers (Ref. group) 258 1 0.4 [0 to 2.1] 1

Chewers without tobacco 44 1 2.3 [0.06 to 12] 6 [2 to 17]

Chewers with tobacco 240 23 9.6 [6.2 to 14] 27 [12 to 62]

Smoking habit

Non-smoker (Ref. group) 371 17 4.6 [2.7 to 7.2] 1

Smoker 171 8 4.7 [2.0 to 9.0] 1.02 [0.4 to 2.6]

Alcohol drinking habit

Non-drinker (Ref. group) 451 17 3.8 [2.2 to 6.0] 1

Drinker 91 8 8.8 [3.9 to 16.6] 2.5 [1.1 to 5.7]

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Prevalence and unadjusted risk of oral potentially

malignant lesions by betel quid chewing

Prevalence of oral precancer rose from 0.5% in non-

chewers through 2.3% in chewers without tobacco to

9.6% in chewers with tobacco.



Number Percent

[95% CI]

Crude Odds Ratio

[95% CI]





malignant lesions by betel quid chewing

Betel chewers were 6 times more likely to have oral

precancer than non-chewers.

The risk increased to 27 times with addition of

smokeless tobacco to betel quid, compared to non-

chewers. .



Number Percent

[95% CI]

Crude Odds Ratio

[95% CI]




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The prevalence of oral precancer was similar between

non-smokers and smokers.

Unadjusted ORs were similar too.


malignant lesions by smoking

Smoking habit


Number Percent

[95% CI]

Crude Odds Ratio

[95% CI]

Non-smoker (Ref. group) 371 17 4.6 [2.7 to 7.2] 1

Current smoker 171 8 4.7 [2.0 to 9.0] 1.02 [0.4 to 2.6]



Number Percent

[95% CI]

Crude Odds Ratio

[95% CI]

Non-drinker (Ref. group) 451 17 3.8 [2.2 to 6.0] 1

Drinker 91 8 8.8 [3.9 to 16.6] 2.5 [1.1 to 5.7]

CI=Confidence interval

Drinkers were 2.5 times more likely to have oral

precancer than non-drinkers.


malignant lesions by alcohol drinking

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Odds ratios of oral precancer from multiple logistic

regression according to demographic and major

lifestyles characteristics

Multiple logistic regression was performed to determine

the independent effect of demographic and life style

factors on oral pre-cancer.

Initially, 5 variables (age, sex, betel chewing, smoking

and alcohol drinking, , all of which were defined as

categorical, were included in the model.

In the final model, only 4 variables (age, sex, betel

chewing and alcohol drinking) remained: smoking was

omitted because it was multicollinear with alcohol

drinking.

Odds ratios of oral potentially malignant lesions

from multiple logistic regression according to four

demographic and major lifestyles characteristics

Variable Adjusted Odds Ratio 95% Confidence Interval

Age

<=40 years (Ref. group) 1.0

40-60 years 1.5 0.6 to 4.2

60+ years 2.0 0.7 to 5.7

Sex

Female (Ref. group) 1.0

Male 0.7 0.3 to 1.7


Non-chewers (Ref. group) 1.0

Chewers without tobacco 5.7* 1.4 to 22.9

Chewers with tobacco 28.6* 9.8 to 83.6


Non-drinker (Ref. group) 1.0

Drinker 1.6 0.7 to 4.0

*Significant at 0.05 level

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Betel chewing is significantly associated with risk of oral pre-cancer.

Chewers of betel quid alone has 6-fold increase and chewers of

betel quid with tobacco 29-fold increase in risk of oral precancer,

compared to non-chewers.


Age


40-60 years 1.5 0.6 to 4.2

60+ years 2.0 0.7 to 5.7

Sex


Male 0.7 0.3 to 1.7












Old age, female sex and alcohol drinking were also

associated with increased risk of oral pre-cancer but their

relationship was not significant.


Age


40-60 years 1.5 0.6 to 4.2

60+ years 2.0 0.7 to 5.7

Sex


Male 0.7 0.3 to 1.7









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Discussion

Half of this population were currently chewing betel

quids.

This prevalence of betel chewing is quite high given

the global estimate of 10-20% and regional

estimates of 20%-40% in India, Pakistan and Nepal

over the last two decades.

Discussion(contd.)

In the current study, 85% of the betel quid chewers

added tobacco, comparable to levels for Dhaka,

Bangladesh (85.2%) (Rahman et al.).

Current betel quid chewing in men was highest (81%)

in the most productive age group (24-44 years).

Betel quid chewers mostly started betel chewing

practice around 25 years of age, chewed 8 betel

quids per day for 10 years or more.

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4.6% of study population had oral precancer as

determined by rapid screening tests (Toludine blue

staining and oral brush biopsy).

Prevalence of oral precancer in current chewers of

betel quid without tobacco (2.3%) increased to

nearly 10% with addition of smokeless tobacco to

betel quid.

This finding provides additional evidence for

formulating policy on control of smokeless tobacco

use in Myanmar.

Discussion(contd.)

Multiple logistic regression indicated that older age,

betel chewing, especially with tobacco and

consumption of alcohol were associated with risk of

oral pre-cancer.

These findings are consistent with the internationally

established risk factors for oral pre-cancer.

Discussion(contd.)

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Conclusion

Betel quid chewing was found to be a common habit

in both men and women of the study population

Because betel quid chewing have serious health

consequences, an anti-betel quid chewing programme

is warranted for current chewers.

Health risks of betel quid chewing should be

emphasized in the health education to the public and

especially betel chewers.

Regular oral examination of betel quid chewers may

help prevent avoidable oral cancers in the future.

Conclusion

As the habit is rooted in Myanmar tradition and

culture, anthropological studies are indicated for

designing appropriate educational campaigns.

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Utilization of research findings

The findings were provided to the tobacco control

program of Department of Health for future

programming and policy formulation.

The persons who tested positive for Toluidine blue

stain and oral brush biopsy were referred to

University of Dental Medicine for further

investigation, regular follow-up and necessary

treatment.

Acknowledgements

We wish to thank all respondents who gave up their time

to be interviewed and examined and who welcomed

interviewers into their homes.

We thank local health staff from Urban Health Center in

Ward 133 and from Sitpin RHC, Dagon (East) Township.

We would also like to appreciate the commitment and

professionalism of the interviewers from Department of

Medical Research (Lower Myanmar) and oral

examination teams from University of Dental Medicine

(Yangon).

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References

IARC Monographs Program. A review of human carcinogens–Part E. Lancet Oncol

2009;10:1033–34.

Gupta PC, Ray CS. Epidemiology of betel quid usage. Ann Acad Med Singapore

2004; 33:31–6.

Gupta PC, Warnakulasuriya S. Global epidemiology of areca nut usage. Addict

Biol 2002;7:77–83.

Ministry of Information. Myanmar Encyclopaedia. CD-ROM; Myanmar 2005.

IARC. Tobacco habits other than smoking; betel quid and areca-nut chewing and

some related nitrosamines. IARC Monograph on the Evaluation of Carcinogenic Risk

of Chemicals to Humans, Vol 37. Lyon: International Agency for Research on Cancer;

1985.

IARC. Betel-quid and areca-nut chewing and some areca-nut derived nitrosamines.

IARC Monograph on the Evaluation of Carcinogenic Risk of Chemicals to Humans, Vol

58. Lyon: International Agency for Research on Cancer; 2004.

References (contd.)

IARC. A review of human carcinogens. IARC Monograph on the Evaluation of

Carcinogenic Risk of Chemicals to Humans, Vol 100. Lyon: International Agency for

Research on Cancer; 2012.

Chien-Hung Lee1, Albert Min-Shan Ko, Saman Warnakulasuriya. Intercountry

prevalences and practices of betel-quid use in south, southeast and eastern Asia

regions and associated oral preneoplastic disorders: An international collaborative

study by Asian betel-quid consortium of south and east asia. Int J Cancer. 2011 Oct

1;129(7):1741-51.

World Health Organization. Non-communicable Disease Risk Factor Survey

Myanmar 2009. New Delhi : WHO Regional Office for South-East Asia; 2011.

Mazahir S, Malik R, Maqsood M, Merchant KA, Malik F, Majeed A, et al. Socio-

demographic correlates of betel, areca and smokeless tobacco use as a high risk

behaviour for head and neck cancers in a squatter settlement of Karachi, Pakistan.

Subst Abuse Treat Prev Policy. 2006; 26: 10-15.

http://www.ncbi.nlm.nih.gov/pubmed/21128235

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References

Rahman M, Rahman M, Flora MS, Akter SFU, Hossain S, Mascie-Taylor CGN.

Behavioural risk factors of non-communicable diseases in Bangladesh. Dhaka:

National Institute of Preventive and Social Medicine, 2006.

Meerjady S F, Christopher GN M-T, Mahmudur R. Betel quid chewing and its risk

factors in Bangladeshi adults. WHO South-East Asia Journal of Public Health

2012;1(2):169-181.

Thank you for the kind attention!

betel quid chewing in dagon (east) townshipeast... · 7/15/2014 3 recent epidemiological studies...

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