Patterns of consumption, and levels of addiction among Areca nut chewers in Dakshina Kannada

District, Karnataka

Dr. Shrihari J.S.

Dissertation submitted for partialfulfilment of the requirement for the award of the degree of Master of Public Health

Achutha Menon Centre for Health Science Studies Sree Chitra Tirunal Institute for Medical Sciences and Technology

Thiruvananthapuram, Kerala, India-695011

Declaration: I hereby certify that, the work embodied in this dissertation entitled ‘Patterns of consumption, and levels of addiction among Areca nut chewers in Dakshina Kannada District, Karnataka’ is the result of original research and has not been submitted for any degree in any other university or institution. Thiruvananthapuram June 2004 Dr.Shrihari J.S.

Acknowledgments: I thank almighty for enabling me to accomplish this work with great satisfaction. I am immensely greatful and highly indebted to my teacher and guide Dr.K.R.Thankappan, without whose support and encouragement this work would have been impossible. I sincerely extend my gratitude towards my co-guide Dr.Mark Nichter, who has been motivating and supporting me with his valuable suggestions throughout the work. I am highly privileged and fortunate to work under him. I also extend my humble gratitude for all the faculties of AMCHSS, especially Dr. T.K.Sundari Ravindran whose valuable suggestions and constructive criticism helped me in writing the dissertation; Dr.Sankara Sarma who was always extremely helpful in several stages of the study; valuable inputs from Dr.Mala Ramanathan were extremely useful. I thank Dr.D.Varatharajan from whom I have learned a lot during the course. I also extend my thanks Dr.Biju Soman for his comments. I am thankful to Dr.C.U.Thresia, Dr.Pradeep Kumar, Dr.Sailesh, AMCHSS for their valuable inputs and comments. I express my gratitude to Dr.Mohan Das, Director, SCTIMST, Thiruvananthapuram for his constant support in all academic activities. I also thank Mr.Sundar Jay Singh, assistant registrar, SCTIMST, Thiruvananthapuram for his continuous motivation and support in several stages of our course here. I am also thankful to all my batschmates for their encouragement and inputs received during the course. The study would not have taken place without the valuable help and assistance from many people. I thank all the study participants, key informants and various stakeholders without whose help, the study could not have been done. I thank all who were directly or indirectly involved in this study. Thiruvananthapuram June 2004 Dr.Shrihari J.S.

Title Page numbers

Chapter – I 1.Introduction 1- 19 1.1 Prevalence of chewing 2- 3 1.2 Background 3- 11 1.3 Literature review 11- 17 1.4 Conceptual context 17- 18 1.5 Rationale for the study 18 1.6 Objectives of the study

19

Chapter – II 2. Methodology 20 - 24 2.1 Research Design 20 2.2 Sample selection 20- 21 2.3 Operational definitions 21- 22 2.4 Study instruments 22 2.5 Description of method of data collection 23 2.6 Analysis of data

24

Chapter – III 3. Results 25- 52 3.1 Characteristics of respondents 25 3.2 Perception and beliefs about chewing 26- 30 3.2.1 Utility of chewing 26- 27 3.2.2 Perception about harm 28- 29 3.2.3 Perception about addiction/habituation 29 3.2.4 Perception about Normal dose/harmless chewing 30 3.3 Patterns of areca nut chewing 30- 33 3.4 Initiation of chewing 34- 35 3.5 Quantum per chew 35- 36 3.6 Type of areca nut used in the chew 36- 37 3.6.1 Reason for using a particular type of areca nut 37 3.7 Place, Partner, Time for chewing 38- 39 3.8 Reasons and influences for chewing 39- 42 3.9 Variations in chewing practice 42- 43 3.10 Respondents self reporting about problems from chewing 43- 44 3.11 Oral health problems among respondents 44 3.12 Factors associated with addiction, chewing practices, and oral health problems

44- 52

Chapter- IV 4. Discussion 53- 60 4.1 Strengths and limitations of the study 59 4.2 Conclusion 59- 60 References 61- 66 Appendix I - Dakshina Kannada district map Appendix II - Tables Appendix III - Check list and Interview schedule of the study

Patterns of consumption, and levels of addiction among Areca nut chewers in Dakshina Kannada District, Karnataka

Dr. Shrihari J.S.

Abstract:

Introduction: Areca nut associated oral cancer is one of the leading causes of death in South

Asia & Southeast Asian countries. This study was undertaken to document areca nut chewing

practices, perceived risks and benefits of chewing areca nut products, measure levels of

addiction and correlate it with oral lesions and to investigate the topography of areca nut

chewing practices.

Methodology: Using a purposive sampling, 90 areca nut chewers (78 males, 12 females) were

selected from Dakshina kannada district, Karnataka. Information on patterns of chewing,

perceptions about health benefit, risks and addiction of chewing using a semi-structured

interview and levels of addiction using Fagerstorm scale were collected, followed by

observation and clinical examination. Data were grouped and thematic analysis was done.

Results: Areca nut chewing with tobacco was common than with out tobacco. Among the 90

participants 71% chewed areca nut with tobacco. Majority of the respondents (69%) thought

that chewing had beneficial effects like increasing taste, pleasure, reducing tooth pain, and

reducing bad breath. Only a third of the sample knew about harmful effects of chewing. Among

the participants, 52.2% were found to have higher Fagerstorm score (>6) who were 9 times

more likely to develop oral lesions (88%) compared to those with a Fagerstorm score of < 6

(12%). All the respondents who had oral lesions were chewing areca nut products with

tobacco. When the quantity of ingredients increased, more cancer/precancerous lesions were

seen among the chewers. Chewing ripe and fermented varieties of areca nuts had more chances

of addiction.

Conclusion: In this study of areca nut chewers, majority was chewing areca nut with tobacco.

Scientific validity of perceived benefits of chewing reported by the participants needs further

investigation. Health education programs targeting at harmful effects of chewing are warranted

in this area.

1

Chapter –I

1.Introduction: Areca nut is the fourth most widely used addictive substance. Around 600 million

people chew areca nut worldwide, ranking fourth after nicotine, ethanol, and caffeine in

number of users (Burton-Bradley, 1979; Ko Lin et.al, 2003). Areca nut chewing has been

reported as a major addiction even in south Asian countries especially in India and Taiwan.

Betel quid chewing with tobacco has already proven to be the major risk factor for oral

cancer. Studies from India have shown that even chewing betel quid without tobacco as a

significant risk factor for development of oral and esophageal cancers (Jacob et.al, 2004;

IARC, 2003 & Wu MT et.al, 2001). Areca nut associated Oral Squamous cell carcinoma has

been reported to be one of the leading causes of death in South Asia & Southeast Asian

countries. Premalignant lesions like Leukoplakia and Oral Sub Mucous Fibrosis are also

strongly associated with areca nut chewing (Ko et.al, 2003). Areca nut chewing is found to

be a major independent risk factor besides cigarette smoking and alcohol consumption for

esophageal cancer (Wu et.al, 2001). Globally 390,000 oral and pharyngeal cancers are

estimated to occur annually, out of which 228,00 (58%) occur in South East Asia. The

incidence of oral cancer has been reported to be tripled since 1980’s among the betel quid

chewers (Gupta, & Nandakumar , 1999).

Strickland (2002) reported that the use of areca nut extends through maritime South and

Southeast Asia as far as African seaboard, the Western Pacific and also among Indian

immigrants (WHO, Tobacco Alert, 1996). The long-term historical trends in areca nut use

have been reported to be complex and regionally variable and remain poorly understood

(Strickland, 2002).

2

Areca nut chewing has had wide-ranging cultural influences including on power relations

and politics (Hirsch 1995; Iamo 1987), social relations (Sachdeva, 1958; Marshall 1987), and

even art (Rooney, 1993). In its most traditional form, betel chewing consists of areca nut from

the areca palm (Areca catechu) wrapped with slaked lime in the leaf of the betel vine (Piper

betle). There is little epidemiological data has been available for clearly delineating the risk

factors involved as the composition of the chew itself varies widely among cultures (Gupta and

Warnakulasuriya, 2002).

1.1 Prevalence of chewing:

India has the largest areca nut consuming population in the world (Gupta &

Warnakulasuriya, 2002). In India the consumption of smokeless tobacco has been estimated

to be approximately 128.4 million of whom 90 million are men and 38 million are women

users (Rani et. al, 2004). The following table shows the percentage of household members

age 15 years and above who chews pan masala or tobacco in Karnataka and India (NFHS-2,

1998-99).

Table1: Percentage of chewers in Karnataka and India.

Men (%)

Women (%)

Men (%)

Women (%) Total

Rural Urban Rural Urban Karnataka 13.9 14.9 17.2 8.2 19.6 6.5 14.4 India 28.3 12.4 20.8 31.3 13.8 8.8 20.5 A study from Kerala has showed the prevalence of chewing as 21.6% in above 64 years

age group, where as 0.3% among the 15-24 years age group, but overall use of khaini was

10.2% seemed to be concentrated among the younger age groups. It is reported that smoking

prevalence tends to decline beyond certain age group, but appear to be substituted

spontaneously. Occasional users start chewing without tobacco initially, but later become

3

regular users of the same or shift to smokeless tobacco product chewing / other tobacco use

(Sinha & Gupta, 2001). Studies have shown that there is high consumption of areca nut

among Indian immigrants to Malay Peninsula, South & East Africa and United Kingdom

(Warnakulasuriya, 2002). Prevalence of areca nut consumption in Taiwanese population is

reported to be over 10% (Ko et.al, 1995). In Taiwan, over 2 million people have been

reported to chew betel quid (Jeng et. al, 1996). The use of sweetened areca nut, betel quid or

both was reported to be 74.2% among 160 school children aged 4-16 years in a fisherman

community in Karachi which hints the possible future use of smokeless tobacco among them

(Gupta & Ray, 2003).

1.2 Background:

Although major contents are almost same in all betel quids, usually the ingredients of

the quid can vary according to the local customs and individual preferences. The main

1.2.1 Areca nut chewing in India:

When areca nut is ripe, it is orange – yellow in color and the seed (endosperm) is

separated from fibrous pericarp. The areca nut is usually used as fresh or dried and cured

before use by boiling, baking or roasting. In some areas like eastern India and southern Sri

Lanka, fermented areca nut is also found to be popular whereas in Taiwan areca nut is often

used in the unripe stage when it is green (Gupta & Warnakulasuriya, 2002). In Assam, areca

nuts are chewed in the form of raw (green), ripe (red) and fermented (underground,

processed) (Phukan et.al, 2001). Areca nut is familiarly known as supari in Hindi (Gupta &

Warnakulasuriya, 2002) where as it is either known as ‘adike or adakke or bajjeyi’ in the

study area. Areca nut often mixed with several ingredients to make up a betel quid known as

pan in Hindi (Gupta & Warnakulasuriya, 2002).

4

ingredients used in betel quid are betel leaf, sliced areca nut, slaked lime (Calcium

hydroxide). This lime increases the mouth PH, thus making it alkaline aiding easier

absorption of nicotine via mouth lining. Other contents of pan include, Catechu gum (Acacia

tree gum or boiled areca extract), helps in binding the ingredients in the quid into a consistent

paste to aid in chewing, for which tobacco is often added and sometimes other varieties of

ingredients like cardamom, clove, menthol, aniseed, grated coconut, rose petals in syrup and

silver foil are also added (Chaudhry, 1999).

1.2.2 Use of Areca nut products:

Sometimes along with areca nut chewing, some aromatic varieties of spices are used in

“pan” preparation. The main spices used are; Aromatic seeds like Aniseed, Fennel,

Coriander, Pools & buds, Cardamom, cloves & sweet leaf, flower, Gulkhand (Roses) &

Saffron, extracts of rose and Jasmine. Even sugar products like Scented sugar syrup, saffron

sugar, fruits, desiccated coconut shreds, glazed cherries/fruits, Barks, Cinnamon, liquorices,

myrrh and noble metals like gold or silver leaf are also used as additives in areca nut

preparations. Various additives like saffron, yellow food dyes and sugar syrups are added to

produce sweet Supari (Chaudhry, 1999).

Pan masala is the generic term used for areca nut containing products that are

manufactured industrially and marketed commercially. Pan masalas containing tobacco are

referred to as gutkha (Gupta & Warnakulasuriya, 2002). Usually contents of pan masala vary

from brand to brand with unknown exact composition. Usually types of pan masala popular

in India are: Plain pan masala, sweet pan masala and pan masala-containing tobacco.

Constituents of pan masala include – areca nut (80%) and rest of them are catechu, lime,

sandal oil, menthol, cardamom, flavors, spices, aniseed, sugar, waxes, oil seeds, colors etc.

5

Usually sweet pan contains dry dates where as pan masala contains tobacco apart from above

listed item. Areca nut accounts for 70-80 % of Pan masala containing tobacco. Mava is a

mixture of 5-6 kgs of areca nut shavings, 0.3gm of tobacco and few drops of watery slaked

lime (Chaudhry, 1999).

Currently, gutkha is more frequently by many people in wrong belief that they are

‘mouth fresheners’ (Zain et. al, 1998 & Eswar, 2002). Intense promotion and marketing of

new from of tobacco products have lead to increase in their consumption followed by

increase in prevalence of Oral cancer and oral sub mucous fibrosis (Gupta, Nandakumar,

1999). Previous studies conducted in Dakshina Kannada district, (where that present study

also been conducted) reported that only 18% of male college students had tried chewing

gutkha (Nichter et. al, 2004). It has been reported that attractive packaging methods have

brought down the overall costs and invited market for areca nut. In India, there has been

increase in sales of areca nut products from 5 million dollars in 1985 to 66 million dollars in

1991 (Croucher & Islam, 2002).

Areca nut has been reported to have carcinogenic potential containing 3-methyl

nitrosamine propionitrite (MNPN), a carcinogen, and saffrole like DNA adducts also have

been detected in the saliva of areca nut chewers. Components of Areca nut include tannins

(11-26%), a stimulant and other alkaloids (0.15 – 0.67%) like Arecoline, Arecaidine,

Guacine, guvacoline & Areaolidine (Chaudhry, 1999). The active alkaloid, arecoline in the

areca nut have been shown to be genotoxic and mutagenic (Phukan et.al, 2001).

1.2.3 Carcinogenic potential of areca nut:

Arecoline

has been considered to play major role in many of the areca nut related health problems, but

how areca nut chewing induces alterations in oral mucosa is still yet to be understood

6

completely (Tsai et. al, 2003). Researchers in vitro studies have shown that the presence of

salivary nitrates and the alkaloids in the areca nut can form nitrosamines, which are

carcinogenic (Wu et.al, 2001). It is said that it is areca nut with tobacco poses its most

sinister risks (Winstock, 2002). Long-term use of areca nut with lime has shown to cause

Oral sub mucous Fibrosis. Studies even have found contamination of areca nuts with fungus

“Aspergillus flavus”, Aspergillus niger & Rhisopus species can produce carcinogenic

aflatoxin (Chaudhruy, 1999; Phukan et. al, 2001). Studies have shown that processing of

areca nut prior to use may be important in determining its carcinogenicity. Arecoline and

poly phenols are reported to be very high in unprocessed areca nut followed by sun dried or

roasted with minimum levels in areca nut processed by soaking and boiling (Chaudhry,

1999).

It has been reported that there are many differences in the way areca nut is consumed

(Chaudhry, 1999). In India alone, 38 different combinations of areca nut and tobacco use

have been reported (Gupta & Warnakulasuriya, 2002) and even it also can be used alone for

chewing. Areca nut is usually used as crushed fragments, sliced slithers or grated strands. It

is usual practice to smear lime and catechu on betel leaf and then fold the leaf into a funnel

shape and again it is further folded to make it smaller enough to accommodate in mouth.

Then it is placed in mouth especially in cheek area, chewed gently and sucked as long as

desired

1.2.4 Patterns of areca nut consumption:

(Chaudhry, 1999). This kind of chewing pattern helps in efficiency of the

mastication, release and absorption of main compounds like alkaloids from both betel leaf

and areca nut. The areca nut is usually consumed in combination with other substances (like

7

tobacco/betel leaves), which may be themselves exerting independent psychoactive effect

(Winstock, 2002).

The basic constituents of areca nut chewing depend upon modes of processing of areca

nut and supplementary ingredients of the chew, which varies from region to region. Areca

nut is a constant item in almost all the chews, but it might be used in different possible states

and forms of processing and rest of the items are often added (Strickland, 2002).

The quantity, frequency, and age that one starts chewing vary by local traditions (Scott,

1998). Times appropriate for chewing areca nut have been described as widely as "when I'm

bored", "at parties", "after tea", "after meals", or even "twenty-four hours" (Asma, 1994).

Although in some communities smoking is not considered to be socially acceptable habit,

betel quid chewing was accepted as a traditional cultural feature and they are unaware of the

harmful effects of the habits (WHO, Tobacco Alert, 1996). Like smoking, which is

considered inappropriate by older generation Indians and Bangladeshis and not permitted in

many public spaces (Nichter et. al, 2004; Asma, 1994), pan chewing may be limited to places

where spitting is acceptable whereas other forms of areca nut that involve swallowing the

saliva open up new arenas for chewing (Asma, 1994).

Betel pepper leaf used with pan has a mint/menthol flavor (depends upon the variety),

therefore it is considered as mouth freshener among the chewers, but there has been very

little evidence to indicate any health implications of betel leaf (Gupta & Nandakumar, 1999;

WHO, Tobacco Alert, 1996 & Asian quitline, 2002). With areca nut, pharmacological affects

may promote the sociability and relaxation associated with hospitality (Sachdeva, 1958;

Marshall, 1987) or may act as a labor inducing food (Jankowiak et. al, 1996; Hunt and

8

Barker, 2001) depending on cultural expectancy and other complex factors of behavioral

pharmacology.

Betel usage in India has been reported to have social meaning for different grades of

people from their personal identities and ethnic affiliation showing importance of their social

significance. Courtesy is indicated by offering acceptance of areca nut when greeting

someone or on departure of a visitor. Areca nut also has been used in procedure of courtship

and marriage. Although cultural evidence confers reproductive benefits there is no scientific

evidence till now about association of areca nut consumption and reproductive benefits

(Strickland, 2002).

It reported that traditional betel quid chewing is becoming less popular in India and

more confined to elderly whereas use of new smokeless tobacco forms like “pan masala

/gutkha” (readymade chewable) usage have increased (Gupta, & Nandakumar, 1999; Gupta,

& Ray, 2003) especially among youths, men, children, teenagers, reproductive age group

women, Indian immigrants, medical and dental students (Strickland, 2002; Sinha & Gupta,

2001). A study from rural areas from India reported that one third –two thirds of children

below 10 years of age had experimented with smokeless tobacco or smoking imitating their

parents, grand parents, other elders in the family or peers. As these newer products are

inexpensive, convenient to use with complete social acceptance has become common even

among children and adolescents (Gupta, & Nandakumar, 1999 & Murti et.al, 1995).

Apart from concerns about diseases, adulterations of areca nut with addictive products

like amphetamine, methamphetamine, keemam consisting of opiates and other unidentified

plant resins, wall lizard, dolomite, marijuana, or codeine may be another reason for public

health concern with these prepackaged consumables (Nichter et. al 2004; Wang et. al, 1995

9

& Akhtar, 1988). Thus the fear of adulteration that consumers have of these products may

very well be warranted. However, users are negotiating their perceived risk with tobacco, as

some believe that chewing tobacco rolled inside pan causes the betel leaf to neutralize any

harmful effects (Nichter et. al, 2004). Some of the studies from United Kingdom have

reported existence of an excessive non-permitted food addictives in pan masala and some of

the betel leaves were even found to contain salmonella (Croucher & Islam, 2002).

Traditional Ayurvedic medicinal uses of betel leaf and areca nut do persists in some

areas. Areca nuts have been reported to have anti-microbial properties in their non-alkaloid

fractions, and folk uses for the areca nuts include for diarrhea and laxative uses, antihelmintic

and vermifuge, stimulant, external skin ulcers, breath freshener (Bavvapa et. al, 1982), to

increase menstrual flow, nerve tonic, strengthen gums, treat urinary disorders etc (Scott,

1998; Strickland, 2002), but there has been no studies conducted to evaluate the efficacy of

areca nut about its therapeutic effects (Strickland, 2002).

1.2.5 Areca nut addiction and habituation

Most drugs of dependence other than stimulants tend to lead for chronic use, which

shows the desire to avoid withdrawal symptoms, drugs primacy as well as loss of control

over its use. It is said that, greater the liability of drug, the greater is the likelihood of daily

use being the norm (Winstock, 2002). Some of the studies from United Kingdom have

reported that majority of youngsters began quid chewing without tobacco, but some

converted to add tobacco to the quid during senior school ages /used gutkha. Areca nut

chewing in adolescents is considered to be an event that goes through a series of behavioral

intentions before becoming a habit. Those who were occasional chewers on reaching school

learning age become regular users of areca nut and often add tobacco to the chew (Trivedy

:

10

et. al, 2002). Psychiatrist Burton-Bradley (1980) described an initial toxic reaction including

dizziness, nausea, cold sweat, sore tongue, constricted throat, and loose stools, which abated

after sustained use. Also, in some "predisposed" individuals, prolonged abstinence followed

by excessive use resulted in "areca nut psychosis" characterized by delusions and

hallucinations (Burton-Bradley, 1966).

Some of the studies even have described about tolerance with areca nut use. Majority

of the chewers increasing the dose over a period of time might be the reason for tolerance. It

is said that substance form and its preparation for administration can also exert significant

influence upon the patterns of use and associated risks of particular drug. Researchers argue

that preparation of a drug for consumption such as betel quid preparation in ritualistic fashion

might be linked to dependence through conditioning and reinforcement especially when these

preparatory actions become associated with drug effect. The ritualistic preparation of areca

nut in its raw form more likely to become a conditioned behavior and cue for continued use.

Later when the use becomes socially integrated, reinforcement might become even stronger.

Purified preparations (commercially prepackaged products) have been reported to be

associated with the potential of obtaining increased levels of drug delivery and blood plasma

levels leading to intense psychoactive effect than traditional preparations. It has been

speculated that purified preparations might lead to a greater likelihood of dependence upon

the constituents of pan masala like areca nut and tobacco etc. The colorful packages and

sweet variety of areca nut products also have been linked into an innocuous route for the

early introduction of tobacco products to children (Winstock, 2002). Some researchers have

argued that human chemical abuse is associated with costs outweighing benefits and

therefore has become maladaptive (Strickland, 2002).

11

Therefore it is important to know the user perceptions of individual habituation,

dependency, and addiction to understand if any public health intervention involving areca nut

chewing is to be undertaken with hope of success. Perhaps analyzing behavior changes from

a social ecology standpoint considering all the pervading socio-economic, cultural, and other

factors would provide the best means of modeling the areca nut chewing phenomenon (Mc

Leroy et. al, 1988).

1.3 Literature review: 1.3.1 Burden of disease:

Diseases caused by areca nut chewing are explained on the basis of effects of areca nut on

the soft tissues and hard tissues in the oral cavity and other parts of the body. Following

lesions and conditions have been documented to be associated with areca nut chewing habits

(Zain et.al, 1998; Eswar, 2002 & Trivedy et. al, 2002).

Effect on soft tissues:

1.Oral cancer

Oral cancer is the eleventh most common cancer in the world and eight most common

cancers in developing countries with approximately 267,000 new cases and 12,800 deaths

annually of which two thirds are in developing countries. India has high incidence of oral

cancer, accounting for one third of the world burden (Gupta et.al, 1998).

:

In south and South

East Asian countries, oral cancer is a major public health problem (Chaudhry, 1999). It is

one of the five leading causes of five leading sites of cancer in either sex (Wu et.al, 2003).

The age standardized incidence rate (ASR) of oral cancer in Bangalore is 6.5 per 1,00,000

and 15.9 per 1,00,000 in Thiruvananthapuram 7.2 in Mumbai, 10.6 per 1,00,000 in Chennai.

Researchers have estimated 75,000-80,000 annually new cases develop in India with only

12

15% of patients diagnosed when disease is at a localized stage (Gupta, Nandakumar, 1999 &

Asian quitline, 2002). 30% of Oral cancers have been attributed to use of betel quid with

tobacco. Along with betel chewing, tobacco smoking produces synergistic effect for risk of

development of Oral cancer. Although combined habits are quite common, they can be

attributed to additional 50% of Oral cancers, around 80% of Oral cancer is caused by tobacco

alone (WHO, Tobacco Alert, 1996). The studies show that risk associated with chewing betel

quid with tobacco is much higher compared to without tobacco (Gupta, Nandakumar, 1999 &

Gupta et. al, 1982).

Studies have demonstrated that “dose response relationship, duration of chewing,

frequency of chewing/day, period of time chewed and retention of quid overnight while

asleep” are important variables in the development of oral cancer (Jacob et.al, 2004; Phukan

et. al, 2001;Gupta, & Nandakumar, 1999). Chewing areca nut wrapped in betel leaf was

seemed to be less of an oral cancer risk than the combination of areca nut, piper beetle

inflorescence, and lime paste (Ko et.al, 1995).

Balaram P et.al (2002) have reported that 30% of Oral cancer is attributable to

combination of smoking and alcohol drinking and 49% to pan –tobacco chewing. Low

educational attainment, occupations such as farmer/ manual worker and poor oral hygiene

were significantly associated with increased risk (Balaram et.al, 2002).

2.Oral Sub mucous Fibrosis:

This Oral Sub mucous fibrosis (OSMF) is a chronic, progressive debilitating disease of

oral cavity and oropharynx, where oral mucosa looses its elasticity and fibrous bands develop

(Gupta et.al, 1998 & Chiang et.al, 2002). OSMF was first reported from India in 1953 and

13

was found only in Indian subcontinents /in Indian immigrants previously, later reported by

other Southeast Asian countries. Incidence in northwestern India is 2.6 & 8.5 per 1,00,000 in

males and females respectively, but in south Indian communities it was estimated to be 9 &

20 per 1,00,000 for males and females (Cox & Walker, 1996). OSMF affects approximately

0.5% (5million) of Indian subcontinent. With immigration from India, OSMF has become

challenging health care problem to many parts of the world (Haque et. al, 2000). Babu et. al

(1996) has reported the estimated prevalence of OSMF in India associated with chewing

areca nut products to be 0.2 –1.2%. The highest prevalence of OSMF is in Ernakulam,

Kerala (0.36%) followed by Bhavnagar district, Gujarat (0.16%). With annual incidence of

tobacco consumption among areca nut chewers and high relative risk of malignant

transformation of OSMF, the researchers have cautioned an increase in the incidence of oral

cancer in the near future (Gupta, Sinor, 1998). OSMF has been reported to develop quickly

among “gutkha” chewers and is evolving, as an epidemic in young adults, as a result there

might be dramatic increase in the incidence of Oral cancer in India in future (Gupta, &

Nandakumar, 1999; Gupta et.al, 1998). OSMF is a permanent condition, which does not

resolve after cessation of the areca nut habit indicating that there is a permanent cellular

change in the affected mucosa (Van, Wyk et.al, 1995). Several epidemiological studies have

proven the association between betel quid with or without tobacco and pan masala chewing

habit and risk of oral cancer and OSMF in India (Hashibe et.al, 2002; Jeng et.al, 1996; Maher

et.al, 1994; Sinor et.al, 1990).

OSMF changes due to ‘Pan masala’ takes approximately half the time taken by quid

chewing (Rajendran & Anila , 2002 & Shah & Sharma, 1998). OSMF severely impairs

eating and oral hygiene care, there may be oropharyngeal involvement causing palato

14

pharyngeal incompetence, deafness and fibrosis within esophagus can cause dysphasia

(Haque et.al, 2000). There is atrophy of epithelium and marked intolerance to spicy food,

burning sensation of mouth, xerostomia, presence of vesicles/ulcers on oral

mucosa/depapillation of the tongue/impaired tongue mobility, leathery and rough mucosal

texture, blanching of mucosa with progressive reduction in opening of mouth. In extreme

cases it may be difficult for even a straw to pass into mouth (Gupta & Sinor, 1998; Chiang &

Hsieh, 2002).

Shah & Sharma (case-control study, 1998) have found that increase masala was

chewed by comparatively younger age group and was associated with OSMF changes earlier

than areca nut / betel quid chewing. Frequency of chewing was directly correlated to OSMF

rather than total duration of the habit (Shah & Sharma, 1998).

Smoking was found to increase carcinogenic potential of OSMF (Merchant et.al, 1997).

Alcohol consumption is considered to be a moderate risk factor and Body Mass Index is

supposed to be inversely proportional to OSMF (Murti et.al, 1990) whereas earlier study

reports did not find any relationship OSMF (Oral sub mucous fibrosis) with tobacco,

lime/chilies (Seedat & Van, Wyk, 1988). There is variation in the characteristics of OSMF

due to differences in the areca nut chewing habits (Bhonsle et.al, 1987). More lesions seen on

the tongue and floor of mouth if areca nut juice is spat out, where as more lesions are seen in

the retro molar area if the areca nut is swallowed. Usually OSMF form at the back of the

mouth and progresses forwards as severity of disease increases. Faucial, buccal and labial

band involvement is reported to be highest in severe compared to mild stage of disease

(Haider et.al, 2000).

15

Habitual chewing of pan masala / gutkha was found to be associated with earlier

presentation of OSMF than betel quid use which may be due to differences in tobacco

content, the absence of betel leaf and its carotenes and higher dry weight of pan masala

/gutkha (Babu et. al, 1996).

3.Oral leukoplakia: Leukoplakia has been defined as a predominantly white patch or plaque

on the oral mucosa that cannot be characterized clinically or pathologically as any other

disease and is not associated with any other physical or chemical agents except tobacco. This

condition is well known for its potential for malignant change and transformation rates

between 0.1 and 17.5 %. Several researchers have documented cessation of areca nut

chewing resulting in resolution of 62% of leukoplakia.

4.Betel Quid lesions: This is characterized by brownish discoloration of oral mucosa. This

discoloration is often accompanied by encrustation of the affected mucosa with quid

particles, which are not easily removed, and with a tendency for desquamation and peeling.

This condition is not considered to be potentially malignant, although it exists with other

mucosal lesions (Trivedy et. al, 2002).

5.Betel quid/areca nut lichenoid lesions: These lesions have been reported exclusively

among betel quid chewers (Zain et.al, 1998). It is found at the site of quid placement in

chewers and may be unilateral in nature (Trivedy et. al, 2002).

6.Periodontal disease: Studies have reported higher prevalence of periodontal disease

among users when compared to non-users of betel quid (Eswar, 2002 & Pradeep Kumar,

1999). Association between smoking and periodontal disease is already accepted, but the

16

association between smokeless tobacco and periodontal disease is still a debatable issue

(Jayakrishnan, 1999).

7.Extra oral diseases: Other than oral diseases, studies have documented significant relation

between betel quid with tobacco and oropaharyngeal cancer, laryngeal cancer and

oesophageal cancers (Gupta & Ray, 2003). It has been reported that the areca nut chewers

also suffer from other health problems like temporary euphoria, giddiness, congested face,

and sensation of heat in the body, which are interpreted as cholinergic effects of arecoline,

the most abundant alkaloids found in the areca nut (Jeng et.al, 1986). Pregnant women who

use smokeless tobacco have been reported to be at three times increased risk of stillbirth and

two – three times increased risk of having low birth weight infant. Previous literatures have

reported that chewing betel quid with or without tobacco among asthma patients might

aggravate the condition by arecholine from areca nut, which is supposed to induce

contraction of bronchiolar smooth muscles by its acetylcholine like actions. (Gupta, & Ray,

2003).

Effect on hard tissues:

1.Dental attrition: The main affects of areca nut chewing are reported to be on the teeth.

The habitual chewing of areca nut might result in sever wear of tooth surfaces, particularly

enamel covering which might further could lead to dental sensitivity (painful condition of

teeth) /root fractures of the teeth.

2.Areca nut staining and dental caries: Among areca nut chewers, extrinsic stains of teeth

due to areca nut deposits are often observed in chewers with minimal oral hygiene practices.

Several researchers have said that chewing might confer a protection against dental caries.

17

Epidemiological studies have found lower dental caries prevalence among chewers when

compared to non-chewers. Apart from these, even temperomandibular joint pathology also

have been speculated to be associated with chewing, but needs further studies for further

confirmation.

1.4 Conceptual context:

Areca nut use has been reported to have a long and adverse history. Some of the

previously discussed factors like individual and community factors (mentioned in the

framework) have been reported to influence the practice of chewing areca nut and tobacco

products (Nichter et. al, 2004; Strickland, 2002 & Asma, 1994). Till now, anthropological

investigations of areca nut chewing practices are in its initial stage (Strickland, 2002). Some

of previous literatures have reported people’s perception about some of the harmful effects

and benefits of chewing (Nichter et. al, 2004; Strickland, 2002), but most of them are related

to use of tobacco products. As there are variations in the time, place, reason, and partners for

chewing, understanding the topography of chewing practices is very important to study

(Nichter et. al, 2004; Strickland, 2002), which could be a useful tool in terms of harm

reduction and disease prevention. Areca nut addiction and habituation has been of great

public health concern among areca nut chewers, but needs to be studied (Winstock et.al,

2000) further to achieve best possible harm reduction and prevention of dreadful disease. The

following diagram1 shows the possible linkages between areca nut chewing practices, and

the diseases.

18

Diagram1: Conceptual framework

:

1.5 Rationale of the study:

Areca nut has been found to be the most popular addictive substance (Burton-Brandly, 1966

& Ko et. al, 2003). Worldwide the burden of oral cancer and precancerous lesions are

increasing especially among South Asia and South East Asian countries and areca nut

associated oral cancer is one of the leading causes of death in these countries (Ko et. al,

2003). The study area has found to be a major producer of areca nut in India. Therefore areca

nut plays multiple important roles in different socio-cultural contexts and economic condition

of the people in the study area (CPCRI, 2004). Previous study from same district reported

that gutkha is becoming more common among agricultural laborers, secondary school

students (Nichter et. al, 2004). Therefore studying areca nut chewing practices here is more

relevant to address existing public health problem.

Individual Factors: Age, sex, religion, caste groups, marital status, occupation, literacy, age of initiation, socioeconomic factors and beliefs about harmful/beneficial effects from chewing.

Community Factors: Geographical variations, Role of siblings, parental influence, cultural practices, and perceptions about harmful/beneficial effects from chewing, role of stakeholders, market force.

Oral cancer/ Precancerous lesions

Areca nut chewing practices

Addiction/ Habituation

Topography of areca nut

chewing

19

1.6 Objectives of the study:

I. To document the range of areca nut chewing practices in rural and urban communities in

Dakshina Kannada district.

II. To investigate perceived benefits and risks of chewing different areca nut products among

users.

III. To measure levels of addiction among areca nut chewers using Fagerstorm scale and

correlate levels of addiction with cancerous and precancerous lesions.

IV. To investigate and describe the topography of some of the areca nut chewing practices

which are more likely to result in development of cancerous and precancerous lesions than

other areca nut chewing practices.

20

Chapter – II

2.Methodology: 2.1 Research Design:

This is an investigative qualitative study using flexible and innovative methods to gather

data about the breadth and depth of areca nut chewing experiences among users in Dakshina

Kannada District, Karnataka State, India.

2.1.1 Research strategies:

The selected subjects were interviewed using structured inquiry followed by semi

structured open-ended interview, observation, and a clinical examination. The researcher is a

dentist. He interviewed all respondents as well as conducted oral examination. Interviews

were tape-recorded.

2.1.2 Research setting:

The area of study ‘Dakshina Kannada district’, Karnataka (appendix – I) has a population

of 1.9 million (Males-0.94 million & Females –0.96 million) (Census of India, 2001). The

study area has been described as demonstrating a wide range of patterns of betel quid

consumption, both with and without tobacco (Nichter et. al, 2004). The data collection of the

study was conducted in a rural as well as urban settings form January 1st to March 30th, 2004.

2.2 Sample selection:

Key informants selection:

Ten key informants were chosen from different areas covering a range of age groups. Key

informants were young, middle age and older male and female chewers, gutkha chewers, a

betel seller, a shop owner who sells prepackaged betel etc. The aim of key informant

selection was to gather as heterogeneous a sample as possible in order to gather widely

21

differing perspectives in patterns of use as well as on the social and health ramifications of

betel chewing etc.

Respondent’s selection: Non-randomized purposive sampling method was followed. Totally 90 respondents (78

males and 12 females) ranging from 7- 78 years of age were included in the study. Key

informants were used to guide in selection of subjects. Subjects from both urban (n=15) and

rural areas (n=75) were included in the study.

2.3 Operational definitions:

Quid has been defined as “ a substance, or mixture of substances, placed in the mouth or

chewed and remaining in contact with the mucosa, usually containing one/both of the two

basic ingredients, tobacco or areca nut, in raw or any manufactured or processed form”.

Betel quid is a specific variety of quid i.e. any type of mixture or quid that includes betel leaf

(Zain et. al, 1998).

Mixed tobacco use is the use of multiple products with combination of any areca nut

products with any tobacco product.

Mixed areca nut use is a use of multiple areca nut products without tobacco.

Ever user of tobacco is a one who used either snuff/ smoke form tobacco during any time in

his life.

Never user of tobacco is a one who never used either snuff/ smoke form tobacco during any

time in his life.

Addiction is a term used to describe an uncontrollable compulsion to repeat a behavior

regardless of its negative consequences.

22

Habituation: It is an example of non-associative learning in which there is a progressive

diminution of behavioral response probability with repetition of a stimulus (Word IQ, 2004).

Traditional healers: They are non-trained treatment providers in the community who follow

Ayurvedic /herbal system of medicines.

Less than fully qualified practitioner (LFQP): They are unqualified treatment providers.

Stake holders-Agriculturists, teachers, pan sellers and shopkeepers, areca nut association

fellow, political leaders, traditional healers and less than fully qualified practitioners and

doctors (dentist, general surgeon, ENT surgeon, general practitioners).

Erythroplakia: WHO defines erythroplakia, as ‘It is a clinical term used for lesions of the oral

mucosa and describes a bright red, velvety plaque which cannot be characterized by

clinically or pathologically as being due to any other condition’. It is an early sign of a

symptomatic oral cancer especially in high-risk people (heavy smokers, drinkers) and high-

risk areas.

Periodontal disease: Its most common clinical manifestation includes ‘periodontal pockects,

bleeding gums, gingival recession’ (Prabhu et. al, 1992).

2.4 Study instruments:

Structured inquiry in to patterns of use, unstructured open – ended interview, observation

of use, and oral examination method was followed in the study. A checklist (shown in

appendix III - table1) was used as a guide to probe details during the study.

23

2.5: Description of method of data collection Key informant interviews helped to develop a semi structured interview format.

Following an interview probing their patterns of use (how much, how often), a Fagerstorm

Tolerance Questionnaire (appendix-III) was administered to measure dependency,

perceptions of areca nut chewing benefits and harm as well as related issues like perceptions

about addiction/habituation were also explored. In the present study, the questionnaire has

been slightly modified after pretesting. The interviews were conducted in three local

languages (Kannada, Tulu, Havyaka) as per the language spoken by the respondents. The

interviewer had good command in speaking all the three local languages in the study area.

Since areca nut chewing is an important public health issue, it was critical to include a

few stakeholders in this study. Totally 17 possible stakeholders were identified and

interviewed in the study. Stakeholders included in the study were ‘two areca nut farmers,

areca nut association president, one local political leader and teacher, five pan sellers and

shopkeepers, four doctors (dentist, general surgeon, general practitioner, Ayurvedic doctor),

two traditional healers, and a less than fully qualified practitioner (LFQP) in gathering their

impressions of and experiences with chewers and chewing practices.

2.5.1 Ethical Issues:

Respondents were explained the purpose of the study and assured confidentiality of the

reports. Verbal informed consent was sought form the respondent’s prior to initiation of the

interview.

24

All the recorded interviews were first translated to Kannada (official language of the

state), later they were translated into English without distorting the richness of the qualitative

data. After transcription, the interviews were again read and corrected to maintain internal

validity. These transcribed interviews were entered in MS Word to get a clear data for further

analysis. Later, the interviewer himself read these transcribed interviews exhaustively to get

the ‘emergent themes’. Care was taken to maintain the richness of information given by

respondents and also to avoid introducing bias into the analysis. Assistance was taken by the

experts to confirm the analytic emergent themes from the interviews. ‘Thematic analysis’

was done manually. The researcher himself performed coding and recoding of the

interviewee responses. These coded interviews were pooled together under emergent themes

for further analysis. Each response under each theme was again coded to locate similar and

variant responses. Wherever relevant, frequencies and percentage of each response were

noted and were linked to research context. Fagerstorm scale was used to analyze addiction

levels (appendix- III). Each question with yes /no were coded and total scorer for each

respondent was calculated.

2.6 Analysis of data:

25

Chapter – III

3.Results:

3.1 Characteristics of respondents:

The demographic characteristics of the informants have been summarized in table 2. In

the study, 73.3% (n=66) of subjects were Hindus and others were Muslims. Among the

respondents, 48.9% were married and 44% unmarried, and others were divorcee/widows.

Among the respondents, 71% were found to chew areca nut products with tobacco

whereas others chew areca nut products without tobacco (table 5). 70% of the respondents

never used of smoke form tobacco whereas others were ever users. 87.8% of them never

users of snuff and only 12.2% of them ever used snuff whereas 23.3% of them also found to

drink alcohol.

Table 2: Sociodemographic factors of the study respondents Demographic characteristics n (%)

Caste groups SC/ST’s 7 (10.6) Lower Caste 37 (56.1) Other castes 22 (33.3)

Literacy status Illiterate 11 (12.2) Primary 38 (42.2) Secondary 22 (24.4) Graduate/post graduate 19(21.1)

Occupation Daily wage workers 26 (28.9) Farmers 13 (14.4) Students 30 (33.3) Others 21 (23.3)

Age group (Years)

<20 30 (33.3) 21-40 28 (31.1) >40 32 (35.6)

26

3.2 Perception and beliefs about chewing:

Type of product

3.2.1 Utility of chewing:

Majority of the respondents (n=62; 69%) have the belief that chewing has some kind of

beneficial effects. The most common responses about beneficial effects from chewing have

been summarized in table 3. The most common uses reported with betel quid with tobacco

were ‘it gives taste (16.1%), gives pleasure to the mind (11.29%), good for tooth pain

(23.19%), good for enjoyment and to get ‘kick’ (11.29%), prevents tastelessness in mouth

(6.4%), strengthens the teeth, helps to evade boredom, good for time pass (4.8%) or some

even chew to avoid sleep. ‘Betel quid without tobacco’ helps in digestion and good for

stomach, some people (4.8%) think that areca nut gives ‘good taste (23.19%), prevents baayi

vaasane (bad odor from the mouth), cleans the teeth' (8.06%). There is also an opinion that

areca nut has got good smell, good for ‘hallu’ (teeth), cures diabetes, increases appetite, has

got ‘virechana shakthi’ (power of motivating sexual activity), it is a stimulant and also good

for ‘aarogya’ (health).

Table 3: Shows beneficial effects of each ingredients used in chewing as perceived by study subjects.

Beneficial effects (n=62) Betel quid with tobacco

It gives taste, for enjoyment and to get ‘kick’, gives pleasure to mind, good for tooth pain, strengthens the teeth, good for time pass, helps to evade boring.

Betel quid without tobacco

It has ‘Jeerna Shakti’ (digestive power), helps in digestion and good for stomach.

Areca nut Gives good taste, cleans the teeth, prevents bad odor from mouth, it has got good smell, good for teeth, cures diabetes, increases appetite, has got ‘virechana shakthi’ (power of increasing sexual activity), it is a stimulant and good for health.

Betel leaf It has got good smell, prevents bad smell from mouth, has got ‘Jeerna Shakti’ (digestive power) and betel leaf with salt is good for ‘hotte bene’ due to ‘huluvina thondare’ (worm problems).

Gutkha It gives ‘kick’, gives good ideas, and helps to work. Some of the gutkha chewers think that gutkha gives them ‘kick’ as well as shakthi

(power) / good ideas to work. A gutkha chewer explains ‘Whatever I take, I should get ‘good

27

kick’ (olle kick sigbeku). I get good ideas to work if I take either ‘Maruti (gutkha) or snuff

(hudi)’. A school student says ‘sometimes I get pleasure (khushi) when I chew, but sometimes

I feel frightened as I am chewing at very early age’ whereas a retired schoolteacher tells ‘If

there is a bad habit, it makes positive changes in mind. I get psychological benefit to do some

work’. Some participants think that those who chew betel quid, can also chew ‘apple and

sugar cane very easily’. Majority of stakeholders during the interview had the opinion that

areca nut chewing has got more benefits than harmful effects except for doctors (dentist,

general surgeon, general practitioner) who think that any type of chewing does not have any

benefits (shown in appendix II - table 1).

Thaamboola (pan) is considered to be an important part of any religious functions

(Nichter et. al, 2004; Winstock, 2002), engagement ceremonies and offering thaamboola

(pan) to god and use in religious functions is also an integral part in any rituals in the study

area. One of the senior farmers says ‘there are several varieties of veelya (another name for

pan, where they keep only betel leaves and areca nut) which are linked to several social

values such as ‘veelya’ given before taking any responsibilities’. When Ayurveda doctor and

Traditional healers were interviewed, they reported that there are different types of

thaamboola (pan) indicated for different therapeutic conditions. They advice people to chew

2-3 times daily after having food to improve oral hygiene and they consider betel quid

without tobacco to be good for health. They recommend that it is good to chew after having

food.

28

Table 4: Shows perceptions of study participants about harm from chewing of different areca nut products:

3.2.2 Perception about harm:

Over all, 31% (n=28) of the respondents had the opinion that chewing is harmful to

health. When the question was asked about the health problems from chewing of different

areca nut products, there were multiple responses from respondents. Some of them said that

chewing betel quid with tobacco or gutkha ‘is bad/it causes problem, causes giddiness’. Only

4.4 % think that either betel quid with tobacco /gutkha causes ‘cancer’. Some even had the

opinion that it is the ‘tobacco’, which is bad among the ingredients of pan. Other problems

narrated by participants have been mentioned in the table.

Type of product

Problems reported

Betel quid with tobacco

(n= 90)

It is bad/it causes problem (27.8%), Causes giddiness (14.4%), causes ‘cancer’ (4.4%), causes weakness, decreases appetite, causes vomiting, weakness, causes breathlessness, ulcer in the mouth, certain varieties of tobacco causes tremors in the body, decreases digestion and taste, increases salivation, difficulty to pronounce words, increases heart rate, increases fear, headache, increases body temperature, tongue becomes thick, feel something bad in the mouth (14.4%).

Gutkha It is bad/it causes problem (25.6%), causes giddiness (14.4%), causes ‘cancer’ (4.4%), gutkha causes weakness, ulcer in the mouth, decreases memory power, decreases taste and hampers digestion, causes tremors in the body especially in hands and legs, tastelessness in mouth, breathlessness, headache and hiccoughs, peels off ‘nidhi’ (gums), spoils the teeth, increases thirsty, removes skin from mouth, causes difficulty in opening the mouth, bad smell, difficulty to have hot/spicy food, stains the teeth, causes ‘holes’ in the check/jaw, danger for tongue, decreases blood level in the body and stamina, dryness in the throat, burns the mouth, causes nerve problem causes burning sensation in mouth, impotency (23.3%).

Areca nut

Causes giddiness (10%), increase sweating (4.4%), makes ear and face red and other body parts, increases body temperature, vomiting, causes problem if taken more, weakness, bad for liver, causes burning sensation in the body (7.8%)

Betel quid without tobacco

Giddiness, sweating, ear becomes red and if lime is more, it burns the mouth (4.4%)

Among the 90 respondents in the study, majority of them had the opinion that betel

quid without tobacco, areca nut and scented sweet supari does not cause any health problems.

Only few respondents had the view that either mava/khaini is bad for health. A farmer

29

describes, “ They say that ‘ele, adakke, hogesoppu’ (betel leaf, areca nut, tobacco -he refers

to betel quid with tobacco) causes ‘Cancer’, but till now I have not heard anyone suffering

from ‘cancer’ due to chewing. This ‘hogesoppu’ (tobacco) gives so much of ‘attraction’ that

it makes us to forget the ‘hedarike’ (fear) that it causes cancer”.

3.2.3 Perception about addiction/habituation:

It was very important to know how the chewers perceive about addiction and

habituation, as these can carry greater implications when some public health interventions are

planned. During the ethnographic interviews, some of the addicted people felt that chewing is

just a habit. As one addicted student describes ‘If I see someone chewing, I also feel like

chewing. It is just a habit’. There is also a common opinion among the study participants that

addiction is mainly because of tobacco. A women explains ‘When I was complaining of

‘hallu bene’ (tooth pain), they (her parents) use to tell me to keep ‘hogesoppu’ (tobacco), so

later it became an ‘abhyaasa’ (habit) for me. Even I have several times tried to use

alternatives, but still I could not quit eating ‘hogesoppu’ (tobacco) till now’. One of betel

chewer says ‘this is a chata (addiction). If I want to eat ‘ele adakke’ (he refers to pan), I will

not hesitate to ask from anyone, because I need that very badly at that time’.

The stakeholders in the community have the view that ‘Initially people start chewing on

special religious occasions, later it becomes a habit for them’. Some of them explained that

‘although people know that chewing tobacco/gutkha is harmful they cannot avoid eating! It

is a chata (addiction), so it will be difficult for them to quit’.

30

3.2.4 Perception about Normal dose/harmless chewing:

Most of the respondents and stakeholders have the view that chewing betel quid 3-4

times /day may not cause any problem to health whereas some consider chewing gutkha even

once a day to be harmful. A betel chewer says ‘Now I am eating 10 times daily. It is more,

but I feel eating 3-4 times daily will be good’.

One traditional healer says that ‘Chewing half adakke (areca nut)/day may be

sufficient /normal. It also depends upon environmental condition. Here chewing one adakke

(areca nut) / day may be more /excessive, but in places like Gujarat, they chew 3-4 adakke

(areca nut)/day but nothing happens to them. Whatever may be the type of chewing habit they

have, I feel that if they chew within limits it may not cause any problem to them’.

General practitioner describes ‘ See my father is in his 60’s, he must have been chewing

since 20-30 years, but he chews very limited number of times. He takes very limited quantity

of tobacco. Till now nothing has happened to him.’

Totally there were 29% (n=26) participants chewing areca nut products without tobacco

whereas other 71% (n=64) of them chew with tobacco (shown in table 5). Interview with

3.3 Patterns of areca nut chewing:

Mainly seven varieties of areca nut products were used for chewing in the study area.

Some of the chewers were found to use more than one combination of areca nut products

daily. These types of respondents were grouped under mixed tobacco use or mixed areca nut

use. The mixed tobacco use category includes use of any tobacco products along with other

areca nut products whereas mixed areca nut use includes chewing any of the combinations of

areca nut products without use of tobacco. The table 5 shows the different chewing practices

among the respondents of the study.

31

stakeholders revealed that chewing areca nut product with tobacco is more popular than

chewing without tobacco. Among the different areca nut products, gutkha and scented supari

are readymade preparations available in the form of sachets whereas others are prepared

freshly just before the consumption. It was found that there are individual differences in the

way different areca nut products consumed in the study area.

Majority of stakeholders in the community think that now traditional chewing practices

are decreasing whereas non-traditional chewing practices are increasing, especially among

the youths. Majority of them even feel that youngsters, college students, coolie workers,

drivers, mechanics, conductors, professionals are reported to chew more gutkha, whereas

older and middle aged people chew mainly betel quid. Even though, most of small children

primary /secondary school children chew sweet scented supari, some of school children also

reported to chew ‘gutkha’.

According to them, women chew comparatively lesser than men. Women usually chew

betel quid with tobacco, as they always prefer red lips. One senior farmer explain ‘ladies in

village side prefer to eat beeda (pan), because they do not have free hand to purchase and no

pocket to keep’. Majority of the stakeholders felt that lower income group chew more

Table 5: Type of chewing among the study participants.

Sl.No Type of chew Total n (%) 1 Betel quid with tobacco* 27 (30) 2 Betel quid without tobacco 8 (8.9) 3 Only Areca nut 5 (5.6) 4 Gutkha* 12 (13.3) 5 Scented Supari 8 (8.9) 6 Mixed tobacco use* 25 (27.8) 7 Mixed areca nut use 6 (6.7)

Total 90 (100) 1 Areca nut product with tobacco 64 (71) 2 Areca nut product without tobacco 26 (29)

Total 90 (100) * These areca nut products contain tobacco.

32

compared to other groups. Chewing is reported to be more common among Hindus than the

Muslims, whereas smoking is more among Muslims than Hindus especially in villages.

In the study, almost every shop keeper/pan seller interviewed was selling at least three

varieties of gutkha in their shop. Short discussion with shopkeepers revealed that there is

transition in use of smoke form tobacco to smokeless form in the study area especially

modern readymade consumables. One of the shopkeeper says ‘All those who were smoking,

now they get kick with gutkha. So they don’t smoke now’. Among the several chewing

products, most commonly sold items in their shop was Maruti, Star (brand names of gutkha),

Madhu (Khaini).

Usually it is common to see ‘ele thatte/ire thattte’ (pan plate) in the houses of betel

chewers. In this ‘ele thatte/ire thattte’ (pan plate), the raw materials will be kept for areca nut

chewing. Most often, higher income group people carry a ‘betel box’ whenever they travel

whereas people from lower income group carry the raw materials in a plastic, which

popularly called as ‘ire thotte/ele thotte’ (pan plastic) and keep the pan within the fold of

their lungi (lower dress). As a first part of quid preparation, they cut one areca nut into 8-12

pieces depending upon the size of the areca nut. Most of the time people have special scissor

to cut the areca nut called ‘edakkathari’ in their house. Betel quid chewers first chew areca

nut pieces, then select a proper, fresh betel leaf. There is a belief in the study area that upper

stalk portion of the leaf is poisonous whereas ‘goddess’ exists in lower tail portion of the

leaf. Therefore elder people do keep the removed lower tail end portion of the leaf on their

right or left sides of their forehead and throw away the stalk portion of the leaf. Later they

clean the leaf by rubbing on the back of their forearm and apply a pinch of lime to the

backside of each betel leaf and fold it roughly into a small rectangular shape so as to

3.3.1 Pattern of quid preparation:

33

accommodate it inside their mouth. Then sometime after keeping the quid in mouth, they add

little amount of tobacco leaf in their mouth to continue chewing. Among the respondents

majority (43.3%) of them prepare the quid this way (Type1) whereas some people do chew

pan by keeping the areca nut inside the betel leaf applied with lime (Type 2). Usually the

quid kept inside his mouth was visible as a ‘prominent bulge’ from their ‘cheek’ externally.

Among the respondents, those who do not have the teeth crush the areca nut and betel leaf

with lime to make it into very smaller fragments before they chew (Type 3). Among gutkha

chewers, some of them (50%) did not remove the powder from the packet before chewing

(Type 1) whereas others removed the powder part from the packet before chewing (Type 2).

3.3.2 Keeping the quid in mouth:

Totally 47 (52.2%) people reported to keep the quid in their mouth. When the question

‘why do you keep the quid in your mouth?, (n=47) was asked among those who keep the

quid in mouth, the responses were ‘just for taste (36.1%), for tooth pain (17%), to prevent

tastelessness in mouth (10.6%), just for keep chewing/to get ‘kick’ (6%). Other reasons

reported by the respondents (4.2%) include ‘it is a habit, to enjoy the taste of it, to get good

mixture of the quid, for getting drowsiness, to avoid sleep, feel happy, good for chewing, to

gives interest to work’. Some off them felt that they could work fast if they chew. Few of

them reported to keep the quid in their mouth as they find it difficult to spit outside when

they got to town/travel somewhere. One of respondent says ‘that is just for ruchi (taste), one

kind of rasa (liquid) comes from that paaka (mixture of quid).

34

3.4 Initiation of chewing:

3.4.1 First areca nut product used while initiation:

There were varied responses to the question ‘what were you using when you initiated

chewing habit?’ 24.4% of informants responded to have used betel quid with tobacco when

they started chewing whereas others used betel without tobacco (25.6%), scented sweet

supari (21.1%), gutkha (16.7%), and areca nut (12.2%) whereas only one person reported to

have initiated chewing with mava. The table 6 shows different areca nut products used by

different age groups during the initiation of chewing.

Table 6: Use of areca nut products during initiation among different age groups:

When question ‘why did you start chewing?’ was asked among the respondents, most

common reason for initiation of chewing (32.2%; n=29) was found to be ‘by seeing friends

or friends gave me’. A gutkha chewer explains ‘I started chewing just because of my

‘Friends’, if one person takes it, other person also starts taking it’. According to 20% (n=18)

of study participants, they started chewing just to control tooth pain. A housewife said

‘previously I had kooli bene (tooth pain) and even I had kooli otte (holes in the teeth). So all

of them (refers to her colleagues and friends) told me to start chewing as it is good for kooli

bene (tooth pain). Initially I used to take without ‘pugere’ (tobacco), later I started taking

‘pugere’ (tobacco) as it relieved my ‘kooli bene’ (tooth pain) immediately.’ Although some

3.4.2 Reason for initiation:

Age group (Years)

Different types of chewing practices n (%) Betel quid with tobacco

Betel quid without tobacco

Gutkha n (%)

Only Areca nut

Scented Sweet Supari

Mava Total

< 20 - 2 (6.7) 5 (16.7) 4 (13.3) 19 (63.3) - 30 (33.3) 21- 40 7 (87.5) 6 (21.4) 13 (46) 1 (3.6) - 1 (3.6) 28 (31.1) >40 15 (46.9) 15 (46.9) - 2 (6.2) - - 32 (35.6) Total 22 (24.4) 23 (25.6) 18 (20) 7 (7.8) 19 (21.1) 1(1.1) 90 (100)

35

of the stakeholders reported that betel quid is given to post partum women as medicine, there

were no sex differences in the reasons for initiation of chewing among the study respondents.

Some of them (14%) explained that they started chewing just because ‘someone gave them’

and ‘to control bad smell from mouth’ (12%). Other reasons (21.9%) reported were to stop

smoking, for fun, by seeing others, as medicine for diabetes, for time pass’. Most common

reason for chewing among youths was related to ‘friends’ whereas among middle aged and

elder participants, it was ‘tooth pain and bad smell from the mouth’.

3.4.3 Person introduced chewing:

There were different responses to the question ‘Who introduced chewing to you?’. 30%

(n=27) of them reported that their friends introduced them for chewing. Friends either

directly have told the respondents to chew or some of them started chewing by seeing their

friends. Other responses were ‘myself by seeing others (30%), parents/family members

(27.8%), relatives and others (7.8%), colleagues (6.7%)’. Some of the respondents thought

that it was just for interest for them to chew by seeing others.

When question asked on quantum of items used in each chew among chewers, there

were different responses among the study participants. The table 7 shows details about

quantity of ingredients used in chewing. The betel leaves were classified uniformly based on

observation and report from respondents. In the study, tobacco leaves were measured using

metallic measuring scale whereas areca nut and lime used for the chew was measured using

micro weighing scale. Apart from the listed items, some of the chewers also use cardamom,

clove, and pepper along with their chew. Usually gutkha/scented sweet supari chewers use

one packet every time when they chew.

3.5 Quantum per chew:

36

3.5.1 Quantum of areca nut used per day:

There are individual variations in the quantity of areca nut consumed among chewers. It

was found that 34.6% of areca nut/betel quid chewers use more than one areca nut per day,

28.8% of them use half to one areca nut /day whereas 36.5% of them use less than half areca

nut /day in their chew. Chewers usually consume areca nut based on the size of the areca nut.

If it is a smaller piece they consume two areca nut pieces or if it is a bigger piece, they

consume one piece of areca nut (appendix II- table 5).

In response to the question ‘what are the different varieties of areca nut do you use

while you chew?’. Majority of the respondents reported to use ripe areca nut (53.3%) or

dried areca nut (21.1%) and some of them also reported to use fermented areca nut (35.6%)

in their chew, but other chewers use other processed varieties of areca nut (25.5%). Since the

study area is the main grower of areca nut, ripe areca nut is available during all the seasons

except in rainy seasons. So most of the people consume fermented areca nut during this

season. Usually people soak the ripe areca nuts inside a big pot filled with water before the

3.6 Type of areca nut used in the chew:

Table7: Shows quantity of ingredients used in each chewing Type Quantity Number of

persons Percentage

Betel leaf Half 2 2.2 One -two 30 33.3 > Three 13 14.4

Areca nut pieces~

One 40 44.4 Two 11 12.3 > Three 8 8.9

Tobacco <1cm 4 4.4 >1cm 32 35.6

Lime* < 1 Pinch 34 37.8 >1 Pinch 12 13.3

~ One areca nut piece is approximately measures 1.5 gms Tobacco is measured in centimeters.

*One pinch is approximately equals to 400-500 mgs.

37

start of monsoon. These soaked areca nuts will be inside the pot for several days to months

and they will be used for consumption till new fresh ripe areca nut is available. Usually these

fermented areca nuts will have very bad smell. Therefore some people also store areca nuts

inside the sand to prevent the bad smell.

Further question was asked about the reason for using the different varieties of areca nut

mentioned above, the most common reasons for chewing ripe areca nut was found to be ‘it

has good taste, dried areca nut is difficult to chew and ripe one is easy to chew, it has got

sweet taste, available all the time, fermented areca nut has got bad smell. Some say that ‘ripe

areca nut gives good kick when chewed with tobacco, gives good taste to quid’. Few of the

respondents on the rural areas think that ripe areca nut makes the mouth red, prevents tooth

pain whereas dried areca nut burns the mouth if chewed with pan.

Those who use dried areca nut say that ‘it has got better/more taste, stays longer time in

mouth, matches well with Zarda/pan which are available in pan shops, hard ones are good for

chewing, increases strength of the teeth, ripe areca nut causes ‘giddiness’. Fermented areca

nut is used by some of the respondents during rainy season approximately for three months,

as they don’t get others varieties during this time. One person says ‘hannadike (ripe areca

nut) has got good ‘ruchi’ (taste) and it gives ‘Olle kick’ (good kick) when chewed with

‘kuniya hogesopu’ (Kuniya hogesopu is a variety of tobacco leaf). One businessman says ‘If

I take ‘hannadakke’ (ripe areca nut) feel as if some heavy weight is kept over my head.

‘Baayi ondu tharaa aavuttu’ (I feel something in my mouth), but ‘dried’ does not cause this

problem!

3.6.1 Reason for using a particular type of areca nut:

38

Timing of chewing

3.7 Place, Partner, Time for chewing:

When question ‘Where do you usually chew?’ was asked, there were multiple responses

among 90 respondents. Majority of them reported to chew at home (n=59; 65.6%), while

working (32.2%), at/near shops (23.3%). Usually students reported to chew ‘at/near college

(11.1%), at school (8.9%), while playing, while going home, after coming out of their house,

at hostel, while talking bath, while seeing cinema/TV programs (6.7%)’. Other places of

chewing (15.6%) reported were ‘when going for hunting animals, at friends shop, at some

functions, at relatives house, at office, while coming from work, at free time, when going for

a walk’.

Even there were multiple responses to when the question ‘With whom do you usually

chew?’ was asked to know about the partners for chewing among the study participants.

73.3% (n=66) of the informants reported to chew ‘alone, along with friends (67.8%), with

family members (8.9%), with parents (4.4%) whereas others (4.4%) reported to chew along

with relatives, colleagues and workers’. Apart from these, timing of each chewing was

explored during the ethnographic interview. Maximum proportion of chews were seen in

between 8 AM – 6.00 PM (table 8). A person can chew at different time intervals. Therefore,

there is even over lap in timing of chewing among the respondents.

Table 8: Duration of chewing and Proportion of chewing (n=90)

Proportion of chews 5.30AM- 8.00AM 41.1 8.00AM- 1.00PM 82.2 1.00PM- 6.00PM 87.8 >6.00PM 66.7

Stakeholders in the community also had the same opinion as respondents regarding the

timing and place for chewing. They think that it is more likely that people will chew if their

parents are also chewers. A General surgeon says ‘Usually chewing depends upon their work

39

culture. Drivers and cooli workers keep on chewing as they feel like chewing. But

government employees/salaried people chew only during break time. Usually people chew

after having any food/drinks or if they attend any religious functions’.

Table 9: Different reasons for chewing (n=90)

3.8 Reasons and influences for chewing:

The following table shows different responses to the question ‘What are the reasons for

chewing?’. Multiple responses were possible from each respondent to the above question.

41.1% (n=37) of them reported that they just feel like chewing immediately after having any

food/drink, to prevent tastelessness in the mouth (37.8%) etc. One of daily wageworker

describes ‘I have to eat as soon as I get up in the morning. It is abhyaasa (habit). It helps me

to go to toilet. If I chew when I am working, I get shakthi (energy) to kelesa (work).

A farmer narrates ‘When I get some ‘aalochane’ (thoughts), I feel I am missing

something, same time I will get ‘ele, adakke’ (betel leaf, areca nut-he refers to pan) to eat

and my ‘kelasa’ (work) will be a ‘success’.

Reasons for chewing (%) Feel like chewing immediately after having any food/drink 41.1% To prevent tastelessness in the mouth 37.8% It is an habit 20 Just for time pass 17.7 It has got more taste 14.4 Helps to go to toilet 10 Before starting work/going for work 10 For fun 8.9 Just for enjoyment 7.8 To relive tension 6.7 For preventing bad smell from the mouth 6.7 For preventing tooth pain 6.7 Good to chew during work 5.6 Others 22.2

Other reasons reported were ‘just for interest, chew whenever feel like chewing, helps to

digest food, chewing gives taste, helps to get some ideas, by seeing another chewer/relatives,

40

it makes mouth red, it is temptation, gives pleasure to the mind, helps to work, as medicine

for diabetes, to prevent bad ‘jollu’ (saliva), for cleansing the hallu (teeth), by seeing others, to

get ‘kick’, helps to focus and evade boring, to avoid sleep (22.2%).

One of the gutkha chewers says ‘If I eat, I get pleasure (khushi) to my mind. If I am

tensed, it reduces my tension. I started eating just for interest, by seeing others I also wanted

to chew’. Another gutkha chewer says ‘It is very easy to get, no procedure is required to eat’.

Some of the respondents even felt that modern preparations have certain advantages when

compared to traditional pan. They think that betel chewing is more traditional and makes

their mouth red, and they find it difficult to carry around the traditional pan.

A respondent explains the relation between pan chewing and culture ‘this thaamboola

(pan) culture was present since ancient civilizations. There is no religious function without

thaamboola (pan) here. So even Devaru (God) eats, why people should not eat? During

special religious days like Vishu/Ugadi (new year days for Hindus), it is a culture among

Hindus that one should eat thaamboola (pan) that day which is offered to Devaru (God)’.

When reasons for chewing with others (refers to with friends, relatives etc) was

explored, majority of the respondents reported that ‘I take when I see anyone taking’ (n=62;

3.8.1 Reasons for chewing ‘when alone and with others:

Further reasons for chewing when alone and with others were explored to know

possible specific reasons so that effective public health interventions could be targeted to

address these issues, but most of the reasons for chewing ‘when alone’ was found to be

almost similar with previously explained reasons for chewing, except some of them said that

‘I just feel like chewing when I see ele thatte (pan plate)’. According to some, chewing when

alone helped to focus and evade boredom.

41

68.9%), ‘they offer me’ (47.8%), ‘to give company to friends/relatives’ (5.6%). Other

reasons reported were ‘I feel like taking whenever I go to angadi (shop)’, just for interest

(4.4%). A gutkha chewer says ‘ I chew more, if I am along with my friend. When they

purchase, by seeing them, I also purchase’.

There is tradition in the study area that if any guest comes to their house, they offer

them pan for chewing as other food items. A betel chewer explains ‘If someone comes to our

house, if I know that they also eat, I prepare ‘ele’ (betel leaf-he refers to pan here) for them

and I also take. It is a kind of ‘atithi satkaara’ (culture of treating guests) whenever guests

come to house, according to our ‘paddati’ (tradition)’.

3.8.2 Social Influence for chewing

When the question ‘Does any of your family members chew?’ was asked to probe

familial inheritance of chewing, total 64 respondents (71.1%) have said that their parents

/family members chew. One of the informants says ‘my parents use to eat ‘ele, adakke,

hogesoppu’ (betel leaf, areca nut, tobacco- he refers to pan with tobacco here)’. They were

chewing till their death’. One of second standard student describes “My father tells me to

chew adike (areca nut) whenever I have hallu bene (tooth pain)’ whereas another betel quid

chewer said ‘Initially I had severe hallu bene (tooth pain), so my mother told me to start

taking ‘hogesoppu’ (tobacco)’. These findings look to be in consistent with previous studies

:

When question ‘any one of your friend has chewing habit?’ asked among the

respondents, majority of them reported that their friends (n=74,82%) also have one /the other

chewing practice. During the interview, it was very common to see a group of people with

chewing habit. When the above question was asked among the students, they usually referred

their friend’s names in their group.

42

where they had reported about the adults advising their children/non users to chew for-

therapeutic purposes (Gupta & Ray, 2003).

3.8.3 Social pressure:

When question was asked to explore possible social pressures for chewing, 63.3%

(n=57) of responses were ‘I eat more if I attend any kaaryakrama (function)/ jaatre

(festivals). Some said that ‘If I attend maduve (marriages), bacchire, bajjeyi (betel leaf, areca

nut-refers to pan here) will be kept there, therefore I take’ (46.7%), ‘if I attend yakhshagaana

(over night drama), I will eat more to avoid the sleep’ (31%). A daily wageworker explains

‘In case if I attend any of functions, they will ask me ‘onji bacchire paadgonaandu? (Shall

we take one pan?). ‘bukka dettonaande sariyaapujji !’ (Then it is not proper for me not to

chew!)’.

Chewers especially in rural areas say that they chew if they attend religious functions

(16.7%) like ‘bhootha kola’ (a festival for spirits), korida katta (cock fight). Students

(15.6%) often chew more if they go to cinema. A college student narrates ‘I don’t chew if I

go to marriages especially if my parents are present there. If I go to cinema/college day

function/any other functions or even jaatre (festivals), yakshagaana (overnight drama), I

chew whenever I feel like chewing’.

A rickshaw driver says ‘Actually I feel that I should not eat this, but if one of my friends

takes, I get courage and support (dhairya baruttade, support siguttade), and so I take that’.

Information’s about variations in chewing practice especially ‘when the chewers tend to

chew more’ are very important in public health context so that future public health messages

could be designed accordingly. Responses to question ‘When do you tend to chew more than

3.9 Variations in chewing practice:

43

usual?’ has been summarized in the table (appendix II – table 2). The responses for this

question was found to be almost similar to previous descriptions mentioned earlier, except

that some of the respondents reported to chew more during rainy/winter season, because it is

common practice in the study area that people tend to chew to keep themselves ‘warm’

during rainy season or winter season.

One of the respondent says ‘if I am free and don’t have any work, chewing will be the

only work for me’. Other reported occasions (appendix II - table 2) where they tend to chew

more includes ‘after having food, during tooth pain, during religious functions/holidays,

when thinking about some issues/if sleep is disturbed in the night, along with relatives, while

watching cinema/drama’. Students also tend to chew more during exams, while reading,

while playing or whenever they go to see movies.

Majority of the stakeholders in the study had almost same opinion as the respondents of

the study regarding health problems related to chewing of areca nut products. They strongly

believe that harm caused due to betel chewing is due to tobacco. Although majority of them

3.10 Respondents self reporting about problems from chewing:

Out of 90 respondents in the study, 58 (64.4%) of them had reported to have one or

more problems. Among these 44 (75.86%) of them complained of burning sensation in their

mouth after having hot/spicy food, mouth ulcers (37.9%), changes in taste sensation (15.5%)

whereas difficulty in opening the mouth among four persons were reported (6.9%). Other

problems reported (12%) include ‘giddiness, burning sensation in throat while swallowing,

crackling of lip, bitter taste sensation in the lip after chewing gutkha, numbness in mouth,

change in tooth color, changes in voice, neck pain opening mouth, burning sensation in

stomach (hotte uri) and headache’.

44

think that both gutkha and betel quid with tobacco are harmful, gutkha is considered to be

most dangerous than even betel quid with tobacco. It was found that only few people

consider sweet scented supari and areca nut to be harm full to health. They think that

chewing especially gutkha causes problems at younger age whereas smoking causes problem

at old age.

3.11 Oral health problems among respondents:

Among the participants, nine had oral sub mucous fibrosis (OSMF), six of them had oral

leukoplakia and there was one case of oral cancer and erythroplakia (shown in table) whereas

10 of them had betel quid lesion. Apart from these, it was found that 34.4% (n=31) of the

study participants had periodontal disease. Although no indices were used to assess oral

hygiene, majority of betel quid chewers found to have poor oral hygiene when compared to

other types of chewers.

∗ This patient was referred to treatment by the researcher himself and the diagnosis was confirmed at the referred hospital as cancer.

Table 10: Different diseases seen among study participants Type of disease Frequency Percent OSMF 9 10.0 Leukoplakia 6 6.7 Oral cancer 1 ∗ 1.1 Erythroplakia 1 1.1 Betel quid lesion 10 11.1 Total 27 30.0

45

3.12 Factors associated with addiction, chewing practices and oral health problems: 3.12.1 Levels of addiction versus characteristics of respondents:

To asses the addiction level among areca nut users, Fagerstorm scale questions were

asked with the respondents. Responses to the Fagerstorm scale questions have been

summarized in the table 12. The mean Fagerstorm score for study participants was found to

be 6.08 whereas median score was six (range1-12). All the questions in the Fagerstorm scale

were coded and added to get the final score and Fagerstorm score below six was considered

to be low whereas score six or above was considered to be high in the study.

Lower caste groups were more addicted than other caste groups. Among the different

caste groups, 7.1 % of SC/ST’s, 54.8% of lower caste group and 38.1% of other caste groups

had higher score. Among the study participants, 66% of married, 23.4% of unmarried and

10.6% of widow/divorcees had high Fagerstorm score. Even there was high score was found

among higher income category group (44.7%) when compared to other income groups.

Among educational groups, lesser educated were more addicted than more educated groups.

40.4% of primary school level educated, 27.7% among graduates /postgraduates had higher

Fagerstorm score than other groups. Respondents above 40 years age group (51%) were more

addicted than other age groups. Daily wageworkers (34%), and other occupational groups

(34%) like businessmen, drivers, housewives etc were more addicted when compared to

farmers (19%) and students. It was found that 61.9 % among the alcohol consumers, 66.7%

of the ever smokers and 81.18% of ever snuff users had higher Fagerstorm score (Shown in

appendix II - table 4).

46

3.12.2 Levels of addiction Vs Type of chewing and different ingredients used in chewing:

Among those chewed areca nut products with tobacco a much higher proportion of

them had a high level of addiction. It was found that 65.6% (n=42) of the areca nut chewers

with tobacco had Fagerstorm score had higher score (>6) whereas only 19.2 % of the

chewers without tobacco higher Fagerstorm score. Betel quid with tobacco chewers fared

worst of all. 24.4 % of betel quid chewers with tobacco, 13.3% of mixed tobacco users and

8.9% of gutkha chewers had high Fagerstorm score (table 11). Use of ripe areca nut was far

more addiction causing than use of dried or other varieties. Among the participants, 70.2%

(n=33) of those who use ripe areca nut, 6.4% of dried areca nut users and 23.3% of other

varieties of areca nut users (areca nut used in readymade preparations) and 55.3% of

fermented areca nut users had high Fagerstorm score.

Those who consume more quantity of ingredients during chewing, more proportion of

them were more addicted. Respondents consuming more than 8 betel leaves/day (n=18,

58.1%), chewers who use more than 6 cms tobacco leaf per day (60 %) and those who use

more than 8 pinches (60%, one pinch equals to 400-500mgs) had higher Fagerstorm score.

Among the study respondents, 51.4 % of those who use 0.25-1 areca nuts per day and 48.6%

of those who use more than one areca nut per day had high Fagerstorm score. This may be

Table 11: Comparison between type of chewing and Fagerstorm score Type of chewing Fagerstorm score N (%)

< 6 > 6 Betel quid with tobacco 5 (5.6) 22 (24.4) Betel quid without tobacco 5 (5.6) 3 (3.3) Gutkha 4 (4.4) 8 (8.9) Areca nut only 3 (3.3) 2 (2.2) Sweet supari 8 (8.9) - Mixed tobacco use 12 (13.3) 12 (13.3) Mixed areca nut use 6 (6.7) - Total 43 (47.8) 47 (52.2)

47

because, those who consume less than one areca nut per day also consume other varieties of

areca nut products.

Type 1 pattern of betel quid preparation shared maximum addiction. 90.3% of type 1-

betel quid chewers and 10 % of type 2 & 3 chewers had high score whereas 75 % of type 1-

gutkha chewers who does not remove powder from the mix had higher score when compared

to type 2 gutkha chewers who remove powder (25%) from the mix before they chew (shown

in appendix II - table 5).

3.12.3 Levels of addiction Vs social influence for chewing and other risk factors:

Those who have some kind of social influence tend to be more addictive to chewing.

When Fagerstorm score was compared among the respondents who had chewers in their

family, 70.2% (n=33) of them were found to be highly addicted to chewing. When question

‘do you chew in front of your seniors/parents?’ was asked in less than 18 years age group

participants, all the participants (23.8%) who said ‘yes’ had higher Fagerstorm score.

‘Do you think chewing is also seen on among rich people?’, was asked to explore the

affect of role models on the participants, it was found that 57.4% (n=27) of participants who

said ‘yes’ and 42.6% (n=20) among those who said ‘no’ had higher Fagerstorm score. Apart

from these, all the participants (n=28) who chew before tiffin were highly addicted to

chewing (shown in appendix II - table 6).

48

3.12.4 Cancerous/pre cancerous lesions Vs characteristics of respondents:

Majority of lesions were seen among above 40 years age group when compared to other

age groups. Younger chewers are predominantly affected with OSMF whereas chewers

above 40 years age group found to be more affected with Leukoplakia and other lesions.

Table 11a shows that OSMF (Oral sub Mucous Fibrosis) affects early age groups whereas

other diseases are more commonly seen among elder age groups. In the study, more

cancerous/precancerous lesions were seen among the above 40 years age group

(n=11,64.7%) and 21- 40 years age group (29.4%) when compared to <20 years age group

(5.9%). It was found that 23.5% of them among those who consume alcohol and 64.7% of

the never smokers had the lesions whereas 11.8% of ever users of snuff had the lesions

(shown in appendix II - table 7).

In the study, all the 17 (100%) cases were seen among areca nut chewers with tobacco

whereas 10 % of the cases were found among betel quid chewers with tobacco, 6.7% of the

cases were seen among mixed tobacco users whereas other cases were seen among gutkha

chewers (table 11b). Majority of the OSMF cases were seen among chewers with mixed

3.12.5 Cancerous/pre cancerous lesions Vs type of chewing and ingredients used in

chewing:

Table 11a: Different types of lesions among different age groups. Type of lesions Age groups n (%) Total

n (%) <20 21- 40 >40 Oral sub Mucous Fibrosis 1 (1.1) 4 (44.4) 4 (44.4) 9 (52.9) Leukoplakia 1 (16.7) 5 (83.3) 6 (35.3) Oral cancer 1 (100) 1 (5.9) Erythroplakia 1(100) 1 (5.9) Total 1 (5.9) 5 (29.4) 11 (64.7) 17 (100)

49

tobacco use whereas other lesions are predominantly seen among betel quid chewers with

tobacco.

Among the respondents affected with OSMF, two of them were chewing exclusively

gutkha, five were chewing gutkha along with other areca nut products whereas only two of

them chewed betel quid with tobacco. Younger gutkha chewers get diseases like OSMF

earlier whereas betel quid with tobacco chewers develop diseases in late stages of their life

(appendix II - table 8).

Among the respondents, majority of those who consume of ripe (82.4%) or fermented

areca nut users had more lesions (58.8%) than dried areca nut users (5.9%) or other varieties

of areca nut users (areca nut used in readymade preparations-11.8%). It was found that

69.2% of those use more than 8 betel leaves per day and 30.8% of 1-8 betel leaf users had

lesions in their mouth.

Among the daily chewers (this excludes areca nut used in readymade preparations),

57.1 % of those who use more than one areca nut per day and 14.3% of those who use 0.5-1

areca nut per day had the disease whereas 28.6 % of those who use less than half areca nut

Table 11b: Comparison between different types of chewing and cancerous /precancerous lesions

Type of chewing Caner/precancerous conditions N (%)

Betel quid with tobacco 9 (10) Betel quid without tobacco Gutkha 2 (2.2) Areca nut only Sweet supari Mixed tobacco use 6 (6.7) Mixed areca nut use

Total 17 (18.9) Areca nut with tobacco 17 (100) Areca nut without tobacco -

Total 17 (100)

50

per day had lesions in their mouth. This might be because those who use less than half areca

nut per day also use other areca nut products like gutkha.

More lesions were seen when the quantity of ingredients used for chewing increased.

Among betel quid chewers with tobacco leaf (n=45), 69.2% (n=9) of those who consume

more than 6 cms tobacco leaf users and 30.8% of 1-6 cms tobacco leaf users had lesions.

76.9% of more than 8 pinch lime and 23.1% of 1-8 pinch lime users had the lesions in their

mouth. 70.6% of the lesions were seen among these who were type1 betel quid chewers

whereas among gutkha chewers, 60% of the lesions were seen among those who did not

remove the powder before chewing (shown in appendix II - table 9).

3.12.6 Cancerous/pre cancerous lesions Vs other possible risk factors:

More proportion of lesions was seen among respondents those who chew before Tiffin,

keep the quid in their mouth while chewing, those who do not clean their mouth after

chewing and also among those who did not knew that chewing causes problem. Among the

study participants, more proportion of the cases (64.7%) were found among the participants

who have their first chew before the Tiffin. 70.6% of the cases were seen among those who

keep the quid in mouth and 58.8% of the cases were seen among those who did not knew that

chewing causes problem. 58.8% (n=10) of lesions was seen among the respondents who did

not clean their mouth after chewing (Shown in appendix II- table 10).

51

3.12.7 Cancerous/precancerous lesions Vs Fagerstorm scale items:

More cancerous/precancerous lesions are seen among the respondents who are highly

addicted to chewing. Those who had high Fagerstorm score were 9.06 times likely to develop

disease than who had low score. 88.2% (n=15) of the participants who had score >6 had

lesions in their mouth whereas only 11.8% of those who had <6 Fagerstorm score had lesions

in their mouth (appendix II -table 10).

In the study, 12 persons (40%) who chew immediately after waking had disease whereas

only 5 persons (8.3%) among those who did not chew immediately after waking had the

disease and 52.9% (n=11) those who had reported to have the difficulties to refrain from

chewing were found to have disease. More proportion of cases were seen when the number

of chews increased above 44 chew/week or more than 5 chews /day. 36.6% of those who

chew above 44 chews per week and 4.1% of those who chew <44 chews /week had the

disease whereas 34% of those who chew more than five chews/day and 5.8% among those

who chew <5 chews per day had the disease. All the people who had the disease have their

first chew between 5.30AM –9.30 AM whereas among those who have their last chew above

7.30 PM in the night, majority of them had lesions in their mouth.

52.9% (n=9) of them among those who reported to have difficulties to give up the first

chew of the day and 29.6% (n=13) of informants who reported to experience strong crave

had the disease. It was found that 30% (n=12) were diseased among those who reported to

chew even when they are severely ill whereas only 8.3% (n=5) of were diseased among those

who do not chew in such conditions (shown in table 12).

52

Table 12: Showing responses and frequencies for Fagerstorm questions and lesions:

Fagerstorm scale questions: Scoring criteria

Cancerous /precancerous lesions n (%)

Yes No Total n (%)

After normal sleeping period, do you chew within 30 minutes of waking?

Yes-1 12 (40) 18 (60) 30 (33.3) No-0

5 (8.3) 55 (91.7) 60 (66.7)

Do you find difficult to refrain from chewing in situations where it would be inappropriate?

Yes-1 11(52.9) 32 (47.05) 43 (47.8) No-0 6 (26.1)

41 (56.2) 47 (52.2)

On average how many tins/sachets of areca nut products do you use per week………tins/sachets/week

> 44-1 15 (36.6) 26 (63.4) 41 (45.6) < 44-0 2 (4.1) 47 (95.9) 49 (54.4)

On average, how many dips/chews areca nut products do you take each day?

> 5-1 15 (34) 29 (56) 44 (61.1) < 5-0 2 (5.8) 33 (94.2) 35 (38.9)

On average, how long is each chew in your mouth? (In minutes)

> 5-1 8 (19.7) 35 (81.3) 43 (47.8) < 5-0 9 (19.15) 38 (80.85) 47 (52.2)

How often do you swallow your quid juice rather than spit?

Never -0 12 (19.3) 60 (80.7) 72 (80) Sometimes-1

4 (57.1) 3 (42.85) 7 (7.8)

Always-2 1 (9.1) 10 (90.9) 11 (12.2) What time do you have your first chew of the day? (AM)

5.30-9.30-1 17 (32.1) 36 (67.9) 53 (58.9) >9.30-0 37 (100) 37 (41.1)

What time do you have your last chew of the day? (PM)

>19.30-1 14 (28.6) 35 (71.4) 49 (54.4) <19.30-0 3 (7.3) 38 (92.7) 41 (45.6)

Which chew of the day would be the hardest to give up?

First one–1 9 (52.9) 19 (26.1) 28 (21.1) Others -0 8 (47.05) 54 (73.9) 62 (68.9)

Do you experience strong cravings for a dip/chew when you go more than 2 hours without one?

Yes-1 13 (29.6) 31 (70.45) 44 (48.9) No-0 4 (8.7) 42 (91.3) 46 (51.1)

Do you chew more in the morning than during the rest of the day?

Yes-1 3 (37.5) 5 (62.5) 8 (8.9) No-0 14 (17) 68 (83) 82 (91.1)

Do you keep the dip /chew in your mouth almost all the time?

Yes-1 2 (25) 6 (75) 8 (8.9) No-0 15 (18.3) 67 (81.7) 82 (91.1)

Do you use areca nut products in the night (while sleeping)?

Yes-1 1 (100) 1 (1.1) No-0 16 (18) 73 (82) 89 (98.1)

Do you use areca nut products even if you are severely ill, or you have mouth sores?

Yes-1 12 (40) 18 (60) 30 (33.3) No-0 5 (8.3) 55 (91.7) 60 (66.7)

53

Chapter- IV

4. Discussion: The study consisted of 90 respondents ranging from 7 –78 years (median age –28

years). Although there are different varieties of areca nut chewing reported in the study area,

betel quid chewing with tobacco and gutkha chewing were found to be more common. It was

found that there is transition from use of smoke form tobacco to smokeless form in the study

area especially to modern readymade areca nut preparations. Therefore there is a chance that

restriction on smoking might further increase this kind of transition, which might need

careful attention by public health advocates in the future.

Most of the middle/elder respondents reported to have started chewing either ‘betel quid

with tobacco’ (27.8%) or betel quid without tobacco (21.1%) whereas students most

commonly either reported to have started chewing with scented sweet supari (16.67%) or

gutkha (12.2%). This finding poses question of future possibility of increase in smokeless

tobacco use among these students as observed in previous study reports (Gupta & Ray,

2003). Most common reason for initiation of chewing among young chewers in the study was

found to be ‘related to friends’ whereas among middle aged and elder populations, most

common reason for initiation was found to be for tooth pain and bad smell from the mouth.

In the study area, it was found that chewers use different quantities of ingredients according

to their need. This is the first attempt among areca nut studies to assess the quantity of

ingredients used in the chew. Most of the betel quid chewers use ripe areca nut or dried areca

nut and some of them even to use fermented areca nut during rainy seasons. This finding is

very important as previous studies reported that some types of areca nuts (like fermented

areca nut) poses more risk for development of cancer (Phukan et. al, 2001)

54

Identification of place, partner and timing of chewing was very important in terms of

future possible public health intervention programs for harm reduction among chewers.

Majority of participants in the study reported to chew either at home, while working, at/near

shops, at or near college, at school or while playing. Most of the respondents were found to

chew ‘alone’, or along with their friends, with family members, with parents. Although

previous literatures have addressed place and partners for chewing to some extent (Nichter et.

al, 2004) timing for chew has been a new addition to the areca nut literature. It was found

that among the study respondents, maximum numbers of chew were observed during

8.00AM – 6.00PM time interval.

Most common reasons for chewing were found to be ‘feel like chewing immediately

after having any food/drink, to prevent tastelessness in the mouth, it is an habit, just for time

pass, it has got more taste, helps me to go to toilet, before starting work/going for work, just

for fun, just for enjoyment, to relive tension, and for preventing bad smell from the mouth/to

prevent tooth pain’ etc. Some of these findings are in consistent with previous study reports

(Asma 1994; Gupta, Nandakumar, 1999 & Asian quitline, 2002). Chewing when alone was

found to help to focus and evade boredom. Whereas popular reasons for chewing with others

was found to be ‘I take when I see anyone taking’, ‘they offer me’, ‘to give company to

friends/relatives. Apart from these, social pressures were also found to a play major role in

chewing practices in the study area. Thaamboola (pan) has been found to be deeply culturally

bound in the study area and is used extensively in several ritual performances. It is common

to see offering pan to guests shortly after reaching home (Nichter et. al, 2004) as any other

food items.

55

Majority of the respondents in the study reported that their friends (82%) also chew

whereas 71.1% of them have said that their parents /family members chew (Asma, 1994).

Most popular person to introduce chewing was found to be ‘friends’. Role of friends was

found to have either direct or indirect influence for chewing. Other persons played role in

introducing chewing were parents/family members, relatives, and colleagues.

People tend to chew more than usual in different situations like ‘along with friends,

when tensed, when happy, at work, during rainy season. It is common in the study area that

people tend to chew more to keep themselves ‘warm’ during rainy season or winter season.

Usually students tend to chew more during exams/while reading, while playing or whenever

they go to see movies.

Majority of the respondents (68.9%) think that chewing has some kind of beneficial

effects rather than just for chewing. Although there were different responses to perceptions

about harm, it was found that only 4.4% of the participants believed that chewing either betel

quid with tobacco/gutkha causes cancer. In future studies might be conducted to explore

possibility of health effects like impotency, decrease in memory power related to gutkha

chewing. Over all, there is poor knowledge among the respondents about harmful effects

from chewing (31%).

In the study, more proportion (64.4%) of respondents reported to have one or more

health problems related to chewing. Although some of the participants knew about health

problems related to chewing, they could not quit chewing, as they are addicted. In the study,

it was found that some of the respondents are unaware that they are ‘addicted’ to chewing

rather they consider themselves as ‘habituated’. Previous study reports among male college

students from the same district, has showed that people had somewhat clear view about

56

addiction/habituation (Nichter et. al, 2004), but this difference could be due to heterogeneous

population characteristics in the present study. This may be one of the areas, which needs

public health interventions, which in turn possibly might help the chewers in future to be

aware of their risky behavior.

Previous studies have used Fagerstorm scale questions from Fagerstorm Tolerance

Questionnaire for smokers. They have significantly correlated levels of addiction with

salivary cotinine levels among the smokeless tobacco users. The questionnaire actually

inquires patterns of use, ability to refrain and rate of use (Raymond et. al, 1995).

In the present study, the mean Fagerstorm score for study participants was found to be

6.08 whereas median score was six. Among the study participants, 52.2% (n=47) were found

to have higher Fagerstorm score. Areca nut chewers with tobacco were more addicted than

those who do not use tobacco. Betel quid chewers with tobacco were more addicted than

other varieties of chewers. Type of areca nut (Ripe and fermented), type of quid preparation

(type 1 betel quid and gutkha preparation) and quantity of ingredients used for chewing was

found to be more related addiction among chewers. When the quantity of contents increased,

the Fagerstorm score also found to increase. Type 1 betel quid and gutkha preparation shared

maximum addiction among different types of quid preparations. Future studies could be

conducted to address significance between different types of quid preparations and lesions.

Previous studies have revealed that some varieties of (ex: fermented) areca nut users are

at more risk for development of disease (Phukan et. al, 2001). In the present study, more

proportion of ripe and fermented areca nut users had lesions in their mouth. When the

quantity of ingredients increased, lesions are also found to increase.

57

In the study, more number of respondents reported to keep the quid in their mouth. This

finding is very important, as previous studies have reported site specificity of oral cancer in

areas where betel quid with tobacco is been kept (Gupta & Nandakumar, 1999; Gupta et. al,

1982). With possibilities of harm reduction in mind, in future epidemiological studies may be

conducted to test the significance of relation between cancerous/precancerous lesions along

with oral hygiene after chewing, chewing before Tiffin, first and last chew of the day,

quantity of ingredients used for chewing. Frequency and timing of chewing was also found to

be very important factors in development of lesions. More lesions were seen among those

who chew above 44 chews per week or those who chew more than five chews/day. It was

found that all the people in the study who had the disease their first chew between 5.30AM –

9.30 AM whereas among the people with disease, majority of them chew above 7.30 PM in

the night.

Younger chewers are more affected with OSMF whereas chewers above 40 years age

group found to be predominantly affected with Leukoplakia and other lesions. Younger

gutkha chewers get diseases like OSMF earlier whereas betel quid with tobacco chewers

develop diseases in late stages of their life. So there is difference in timing in appearance of

different lesions among different types of chewers.

More cancerous/precancerous lesions are seen among the respondents who are highly

addicted to chewing. Those who had high Fagerstorm score were 9.06 times likely to develop

disease than who had low score. Fagerstorm scale has relevance to identify these highly

addicted chewers in the community, which in turn might help to conduct de-addiction

programs and counselling of chewers. This Fagerstorm Tolerance Questionnaire could also

be used to inform public how likely they will develop the lesions if they chew and they can

58

be made aware that they are addicted. They can be made to locate themselves among

different levels of addiction as well as they can be made aware of warning signs for

development of disease. Apart from these, application of degree of dependence in users has

potential benefit for clinicians and researchers (Raymond et. al, 1995). Given these many

information’s related to levels of addiction, this scale might be used in large populations in

future for public health researches and harm reduction programs.

Currently chewing of areca nut products is found to be becoming more popular than

smoking. Traditional pan chewing is decreasing in the community whereas modern non-

traditional chewing practices (gutkha) are increasing especially among youths (Gupta &

Nandakumar, 1999). Generally there is an opinion in the study area that chewing 3-4 times a

day is good for health. Previous studies have shown that type 2 betel quid chewing poses

lesser risk for development of oral cancer than type 1 (Ko et. al, 1995). Differences in the

way quid is prepared and cancerous/precancerous lesions needs further study to explore

future ways of safe methods of chewing practices. Although Thaamboola (pan) has been

linked to several socio cultural practices as well as for its Ayurvedic medicinal values, there

have been no studies to evaluate the efficacy of areca nut about its therapeutic effects

(Bavappa et. al, 1982; Scott, A. Nortan, 1998 & Strickland, 2002). Given these socio cultural

practices and economic conditions related to areca nut, attempts to stigmatize use of areca

nut could pose strong resistance (Winstock, 2002). With these issues in mind, future

researches should address culturally sensitive and economically acceptable ways of harm

reduction practices as well as possible ways of dissemination of health consequences of

health consequences of areca nut chewing practices.

59

4.1 Strengths and limitations of the study:

1. Generalizaility of study results has been limited.

2. Very small population has been included in the study.

3. Present study includes all possible reasons for chewing at different levels.

4. Highlights risky behaviors among area nut chewers and shows future possible areas for

epidemiological studies

5. The study includes heterogeneous populations

6. This study has attempted to fill a gap in the history of anthropological literature of health

consequences of areca nut chewing.

4.2 Conclusion:

1. How valid are the perceived beneficial effects of areca nut on health especially its

role in digestion and diabetes?

Areca nut chewing has unique longstanding history of usage in the study area. Areca

nut has been found to have strong relation with culture, related social meanings and

therapeutic uses have been popular in the community. The present study has brought out

possible future areas of public health researches and interventions in the field of areca nut.

Therefore it is a challenging area to make decisions for policy makers on how to address

these sensitive issues. Certainly there is a need for public health researches as well as

education programs to reduce further avoidable mortality and morbidity related to chewing

habits. The future researches might address following questions:

2. Is there any normal dose/normal time period for chewing?

60

3. How significant is the relation between some of the risky behaviors, which are

identified in the present study and cancerous/precancerous lesions?

4. How to disseminate public health messages to the community about areca nut

chewing practices, which have been deeply rooted into cultural practices?

5. How best chewers themselves can be made to diagnose themselves if they have

cancerous/precancerous lesions?

6. What are the most feasible, culturally acceptable and user-friendly methods to help

the chewers to quit or reduce chewing?

7. What is the social cost of disease caused by chewing?

8. Why there is difference in timing in appearance of different lesions among different

types of chews?

9. How significant is the relationship between different quantity of ingredients used in

chewing and cancerous/precancerous lesions?

10. Is there any significant relationship between different types of preparation of quid

before chewing and cancerous/precancerous lesions?

11. Does chewing of gutkha/other smokeless tobacco cause impotency?

61

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66

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67

APPENDX - I India map:

Dakshina Kannada map:

68

Table 1: Beneficial effects as perceived by stakeholders

Appendix – II

Type of product Beneficial effects Betel quid without tobacco

Good for digestion and also good for the health. It is a food supplement, has got aphrodisiac effect and helps in mastication and proper salivation, important part of any religious functions, engagement ceremonies, offered to god, several varieties of pan indicated for several therapeutic conditions.

Areca nut Good for health, it has got digestive power, cures diabetes, used for soaps and tooth pastes and tooth powder

Lime ‘Sunna’ (lime) in pan gives calcium to the body and good for hallu (teeth).

Betel leaf Germicidal action, It neutralizes the effect of areca nut.

Table 2: Conditions for chewing more than usual (n =90) Occasions n (%) With friends 61 (67.8) When tensed 45 (50.0) When happy 45 (50.0) At work 45 (50.0) During rainy, winter season 22 (24.4) After drinks 10 (11.1) When alone 8 (8.90) When free/without any work or during start of work 6 (6.70) Others: 14 (15.6) After having food, during religious functions/holidays, when thinking about some issues/if sleep is disturbed in the night, along with relatives, while watching cinema/drama, during exams, while reading, while playing, during tooth pain.

69

Table 3: Type of chewing in relation to various risk factors:

Risk factors Type of chewing n (%)

Total n (%)

With Tobacco

Without Tobacco

Religion Hindu 53 (82.8) 13 (50.0) 66 (73.3) Muslim 11 (17.2) 13 (50.0) 24 (26.7)

Caste groups SC/ST’s 5 (9.40) 2 (15.4) 7 (10.6) Lower Caste 32 (60.4) 5 (38.5) 37 (56.1) Other castes 16 (22) 6 (46.2) 22 (33.3)

Sex Men 57 (89.1) 21 (80.8) 78 (86.7) Women 7 (10.9) 5 (19.2) 12 (13.3)

Literacy status

Illiterate 9 (14.1) 2 (7.70) 11 (12.2) Primary 28 (43.8) 10 (38.5) 38 (42.2) Secondary 15 (23.4) 7 (26.9) 22 (24.4) Graduate/post graduate 12 (18.8) 7 (26.9) 19(21.1)

Location Urban 11 (17.2) 4 (15.4) 15 (16.7) Rural 53 (82.8) 22 (84.6) 75 (83.3)

Marital status Married 35 (54.7) 9 (34.6) 44 (48.9) Un married 24 (37.5) 16 (61.5) 40 (44.4) Widow/divorcee 5 (7.80) 1 (3.80) 6 (6.70)

Income groups (Rs)

<1000 10 (15.6) 1 (3.80) 11 (12.2) 1001-2000 21 (32.8) 13 (50.0) 34 (37.8) 2001-5000 11 (17.2) 5 (19.2) 16 (17.8) >5000 22 (34.4) 7 (26.9) 29 (32.2)

Smoking Never user 43 (67.2) 20 (76.9) 63 (70.0) Ever 21 (32.8) 6 (23.1) 27 (30.0)

Snuff use Never user 54 (84.4) 25 (96.2) 79 (87.8) Ever user 10 (15.6) 1 (3.80) 11 (12.2)

Alcohol use Yes 18 (28.1) 3 (11.5) 21 (23.3) No 23 (88.5) 46 (71.9) 69 (76.7)

Age groups <20 14 (21.9) 16 (61.5) 30 (33.3) 21-40 26 (40.6) 2 (7.70) 28 (31.1) >40 24 (37.5) 8 (30.8) 32 (35.6)

Age of Initiation (Years)

7-16 16 (25.0) 16 (61.5) 32 (35.6) 17-25 27 (42.2) 2 (7.70) 29 (32.2) >25 21 (32.8) 8 (30.8) 29 (32.2)

Occupation Daily wage workers 23 (35.9) 3 (11.5) 26 (28.9) Farmers 10 (15.6) 3 (11.5) 13 (14.4) Students 14 (21.9) 16 (61.5) 30 (33.3) Others 17 (26.6) 4 (15.4) 21 (28.3)

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Table 3a: Type of chewing in relation to various risk factors:

Risk Factors

Type of chewing n (%) Total n (%)

With Tobacco

Without Tobacco

Expenditure

< 17.00 17 (26.6) 24 (92.3) 41 (45.6) >17.00 47 (73.4) 2 (7.70) 49 (54.4)

Chewing among rich people

Yes 41 (64.1) 16 (61.5) 57 (63.3) No 23 (35.9) 10 (38.5) 33 (36.7)

Chewing in front of seniors

Yes 7 (77.8) 3 (25.0) 5 (23.8) No 2 (22.2) 9 (75.0) 16 (76.2)

Chewing among friends

Yes 53 (82.8) 21 (80.8) 74 (82.2) No 11 (17.2) 5 (19.2) 16 (17.8)

Chewing among family membres

Yes 31 (72.1) 33 (70.2) 64 (71.1) No 12 (27.9) 14 (29.8) 26 (28.9)

Age of Initiation (Years)

7-16 16 (25.0) 16 (61.5) 32 (35.6) 17-25 27 (42.2) 2 (7.70) 29 (32.2) >25 21 (32.8) 8 (30.8) 29 (32.2)

Fagerstorm score

<6 22 (34.4) 21 (80.8) 43 (47.8) >6 42 (65.6) 5 (19.2) 47 (52.2)

Perception about harm

Yes 28 (43.8) 3 (11.5) 31 (34.4) No 36 (56.3) 23 (43.8) 69 (65.6)

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Table 4: Fagerstorm score level among different risk factors

Risk Factors Fagerstorm score n (%) Total n (%) <6 >6

Religion Hindu 24 (55.8) 19 (44.2) 43 (47.8) Muslim 42 (89.4) 5 (10.6) 47 (52.2)

Caste groups

SC/ST’s 4 (16.7) 3 (7.10) 7 (10.6) Lower Caste 14 (58.3) 23 (54.8) 37 (56.1) Other castes 6 (25.0) 16 (38.1) 22 (33.3)

Sex Men 39 (90.7) 39 (83.0) 78 (86.7) Women 4 (9.30) 8 (17.0) 12 (13.3)

Literacy status

Illiterate 4 (36.3) 7 (65.7) 11 (12.2) Primary 19 (50.0) 19 (50.0) 38 (42.2) Secondary 14 (63.6) 8 (36.4) 22 (24.4) Graduate/post graduate

6 (31.6) 13 (68.4) 19 (21.1)

Location Urban 5 (11.6) 10 (21.3) 15 (16.7) Rural 38 (88.4) 37 (78.7) 75 (83.3)

Marital status

Married 13 (30.2) 31 (66.0) 44 (48.9) Un married 29 (67.4) 11 (23.4) 40 (44.4) Widow/divorcee 1 (2.30) 5 (10.6) 6 (6.70)

Income groups (Rs)

<1000 2 (4.70) 9 (19.1) 11 (12.2) 1001-2000 26 (60.5) 8 (17.0) 34 (37.8) 2001-5000 7 (16.3) 9 (19.1) 16 (17.8) >5000 8 (18.6) 21 (44.7) 29 (32.2)

Smoking Never user 34 (79.1) 29 (61.7) 63 (70.0) Ever 9 (20.9) 18 (38.3) 27 (30.0)

Snuff use Never user 41(95.3) 38 (80.9) 79 (87.8) Ever user 2 (4.70) 9 (19.1) 11(12.2)

Alcohol use

Yes 8 (18.6) 13 (27.7) 21 (23.3) No 35 (50.7) 34 (72.3) 69 (76.7)

Age groups <20 26 (60.5) 4 (8.50) 30 (33.3) 21-40 9 (20.9) 19 (14.4) 28 (31.1) >40 8 (18.6) 24 (51.1) 32 (35.6)

Occupation Daily wage workers 10 (28.5) 16 (61.5) 26 (28.9) Farmers 4 (20.5) 9 (69.2) 13 (14.4) Students 24 (80.0) 6 (20.0) 30 (33.3) Others 5 (24.0) 16 (76.0) 16 (23.3)

72

Table 3: Shows

Fagerstorm score

level among

different variables.

Table 5: Fagerstorm score levels among different risk factors.

Type of material used for chewing Fagerstorm score

n (%)

Total n (%) <6 >6

Type of areca nut Ripe areca nut 15 (34.9) 33 (70.2) 48 (53.3) Dried areca nut 16 (37.2) 3 (6.40) 19 (21.1) Other types 12 (27.9) 11 (23.3) 23 (25.5)

Use of fermented areca nut

Yes 6 (14.0) 26 (55.3) 32 (35.6) No 37 (86.0) 21 (44.7) 58 (64.4)

Number of betel leaves used/day

1-8 leaves 11 (84.6) 13 (41.9) 24 (54.5) > 8 leaves 2 (15.4) 18 (58.1) 20 (45.5)

Number of areca nuts used /day *

<0.5 10 (58.8) 9 (25.7) 19 (36.5) >0.5 -1 6 (35.3) 9 (25.7) 15 (28.8) >1 1 (5.90) 17 (48.7) 18 (34.6)

Usage of lime/day 1-8 pinches 11 (84.6) 12 (40.0) 23 (53.5) >8 pinches 2 (15.4) 18 (60.0) 20 (46.5)

Tobacco use/day

1-6cms 10 (90.9) 12 (40.0) 22 (53.7) >6 cms 1 (9.10) 18 (60.0) 19 (46.3)

Pattern of quid preparation for chewing

Betel quid

Type 1 11 (78.6) 28 (90.3) 39 (86.7) Type 2 2 (14.3) 1 (3.20) 3 (6.70) Type 3 1 (7.10) 2 (6.50) 3 (6.70)

Gutkha Type 1 (Removes powder)

4 (28.6) 9 (75.0) 13 (50.0)

Type 2 (Does not remove powder)

10 (71.4)

3 (25)

13 (50.0)

*One areca nut weighs approximately 15 gms

73

Table 6: Fagerstorm score level among different risk factors.

Risk Factors Fagerstorm score n (%)

Total n (%) <6 >6

Expenditure < 17.00 30 (69.8) 11 (23.4) 41 (45.6) >17.00 13 (30.2) 36 (76.6) 49 (54.4)

Chewing among rich people

Yes 30 (69.8) 27 (57.4) 57 (63.3) No 13 (30.2) 20 (42.6) 33 (36.7)

Chewing in front of seniors

Yes 5 (23.8) - 5 (23.8) No 16 (76.2) - 16 (76.2)

Chewing among friends

Yes 37 (86.0) 37 (78.9) 74 (82.2) No 6 (14.0) 10 (21.3) 16 (17.8)

Chewing among family membres

Yes 31 (72.1) 33 (70.2) 64 (71.1) No 12 (27.9) 14 (29.8) 26 (28.9)

Perception about harm

Yes 9 (20.9) 22 (46.8) 31 (34.4) No 34 (79.1) 25 (53.2) 59 (65.6)

Chew before Tiffin

Yes 28 (59.6) 28 (31.1) No 43 (100) 19 (40.4) 62 (68.9)

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Table 7: Cancer/Precancerous lesions among different risk factors:

Risk Factors Cancer/Precancerous

lesions n (%)

Total n (%) Yes No

Cast groups SC/ST’s 2 (12.5) 5 (10.0) 7 (10.6) Lower Caste 6 (37.3) 31 (62.0) 37 (56.1) Other castes 8 (50.0) 14 (28.0) 22 (33.3)

Literacy status

Illiterate 2 (11.8) 9 (12.3) 11 (12.2) Primary school 7 (41.2) 31 (42.5) 38 (42.2) Secondary school

4 (23.5) 18 (24.7) 22 (24.4)

Graduates/post graduates

4 (23.5) 15 (20.5) 19 (21.1)

Location Urban 4 (23.5) 11 (15.1) 15 (16.7) Rural 13 (76.5) 62 (84.9) 75 (83.3)

Occupational status

Daily wage workers

6 (35.3) 20 (27.4) 26 (28.9)

Farmers 5 (29.4) 8 (11.0) 13 (14.4) Students 1 (5.90) 29 (39.7) 30 (33.3) Others 5 (29.4) 16 (21.9) 21 (23.3)

Expenditure < 17.00 1 (5.90) 40 (54.8) 41 (45.6) >17.00 16 (94.1) 33 (45.2) 49 (54.4)

Smoking Never user 11(64.7) 52 (71.2) 63 (70.0) Ever user 6 (35.3) 21 (28.8) 27 (30.0)

Snuff Use Never 15 (88.2) 64 (87.7) 79 (87.8) Ever 2 (11.2) 9 (12.3) 11 (12.2)

Alcohol use Yes 4 (23.5) 13 (76.5) 17 (18.9) No 17 (23.3) 56 (76.7) 73 (81.1)

Age group <20 29 (39.7) 1(5.90) 30 (33.3) 21-40 23 (31.5) 5 (29.4) 28 (31.1) >40 21(28.5) 11 (64.7) 32 (35.6)

Age of

Initiation

7-16 years 31 (42.5) 1 (5.90) 32 (35.6) 17-25 years 22 (30.1) 7 (41.2) 29 (32.2) >25 years 20 (27.4) 9 (52.9) 29(32.2)

Expenditure Rs <=17.5 49 (67.1) 3 (17.6) 52 (57.8)

Rs >17.5 24 (32.9) 14 (82.4) 38 (42.2)

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Table 8: Different types of lesions among different varieties of chewers.

Type of lesions

Type of chewing n (%) Total n (%)

Betel quid with tobacco

Gutkha Mixed tobacco use

OSMF 1 (5.9) 2 (22.2) 6 (66.7) 9 (52.9) Leukoplakia 6 (100) - - 6 (35.3) Oral cancer 1 (100) - - 1 (5.9) Erythroplakia 1 (100) - - 1 (5.9) Total 9 (52.9) 2 (11.8) 6 (35.3) 17 (100)

Table 9: Different frequencies of Cancerous /precancerous lesions among different risk factors:

Type of raw materials used for

chewing

Cancerous /precancerous lesions

n (%)

Total n (%)

Yes No Type of areca nut Ripe areca nut 14 (82.4) 34 (46.6) 48 (53.3)

Dried areca nut

1 (5.90) 18 (24.7) 19 (21.1)

Other types 2 (11.8) 21 (28.8) 23 (25.5) Use of fermented areca nut

Yes 10 (58.8) 22 (30.1) 32 (35.6) No 7 (41.2) 51 (69.9) 58 (64.4)

Number of betel leaves used/day

1-8 leaves 4 (30.8) 20 (64.5) 24 (54.5) > 8 leaves 9 (69.2) 11 (35.5) 20 (45.5)

Number of areca nuts used /day

< 0.5 4 (28.6) 15 (39.5) 19 (36.5) >0.5-1 2 (14.3) 13 (34.2) 15 (28.8) >1 8 (57.1) 10 (26.3) 18 (34.6)

Usage of lime/day 1-8 pinches 3 (23.1) 20 (66.7) 23 (53.5) >8 pinches 10 (76.9) 10(33.3) 20 (46.5)

Tobacco use/day

1-6 cms 4 (30.8) 18 (64.3) 22 (53.7) >6 cms 9 (69.2) 10 (35.7) 19 (46.3)

Pattern of quid preparation for before chewing

Betel quid

Type 1 1 (7.70) 2 (6.3) 3 (6.70) Type 2 10 (70.6) 29 (90.6) 39 (86.7) Type 3 2 (15.4) 1 (3.10) 3 (6.70)

Gutkha Type 1 (Does not remove powder)

3 (60.0) 10 (47.6) 13 (50.0)

Type 2 (Removes powder)

2 (40.0) 11 (52.4)

13 (50.0)

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Appendix- III

Table 10: Frequencies and percentages for risk factors and cancerous /precancerous lesions

Risk factors

Cancer/Precancerous lesion n (%)

Total n (%) Yes No

Hygiene after use

Yes 7 (41.2) 50 (68.8) 57 (63.3) No 10 (58.8) 23 (31.5) 33 (36.7)

Keep the quid in the mouth

Yes 12 (70.6) 35 (47.9) 47 (52.2) No 5 (29.4) 38 (58.1) 43 (47.8)

Awareness about problem

with use

Yes 7 (41.2) 24 (32.9) 31 (34.4) No 10 (58.8) 49 (67.1) 59 (35.6)

Chew before Tiffin

Yes 11 (64.7) 17 (23.3) 28 (31.1) No 6 (35.3) 56 (76.6) 62 (68.9)

Fagerstorm score

<6 2 (11.8) 41 (56.2) 43 (47.8) >=6 15 (88.2) 32 (43.8) 47 (52.2)

Table1: Checklist for the study 1. Structured inquiry-

2.Unstructured open-ended interview

3.Observation checklist

Patterns of use Fagerstorm scale measurement

Area nut chewing history Topography of chewing practices Patterns of areca nut chewing Preparation of areca nut Perceptions about benefits associated with areca nut use

Quantity of contents used in areca nut chewing

Perceptions about addiction/habituation

Consumption of areca nut

Perceptions of problems associated with areca nut use

Mode of disposal of the splatter Oral hygiene practice after disposal of splatter

77

Appendix- III

Interview schedule: ‘ Patterns of consumption, and levels of addiction among Areca nut chewers in

Dakshina Kannada District, Karnataka ’

Shrihari .J.S, MPH Student, AMCHSS, SCTIMST, Tiruvananthapuram.

Sl.no. Date Name* Age in completed years Address* Sex Male-1; Female-2

1. Religion: 1-Hindu, 2-Muslim, 3 -Christian 1a.Cast:__________________________

2.Educational status: 1- Illiterate, 2-Primary level, 3-High school level, 4-Under graduate/more 3.Marital status.1-Married, 2-Unmarried, 3-Divorcee/Widow

4.Occupational status:……………………………………………………..

4a.Total income of the family/month in Rs.______________

5.What is the type of diet you have? Vegetaian-1, Non vegetarian-2

6.Do you currently (Last 30 days) use alcohol? Yes –1,No – 2 7.Have you ever smoked? Yes –1,No – 2

I have personally explained the respondent the purpose and the nature of the study. The respondent has full right to inform/withhold any information. The respondent has given his verbal consent to being interviewed in the study.

Signature of the interviewer

78

8.Do you currently (Last 30 days) have the habit of using tobacco along with chewing? 9. At what did you start chewing? (In completed years) 9a.Why did you start chewing initially?

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10.Please do specify the items you use along with the chew? ________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

11.Do you chew in front of elders? Yes - 1, No -2 (for youths less than 18 years old) 12.How much do you spend for chewing /week (in rupees)?________________________________

13. Do any of your family members have chewing habit? Yes - 1, No -2

14.Any of your friends have chewing habit? Yes - 1, No -2

15. Who introduced you to chewing? _________________________________________________

16.Do you think rich people also have the chewing habit? Yes –1,No -2 (Only for lower socio economic group) 17.Please mention the quantity of areca nut contents used in every chewing ________________________________________________________________________________________________________________________________________________________________

18.What form of Areca nut do you use? ________________________________________________

(Example- 1.Raw, 2.Dried, 3. Fried, 4.Fermented)

19.Please explain why you use that particular type of areca nut.______________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 20. Could you describe how do you prepare the areca nut quid; __________________________________________________________________________________________________________________________________________________________________

79

___________________________________________________________________________

21.Do you have the habit of keeping of quid /areca nut in mouth? Yes –1,No –2 22. If yes, please mention why do you keep the chew in your mouth? ______________________________________________________________________________________________ _______________________________________________________________________________

23. Do you clean your mouth after every chewing? Yes –1,No –2

24. Could you tell me the Occasions when you chew more? ________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

25. Did you ever have any of the following problems?

1.Difficulty in opening the mouth, 2.Altered speech 3.Altered taste sensation, 4.Inability to tolerate hot/spicy food 4.Ulcer in the mouth >15 days, 5.if others please mention 6.None of the above

__________________________________________________________________________________________________________________________________________________________________

26. In your opinion, what are the advantages of chewing different areca nut products?

______

__________________________ ____________________________________________________________

27. Does areca nut chewing causes any health problem? Yes –1,No –2

28.If yes, tell me the health problems associated with the following combinations on health? Areca nut alone; …………………………………………………………………………………………… Areca nut with lime, leaf without tobacco; ……………………………………………………… Areca nut with lime, leaf with tobacco;……………………………………………………

Pan; ……………………………………………………………………………………………..…..

Gutkha; ……………………………………………………………………………………………….

Khaini:/Mava………………………………………………………………………………………

_______________________________________________________________________________ ________________________________________________________________________________

80

29.After normal sleeping period, do you chew areca nut products within 30 minutes of waking? Yes –1,No -0

Fagerstorm Scale Questions:

30.Do you find difficult to refrain from chewing in situations where it would be inappropriate? Yes –1,No -0 31.On average how many tins/sachets (areca nut products) do you use peer week………tins/sachets/week 32.On average, how many dips/chews do you take each day? 33.On average, how long is each chew in your mouth? 34. How often do you swallow your quid juice rather than spit? 1-Never, 2-Somwetimes,3-Always. 34a. what time do you have your first chew of the day? (AM/PM) 34b.What time do you have your last chew of the day? (AM/PM) 35.Which chew would be the hardest to give up? 1-First chew of the day,2-Any other chew 36.Do you experience strong cravings for a dip/chew when you go more than 2 hours without one? Yes –1,No -0 37.Do you chew more in the morning than during the rest of the day? Yes –1,No -2 38.Do you keep the dip /chew in your mouth almost all the time? Yes –1,No -2 39.Do you use areca nut products in the night (while sleeping)? Yes –1,No -2 40.Do you use smokeless tobacco even if you are so ill that you are in bed most of the day, or you have mouth sores? Yes –1,No –2

81

* Daily calendar: typical day of chewers:

Chew instruments:

Time (when) Where (work, home, etc)

Who was there when chewed, or alone

The mix of chew used, what chewed

How long does one chewing habit continues? : Time, topography notes

Any particular reason for chewing

Time blocks Early morning from 4 AM -8AM

8 AM -12PM

Noon time: 12PM -6PM

Evening time: 6PM-before going to bed

Daily total