Betel Nut (areca) and Smokeless Tobacco Use in Myanmar

Abstract

Background: Betel nut (areca) is the world's fourth most commonly used addictive substance. Arecoline, a muscarinic agonist in areca, is also a partial agonist for the addiction-related high-affinity brain nicotine receptors. In many countries, smokeless tobacco is commonly mixed with areca. Objective: We sought to evaluate the knowledge of self-harm, and addiction associated betel quid use in an unban population. Methods: We conducted a survey study of 200 betel quid users in Yangon, Myanmar, and a survey of betel quid vendors to determine the relative amounts of areca and tobacco in the available quids. Results: The data determined that a large majority of the survey subjects (84%) used tobacco with their areca. Users had a general awareness that betel chewing was "a bad habit" (85%) and 80% were aware of the cancer risks. Understanding areca addiction remains a challenge since, aside from the strong muscarinic activity of arecoline stimulating salivation, overt neurologic effects are difficult for even the users to identify. Fifty eight percent of the respondents indicated that chewing betel quid had effects like drinking coffee, and 55.5% indicated that it had effects like drinking alcohol. Data obtained from the quid vendors indicated that 75% added tobacco in equal amounts to areca. Conclusion: The concomitant use of nicotine and areca indicates that betel quid addiction includes a significant component of nicotine dependence. However, the additional activities of areca, including the muscarinic effects of arecoline, indicate that potential cessation therapies should optimally address other factors as well.

Keywords: Areca; addiction; cancer; cessation therapy; drug dependence; tobacco.

Figure 1.

Initial use of areca. (A) The average age at which subjects began using betel quid was 20 years old (±0.5), with a median age of 19. (B) Leading influences on the initiation of betel use.

Figure 2.

Daily use of betel quid by study subjects. (A) Preferred time(s) of day. Although the highest reported use was in the mornings, 13% of the subjects reported using betel quid at all times of day. (B) The average number of quids chewed per day was 4.3 (±0.2), with a median of 4.

Figure 3.

The longest period without chewing betel quid within the last year. The subjects fell into two groups, with 37% reporting that they had not gone as long as a day without chewing, and the remaining 63% had varying durations of abstinence. Not fitting a normal distribution, data were plotted as the log of the duration. For those subjects who reported abstinence periods of a day or longer, the average was 10.1 days (±1.1), with a median of 10 days.

Figure 4.

The composition of betel quids sold by vendors within the study area. (A) The average values (±SEM) in grams of the four principle quid components. (B) Histograms of the values from the 12 vendors sampled. (C) The generally strong correlation between the amounts of tobacco and areca in the quids made by individual vendors.