原文題目(出處)： Areca nut chewing and dependency syndrome: Is the dependence comparable to smoking? A cross sectional study. Substance Abuse Treatment, Prevention, and Policy 2011, 6:23.
原文作者姓名： Saira S Mirza
通訊作者學校： Centre of Population & Health Sciences, Department of Public Health and Health Policy, university of Glasgow, Glasgow, UK.
報告者姓名(組別)： 吳宗勳 (Intern E 組)
1. Areca nut is the seed of the fruit of the tropical palm tree, Areca Catechu.
2. Thin slices of nuts either natural or processed are then mixed with a variety of substances including slaked lime (calcium hydroxide) and spices.
3. Most importantly these nuts are also mixed with some tobacco products.
4. Four most commonly used psychoactive substance: tobacco, alcohol, caffeine and Areca nut
5. Approximately 10% of the World’s population chew it regularly.
6. Many epidemiological studies have revealed that continuous use of areca nut is associated with many adverse health effects from oral leukoplakia to submucous fibrosis which is subsequently linked with cancer risk.
7. WHO International Agency for Research on Cancer Monograph Working Group (2009) highlighed that the evidence on areca nut and its association with oral, pharyngeal and esophageal cancer is sufficient to establish a causal link.
8. Areca nut chewing has been claimed to manifest a sense of well-being, euphoria, salivation, warm sensation of the body, low to moderate sweating and palpitations.
9. Little is confirmed about the dependency syndrome among areca nut users as compared to the symptoms of dependency among tobacco users.
10. The present study was carried out to explore the dependency syndrome among the areca nut chewers in comparison with cigarette smokers.
11. Furthermore, the study also has an objective to investigate the major determinants associated with the dependency syndrome among the areca nut chewers and cigarette smokers.
1. We included healthy individuals from population for this study who were invited to outdoor patients department of Civil Hospital Karachi.
2. Users of any one of the three products (i.e. Areca nut only or Areca nut with tobacco additives or just tobacco use in the form of cigarettes).
1. All willing healthy male individuals between the ages of 16 to 35 who visited the outdoor patient department during January 2009 to December 2010
1. Refused to participate in the survey
2. Unable to understand Urdu (National language of Pakistan)
3. Individuals who visited the hospital due to current illness or follow up of a previous illness were also excluded.
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1. Information was collected by using a pre-tested questionnaire
A. Sociodemographic profile (including age, years of education, nature of job/study)
B. Pattern of substance use (frequency, number of years since use, daily consumption, type of substance and family history of use).
2. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) module for substance dependence.
A. We translated the DSM-IV module of substance dependence to Urdu by using a committee approach.
B. Bilingual and selected for their proficiency in both English and Urdu.
C. Two of them translated the English questionnaire to Urdu at an initial stage.
D. Another two judged the translation in relation to the original questionnaire.
E. On second step, the other two individual who had no prior knowledge about this DSM-IV module translated the Urdu version back to English.
F. The two judges again compared the converted English version of questionnaire to original questionnaire
G. All six members sat together to select the best translations.
H. This questionnaire was piloted to the first 25 participants of the study.
3. Questions were about the
A. tolerance (needing more to become intoxicated or discovering less effect with same amount)
B. withdrawal (characteristic withdrawal associated with this type of drug) C. Using more or for longer periods than intended?
D. Desire to or unsuccessful efforts to cut down?
E. Considerable time spent in obtaining the substance or using, or recovering from its effects?
F. Important social, work, or recreational activities given up because of use?
G. Continued use despite knowledge of problems caused by or aggravated by use.
4. Presence of any three of these during the same 12 months period confirmed the presence of dependency syndrome.
Sample size estimation
1. A sample of 630 participants was the minimum number required to be accrued to perform this survey.
Basic characteristics of study sample
1. 900 individuals were regular users of any of the three products (i.e. areca nut or areca with tobacco additives or cigarette smokers).
2. 35 subjects lacked basic information about age, use of product and exact quantity of substance used,
3. 14 subjects missed some important questions related to dependency symptoms.
4. Final analysis was carried out on 851 individuals A. 36.8% (n =314) were areca nut users
B. 28.4% (n = 242) were the chewers of areca nut with tobacco additives C. 34.7% (n = 295) were regular smokers.
5. Similar average age in all three groups (25.5 ± 5.53 vs 25.0 ± 5.62 vs 25.9 ± 5.81: p = 0.19).
6. No significant difference of years of formal education between the three groups (11.3 ± 2.56 vs 11.8 ± 3.26 vs 11.6 ± 2.10).
7. Significant differences were noted in the family history of substance use and the
number of years since they began using these products.
Dependency syndrome among users
1. The frequency of dependency syndrome between the three groups was significantly different.
A. Areca only users, 67.2% (n = 211)
B. Areca with tobacco additives users, 7 8.1% (n = 189) C. Smokers, 89.8% (n = 265)
2. Withdrawal symptoms, attempt to cut down and continue use were significantly higher among the cigarette smokers (p < 0.001).
3. Excess use than intended and social or recreational activity given up were highest among the areca nut only users (p < 0.001).
4. On univariate analysis, increasing age, family history of substance use and increasing duration of use were significantly associated with increased likelihood of dependency syndrome.
5. Taking the areca only as a reference group showed that
A. Areca nut with tobacco additives (OR = 1.74, 95% CI 1.18-2.56) users B. Smoking only group (OR = 4.31, 95% CI 2.76-6.73) were more likely to have dependency syndrome.
6. Multivariate analysis also showed similar findings as univariate analysis except that age was no longer associated with dependency syndrome after adjustment for the duration of use.
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7. No significant association between years of full time education and dependency syndrome.
1. 9 out of 10 cigarette smokers had dependency syndrome, while 8 out of 10 areca users with tobacco additives had dependency syndrome.
2. This can be explained by the addictive potential of nicotine.
3. It is difficult to exactly differentiate and estimate the dependency symptom associated with areca nut or tobacco independently.
4. Dependency syndrome among the areca nut only group was 67%, although high, but have been found slightly inconsistent in earlier studies as well. Because of
A. different sample sizes
B. only included male participants C. different regions
5. Biological mechanism underlying the association of areca nut chewing with dependency syndrome is less clear, however Arecoline (a psychoactive agent) has been thoroughly investigated and areca nut chewing has been suggested to produce a sense of well being, euphoria, heightened alertness, sweating, salivation and a hot body sensation.
6. Increasing age was significantly associated with increased likelihood of dependency syndrome in univariate model, but in multivariate model age was not significantly associated with dependency syndrome.
7. The longer duration of substance, the more likely it is to lead to dependency syndrome.
8. Positive family history of substance usage doubles the likelihood of developing dependency syndrome.
9. Previous evidence showed that increasing education decreases the likelihood of areca nut use and dependency, however we did not observe any association between education and dependency.
Limitations of this research
1. The participants were selected by convenient sampling and from one region of this city.
2. We used only male individuals
3. Most of the individuals were from average or below average socio-economic class.
4. We used a cross-sectional design, so our study was unable to explore any time trends in use and the development of dependency syndrome among areca nut users.
Public health implications
1. Areca nuts may lead to oral diseases and malignancy, adverse pregnancy outcome and systemic diseases.
2. Health education and awareness are perhaps the most crucial interventions required to be delivered so that the adverse effects of the substance can be s need to be focused on all age groups, in particular early age appreciated by the community.
3. These intervention school children.
1. Areca nut with and without tobacco additives is significantly associated with the dependency syndrome.
2. In comparison to areca nut only users, the smokers are eight times more likely to develop dependence, while areca nut users with tobacco additives are also
gnific ore likely to have the dependence.
si antly m
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