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

86 Pages·2014·0.49 MB·English

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, 44- 52
and oral health problems

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.
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).
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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
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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:
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).
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
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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.
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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).

1.2.3 Carcinogenic potential of areca nut:
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). 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
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