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Tob Control. 2005 Jun; 14(Suppl 1): i16–i22.
PMCID: PMC1766184

Uncovering the relation between betel quid chewing and cigarette smoking in Taiwan


Objective: To describe the characteristics of betel quid chewers and to investigate the behavioural and mortality relations between betel quid chewing and cigarette smoking.

Method: Prevalence and mortality risks of betel quid chewers by smoking status were calculated, based on the National Health Interview Survey in 2001 and a community based cohort, respectively. Cox's proportional hazards model was used to adjust mortality risks for age, alcohol use, and education.

Results: Almost all betel quid chewers were smokers, and most started chewing after smoking. Chewers were predominantly male, mostly in their 30s and 40s, more likely being among the lowest educational or income group, and residing in the eastern regions of Taiwan. On average, betel quid chewers who smoked consumed 18 pieces of betel quid a day, and smoked more cigarettes per day. Far more smokers use betel quid than non-smokers (27.5% v 2.5%), but ex-smokers quit betel quid more than smokers (15.1% v 6.8%). The significantly increased mortality of betel quid users who also smoked, for all causes, all cancer, oral cancer, and cancer of the nasopharynx, lung, and liver, was the result of the combined effects of chewing and smoking. Smokers who chewed betel quid nearly tripled their oral cancer risks from a relative risk of 2.1 to 5.9. Increasing the number of cigarettes smoked among betel quid chewers was associated with a synergistic effect, reflective of the significant interaction between the two.

Conclusion: To a large extent, the serious health consequences suffered by betel quid chewers were the result of the combined effects of smoking and chewing. Betel quid chewing should not be considered as an isolated issue, but should be viewed conjointly with cigarette smoking. Reducing cigarette smoking serves as an important first step in reducing betel quid chewing, and incorporating betel quid control into tobacco control may provide a new paradigm to attenuate the explosive increase in betel quid use in Taiwan.

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Selected References

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  • Warnakulasuriya Saman, Trivedy Chetan, Peters Timothy J. Areca nut use: an independent risk factor for oral cancer. BMJ. 2002 Apr 6;324(7341):799–800. [PMC free article] [PubMed]
  • Winstock A. Areca nut-abuse liability, dependence and public health. Addict Biol. 2002 Jan;7(1):133–138. [PubMed]
  • Gupta PC, Warnakulasuriya S. Global epidemiology of areca nut usage. Addict Biol. 2002 Jan;7(1):77–83. [PubMed]
  • Ko YC, Chiang TA, Chang SJ, Hsieh SF. Prevalence of betel quid chewing habit in Taiwan and related sociodemographic factors. J Oral Pathol Med. 1992 Jul;21(6):261–264. [PubMed]
  • Williams S, Malik A, Chowdhury S, Chauhan S. Sociocultural aspects of areca nut use. Addict Biol. 2002 Jan;7(1):147–154. [PubMed]
  • Glassman AH, Koob GF. Neuropharmacology. Psychoactive smoke. Nature. 1996 Feb 22;379(6567):677–678. [PubMed]
  • Johnston GA, Krogsgaard-Larsen P, Stephanson A. Betel nut constituents as inhibitors of gamma-aminobutyric acid uptake. Nature. 1975 Dec 18;258(5536):627–628. [PubMed]
  • Chu NS. Sympathetic response to betel chewing. J Psychoactive Drugs. 1995 Apr-Jun;27(2):183–186. [PubMed]
  • Cawte J. Psychoactive substances of the South Seas: betel, kava and pituri. Aust N Z J Psychiatry. 1985 Mar;19(1):83–87. [PubMed]
  • Chen KT, Chen CJ, Fagot-Campagna A, Narayan KM. Tobacco, betel quid, alcohol, and illicit drug use among 13- to 35-year-olds in I-Lan, rural Taiwan: prevalence and risk factors. Am J Public Health. 2001 Jul;91(7):1130–1134. [PMC free article] [PubMed]
  • Yang MS, Su IH, Wen JK, Ko YC. Prevalence and related risk factors of betel quid chewing by adolescent students in southern Taiwan. J Oral Pathol Med. 1996 Feb;25(2):69–71. [PubMed]
  • Wang Su-Chen, Tsai Chi-Cheng, Huang Shun-Te, Hong Yu-Jue. Betel nut chewing and related factors in adolescent students in Taiwan. Public Health. 2003 Sep;117(5):339–345. [PubMed]
  • Lu CT, Lan SJ, Hsieh CC, Yang MJ, Ko YC, Tsai CC, Yen YY. Prevalence and characteristics of areca nut chewers among junior high school students in Changhua county, Taiwan. Community Dent Oral Epidemiol. 1993 Dec;21(6):370–373. [PubMed]
  • Liaw KM, Chen CJ. Mortality attributable to cigarette smoking in Taiwan: a 12-year follow-up study. Tob Control. 1998 Summer;7(2):141–148. [PMC free article] [PubMed]
  • Sun CA, Wang LY, Chen CJ, Lu SN, You SL, Wang LW, Wang Q, Wu DM, Santella RM. Genetic polymorphisms of glutathione S-transferases M1 and T1 associated with susceptibility to aflatoxin-related hepatocarcinogenesis among chronic hepatitis B carriers: a nested case-control study in Taiwan. Carcinogenesis. 2001 Aug;22(8):1289–1294. [PubMed]
  • Tyas SL, Pederson LL. Psychosocial factors related to adolescent smoking: a critical review of the literature. Tob Control. 1998 Winter;7(4):409–420. [PMC free article] [PubMed]
  • Distefan JM, Gilpin EA, Choi WS, Pierce JP. Parental influences predict adolescent smoking in the United States, 1989-1993. J Adolesc Health. 1998 Jun;22(6):466–474. [PubMed]
  • Newman IM, Ward JM. The influence of parental attitude and behavior on early adolescent cigarette smoking. J Sch Health. 1989 Apr;59(4):150–152. [PubMed]
  • Lu CT, Yen YY, Ho CS, Ko YC, Tsai CC, Hsieh CC, Lan SJ. A case-control study of oral cancer in Changhua County, Taiwan. J Oral Pathol Med. 1996 May;25(5):245–248. [PubMed]
  • Ko YC, Huang YL, Lee CH, Chen MJ, Lin LM, Tsai CC. Betel quid chewing, cigarette smoking and alcohol consumption related to oral cancer in Taiwan. J Oral Pathol Med. 1995 Nov;24(10):450–453. [PubMed]
  • Wang Li-Yu, You San-Lin, Lu Sheng-Nan, Ho Hsi-Chang, Wu Mei-Hui, Sun Chien-An, Yang Hwai-I, Chien-Jen Chen. Risk of hepatocellular carcinoma and habits of alcohol drinking, betel quid chewing and cigarette smoking: a cohort of 2416 HBsAg-seropositive and 9421 HBsAg-seronegative male residents in Taiwan. Cancer Causes Control. 2003 Apr;14(3):241–250. [PubMed]
  • Sun Chien-An, Wu Der-Min, Lin Chia-Chin, Lu Sheng-Nan, You San-Lin, Wang Li-Yu, Wu Mei-Hsuan, Chen Chien-Jen. Incidence and cofactors of hepatitis C virus-related hepatocellular carcinoma: a prospective study of 12,008 men in Taiwan. Am J Epidemiol. 2003 Apr 15;157(8):674–682. [PubMed]
  • Lin Hans-Hsienhong, Wang Li-Yu, Shaw Cheng-Kuang, Cheng Mu-Liang, Chung Wen-Kuan, Chiang Hsin-Jung, Lin Teng-Yi, Chen Chien-Jen. Combined effects of chronic hepatitis virus infections and substance-use habits on chronic liver diseases in Taiwanese aborigines. J Formos Med Assoc. 2002 Dec;101(12):826–834. [PubMed]
  • Tsai Jung-Fa, Jeng Jen-Eing, Chuang Lee-Yea, Ho Mei-Shang, Ko Yin-Chin, Lin Zu-Yau, Hsieh Min-Yuh, Chen Shin-Chern, Chuang Wan-Lung, Wang Liang-Yen, et al. Habitual betel quid chewing as a risk factor for cirrhosis: a case-control study. Medicine (Baltimore) 2003 Sep;82(5):365–372. [PubMed]
  • Tsai JF, Chuang LY, Jeng JE, Ho MS, Hsieh MY, Lin ZY, Wang LY. Betel quid chewing as a risk factor for hepatocellular carcinoma: a case-control study. Br J Cancer. 2001 Mar 2;84(5):709–713. [PMC free article] [PubMed]
  • Chu NS. Cardiovascular responses to betel chewing. J Formos Med Assoc. 1993 Sep;92(9):835–837. [PubMed]
  • Sharma AK, Gupta R, Gupta HP, Singh AK. Haemodynamic effects of pan masala in healthy volunteers. J Assoc Physicians India. 2000 Apr;48(4):400–401. [PubMed]

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