What Motivates Betel Quid Chewers to Quit? An Analysis of Several Cessation-Relevant Variables.

Introduction: Betel quid (BQ) is globally the fourth most consumed psychoactive substance. It is consumed by an estimated 600 million people worldwide, accounting for nearly 8% of the world's population. There have been very few studies assessing chewers' motivation to quit. Objectives: In the current study, we sought to understand the relationship between several cessation-relevant variables and chewers' motivation to quit. Hypotheses: Based on analogous research on cigarette smoking, we hypothesized that the following cessation-relevant variables would be associated with motivation to quit: health risk perceptions, number of chews per day, cost, degree of BQ dependence, withdrawal symptoms, number of quit attempts, reasons for use, personal health improvement, and type of BQ chewed. Methods: A total of 351 adult BQ chewers from Guam participated in the survey and served as the sample for the analyses. Results: Majority of chewers want to quit and intend to quit. Chewers relatively high in motivation to quit evinced greater health risk perceptions of BQ chewing, greater perceived health benefits to quitting, and a greater number of past quit attempts, compared to those relatively low in motivation to quit. Conclusions: Understanding which factors are associated with chewers' motivation to quit can be helpful for designing BQ cessation programs. The results suggest that BQ cessation programs could be improved by an increased emphasis on information about the negative health effects of BQ chewing and relapse-prevention.

The Reasons for Betel Quid Chewing Scale (RBCS) for Ex-Chewers: Assessment of Factor Structure, Reliability, Validity and Measurement Invariance across Gender in a Guamanian Sample.

BACKGROUND: Over 600 million people chew betel nut worldwide and the behavior is classified by the World Health Organization (WHO) as a Group 1 carcinogen. Having a reliable and valid scale of reasons for chewing betel nut that can be used consistently across gender for both chewers and ex-chewers will assist practitioners to create culturally appropriate risk reduction and cessation programs and address an important public health concern.Purpose/Objectives: We sought to: 1) examine factor structure, reliability, and validity of the Reasons for Chewing Scale (RBCS) for ex-chewers; 2) examine the influence of social-cultural factors on chewing behaviors; and 3) examine if measurement invariance (MI) of the RBCS held consistently across gender groups. METHODS: A Confirmatory Factor Analysis (CFA), a multigroup CFA for testing measurement invariance (MI), and Structural Equation Modeling (SEM) were applied to the RBCS using a convenience sample of (N = 223) of ex-chewers from Guam. RESULTS: The majority of the items in the RBCS were found to be moderately or strongly correlated to each other. The CFA model fit the ex-chewers' data well and the model suggested that the RBCS was found to be reliable and valid. The multi-group CFA showed this scale functions equivalently for both male and female groups.Conclusions/Importance: The RBCS is a valid and reliable measure that is invariant across gender and type of ex-chewer.

Confirmatory factor analysis and structural equation modeling of socio-cultural constructs among chamorro and non-chamorro micronesian betel nut chewers.

Objectives: Betel nut chewing is embedded within the cultures of South Asia, and Southeast Asia, and the Western Pacific. The determinants of betel nut consumption are complex. Ongoing consumption of betel nut is affected by cultural, social, and drug-specific effects (i.e. dependence). This study's first objective was to assess the psychometric properties (i.e. reliability and validity) of the socio-cultural constructs in a survey developed for betel nut chewers. The study's second objective was to investigate the influence of socio-cultural variables on betel nut chewing behaviors among Chamorro and non-Chamorro Micronesians in Guam. Design: The current study was a secondary analysis of a larger study (N = 600; n = 375 chewers and n = 225 former chewers) that examined socio-cultural factors that influence why chewers chew betel nut, along with assessing chewing behaviors, perceptions of risks, probability of changing behaviors, and methods that could be used to reduce use or quit. The socio-cultural constructs of the survey were analyzed using confirmatory factor analysis and structural equation modeling. Results: The socio-cultural factors were a sufficient fit with data and the instrument is reliable and valid, as indicated by various model fit indices (χ2 (13) = 18.49 with p = .14, TLI = .99, CFI = 1.00, SRMR = .02, RMSEA = .03 with 90% CIs [.00,.07]). Cronbach's alpha, the sign and magnitude of the factor loadings, the inter-factor correlations, and the large proportion of variance extracted for each factor, all indicate that the instrument is reliable and valid. Additionally, multivariate analyses showed that socio-cultural reasons were important contributing or chewing betel nut. Participants cited chewing because their friends and family members chewed, the behavior is embedded within their culture, and it would be considered rude and disrespectful to not chew. Conclusion: Based on the findings, this study provides important implications pertaining to creating culturally appropriate cessation programs.

Sociocultural Factors that Affect Chewing Behaviors among Betel Nut Chewers and Ex-Chewers on Guam.

Areca nut (betel nut) is chewed by an estimated 10% of the world's population which is equivalent to about 600 million people. It is classified as a Group 1 carcinogen by the World Health Organization (WHO) and has been linked to various types of oral cancer. Chewing areca predominates in South and South East Asia, East Africa, and the Western Pacific and has important social and cultural implications. The purpose of the pilot study was twofold: (1) to examine sociocultural factors that affect why people on Guam chew betel nut, their chewing behaviors, perceptions of risks, probability of changing behaviors, and methods that could be used to reduce use or quit; and (2) to pilot two surveys (one for chewers and one for ex-chewers) to be used in a larger study in the future. A mixed methods design was employed that included surveys pertaining to their status (chewer or ex-chewer) and in-depth interviews. A total of 30 adults participated in this pilot study: adult betel nut chewers (n = 15) and ex-chewers (n = 15). Chewing betel nut is a learned behavior, embedded within the culture, and is viewed as an important cultural identifier. Socially, chewing is viewed as positive. Chewers stated that they were not as aware of health issues; however, ex-chewers stated health reasons for quitting.

Intention to quit betel quid: a comparison of betel quid chewers and cigarette smokers.

BACKGROUND: Despite the global significance of betel quid chewing and the associated health risks, there have been no studies assessing chewers' intention to quit. Given the difficulties associated with quitting betel quid and the serious health consequences of chewing, it is important for researchers to develop interventions aimed at helping chewers quit. Betel quid chewers experience similar patterns of dependence and withdrawal symptoms as tobacco smokers, and the use of both substances causes serious adverse health effects. Therefore, it is possible that intention to quit betel quid and tobacco would also be similar. If similarities were found, researchers could look to existing tobacco cessation interventions to inform the development of betel quid cessation interventions. In the current study we sought to understand chewers' intention to quit and how it compares to smokers' intention to quit cigarettes. METHODS: A total of 351 adult betel quid chewers from Guam were compared against 1,555 adult tobacco users from Hawaii. These comparisons were made possible because of the deliberate use of identical questionnaire items (mutatis mutandis) for betel quid chewing and cigarette smoking. RESULTS: Smokers reported higher levels of wanting to quit, intending to quit, and wishing they have never started in the first place compared to chewers (p's<.0001). There were no differences across groups with regard to having a plan for how to quit and when to quit, with half of the samples reporting not having a plan for how or when to quit. CONCLUSION: Both smokers and chewers want to quit and intend to quit, but do not have plans of when or how to quit. A deeper understanding of chewers' intention to quit and its similarities to smokers' intention to quit could be used to inform the development of betel quid cessation interventions.

The reasons for betel-quid chewing scale: assessment of factor structure, reliability, and validity.

BACKGROUND: Despite the fact that betel-quid is one of the most commonly used psychoactive substances worldwide and a major risk-factor for head-and-neck cancer incidence and mortality globally, currently no standardized instrument is available to assess the reasons why individuals chew betel-quid. A measure to assess reasons for chewing betel-quid could help researchers and clinicians develop prevention and treatment strategies. In the current study, we sought to develop and evaluate a self-report instrument for assessing the reasons for chewing betel quid which contributes toward the goal of developing effective interventions to reduce betel quid chewing in vulnerable populations. METHODS: The current study assessed the factor structure, reliability and convergent validity of the Reasons for Betel-quid Chewing Scale (RBCS), a newly developed 10 item measure adapted from several existing "reasons for smoking" scales. The measure was administered to 351 adult betel-quid chewers in Guam. RESULTS: Confirmatory factor analysis of this measure revealed a three factor structure: reinforcement, social/cultural, and stimulation. Further tests revealed strong support for the internal consistency and convergent validity of this three factor measure. CONCLUSION: The goal of designing an intervention to reduce betel-quid chewing necessitates an understanding of why chewers chew; the current study makes considerable contributions towards that objective.

The Betel Quid Dependence Scale: replication and extension in a Guamanian sample.

BACKGROUND: Betel quid is the fourth most commonly consumed psychoactive substance in the world. The Betel Quid Dependence Scale (BQDS) is the first instrument designed specifically to measure betel quid dependence. The three factor structure of the BQDS consists of "physical and psychological urgent need," "increasing dose," and "maladaptive use." The BQDS initially was validated in a sample of male prisoner ex-chewers in Taiwan. OBJECTIVE: To replicate and extend the original validation research on the BQDS in a sample of male and female current betel quid chewers in Guam. METHODS: A survey containing the BQDS was administered to 300 current betel quid chewers in Guam. Participants were compensated for their time with a gift card worth $25. RESULTS: Confirmatory factor analysis revealed an adequate fit with the hypothesized three-factor measurement model. ANOVAs and structural equations modeling revealed that betel quid dependence is associated with the inclusion of tobacco in the quid, number of chews per day, years of chewing, and education. CONCLUSIONS: The BQDS is valid for current English-speaking male and female chewers in Guam. Overall levels of betel quid dependence were high, and most chewers included tobacco in their betel quid. The results suggest that levels of dependence for betel quid are similar to those observed for nicotine dependence. Future research should explore other important psychological and behavioral aspects of betel quid chewing such as health risk perceptions and motivation to quit chewing.