Background The purpose of this project was to investigate the use of tobacco with betel nut chewing in Saipan, CNMI (Micronesia). Betel nut is a carcinogenic palm nut chewed mainly in south Asia and the western and southern Pacific islands. It is a habitual practice that is considered by many to be an integral part of their culture. There are many different ways of preparing betel nut, and many include tobacco (mainly cigarettes on Saipan) in the mix. This greatly amplifies the addiction, as well as the risk of oral cancer, among other diseases. It appears that betel nut is being used more frequently and at a younger age on Saipan. Tobacco use by minors has escaped scrutiny because of the role that betel nut has in local culture.
Study Design and Methods All subjects recruited were betel nut chewers between ages 18 and 40 years and were indigenous Micronesians (Chamorro, Carolinian, etc). Interview subjects were recruited during their visit to the Commonwealth Health Center on Saipan. Questions asked structured and open-ended questions aimed at eliciting usage patterns, attitudes, and beliefs about betel nut chewing with or without tobacco.
Results Of the 41 subjects interviewed, 37 (90%) reported chewing betel nut with tobacco. Nearly all first experiences with betel nut occur without tobacco (mean age 12.2 years). After tobacco is introduced (mean age 14.5 years) the addiction habit tends to develop (mean age 15.6 years). Those who chew betel nut with tobacco appear to be about twice as likely not to smoke tobacco. Two out of 3 believe that chewing betel nut is part of their culture. However, nearly all do not believe that including tobacco in betel nut is a cultural practice. Eight out of 10 mentioned the risk of cancer with chewing betel nut. None of those who spoke of cancer identified betel nut itself as a cancer-causing agent. They believed that it was either the tobacco, lime paste, or both that caused cancer.
Conclusion There is a possibility that attempts at reducing chewing betel nut with cigarettes or tobacco may lead to an unintended increase in smoking tobacco. There are no current data to support or refute this concern. To account for this possibility, educational interventions must be focused on reducing tobacco use overall. A holistic approach on educating the public on the harms of tobacco use and chewing betel nut is necessary.
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