title: Areca nut chewing and dependency syndrome: is the dependence comparable to smoking? a cross sectional study.
abstract: BACKGROUND
  Areca nut is the seed of fruit oriental palm known as Areca catechu. Many adverse effects of nut chewing have been well documented in the medical literature. As these nuts are mixed with some other substances like tobacco and flavouring agents, it has been hypothesized that it might also cause some dependency symptoms among its users. Therefore, the objective of this study was to investigate dependency syndrome among areca nut users with and without tobacco additives and compare it with dependency associated with cigarette smoking among the male Pakistani population.
  
  
  METHODS
  This was an observational cross sectional study carried out on healthy individuals, who were users of any one of the three products (areca nut only, areca nut with tobacco additives, cigarette smokers). Participants were selected by convenience sampling of people coming to hospital to seek a free oral check up. Information was collected about the socio-demographic profile, pattern of use and symptoms of dependency using the DSM-IV criteria for substance dependence. We carried out multiple logistic regressions to investigate association between socio-demographic profile, pattern of substance use and dependency syndrome.
  
  
  RESULTS
  We carried out final analysis on 851 individuals, of which 36.8% (n = 314) were areca nut users, 28.4% (n = 242) were the chewers of areca with tobacco additives and 34.7% (n = 295) were regular cigarette smokers. Multivariate analyses showed that individuals using areca nut with tobacco additives were significantly more likely to have dependency syndrome (OR = 2.17, 95% CI 1.39-3.40) while cigarette smokers were eight times more likely to have dependency syndrome as compared to areca nut only users.
  
  
  CONCLUSIONS
  Areca nut use with and without tobacco additives was significantly associated with dependency syndrome. In comparison to exclusive areca nut users, the smokers were eight times more likely to develop dependence while areca nut users with tobacco additives were also significantly more likely to suffer from the dependence.
authors.affiliation: Department of Physiology, Institute of Basic Medical Sciences, Dow University of Health Sciences, Karachi, Pakistan.
authors.forename: Saira S
authors.initials: SS
authors.lastname: Mirza
authors.forename: Kashif
authors.initials: K
authors.lastname: Shafique
authors.forename: Priya
authors.initials: P
authors.lastname: Vart
authors.forename: Moin I
authors.initials: MI
authors.lastname: Arain
mesh_terms: D000293:Adolescent; D000328:Adult; D001114:Areca / Q000009:adverse effects*; D016739:Behavior, Addictive / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology*; D003430:Cross-Sectional Studies / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008409:Mastication; D009754:Nuts / Q000009:adverse effects*; D010154:Pakistan / Q000453:epidemiology; D019966:Substance-Related Disorders / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology*; D014029:Tobacco Use Disorder / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology*