title: Betel-quid dependence domains and syndrome associated with betel-quid ingredients among chewers: an Asian multi-country evidence.
abstract: OBJECTIVE
  Betel-quid (BQ) contains biologically psychoactive ingredients; however, data are limited concerning the symptoms and syndrome of BQ dependence among chewers. The aims of this study were to evaluate the ingredients-associated BQ dependence syndrome and country-specific chewing features and behaviour for BQ dependence among chewers from six Asian communities.
  
  
  METHODS
  An intercountry Asian Betel-quid Consortium study.
  
  
  METHODS
  Six Asian general communities in Taiwan, Mainland China, Indonesia, Malaysia, Sri Lanka and Nepal.
  
  
  METHODS
  Six multi-stage random samples of BQ chewers in the Asian Betel-quid Consortium study (n = 2078).
  
  
  METHODS
  All chewers were evaluated for BQ dependence using the DSM-IV and ICD-10 criteria.
  
  
  RESULTS
  The 12-month BQ dependence rate was 12.5-92.6% and 47.9-99.3% (P = 0.023) among tobacco-free and tobacco-added BQ chewers across the six Asian communities, with a higher dependence rate in chewers who used tobacco-free BQ with lime added than without (23.3-95.6% versus 4.0%, P ≤ 0.001). Taiwanese and Hunanese BQ chewers both notably endorsed the dependency domain of 'time spent chewing'. 'Tolerance' and 'withdrawal' were the major dependence domains associated with the Nepalese and Indonesian chewers, with high BQ dependence rates. Malaysian and Sri Lankan chewers formed a BQ dependence cluster linked closely to 'craving'. In Sri Lanka, the quantity consumed explained 90.5% (P < 0.001) of the excess dependence risk for tobacco-added use, and could be a mediator between tobacco-derived psychoactive effect and BQ dependence development.
  
  
  CONCLUSIONS
  DSM-IV criteria for dependence apply to a significant proportion of betel quid users in Asian communities, more so if they use it with tobacco or lime.
authors.affiliation: Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan; Centre of Excellence for Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors.forename: Chien-Hung
authors.initials: CH
authors.lastname: Lee
authors.forename: Shang-Lun
authors.initials: SL
authors.lastname: Chiang
authors.forename: Albert Min-Shan
authors.initials: AM
authors.lastname: Ko
authors.forename: Chun-Hung
authors.initials: CH
authors.lastname: Hua
authors.forename: Ming-Hsui
authors.initials: MH
authors.lastname: Tsai
authors.forename: Saman
authors.initials: S
authors.lastname: Warnakulasuriya
authors.forename: Salah Osman
authors.initials: SO
authors.lastname: Ibrahim
authors.lastname: Sunarjo
authors.forename: Rosnah Binti
authors.initials: RB
authors.lastname: Zain
authors.forename: Tian-You
authors.initials: TY
authors.lastname: Ling
authors.forename: Chieh-Liang
authors.initials: CL
authors.lastname: Huang
authors.forename: Hsien-Yuan
authors.initials: HY
authors.lastname: Lane
authors.forename: Cheng-Chieh
authors.initials: CC
authors.lastname: Lin
authors.forename: Ying-Chin
authors.initials: YC
authors.lastname: Ko
mesh_terms: D000328:Adult; D001114:Areca; D001208:Asia / Q000453:epidemiology; D015897:Comorbidity; D066249:Craving; D004361:Drug Tolerance; D005260:Female; D006801:Humans; D008297:Male; D008409:Mastication; D008875:Middle Aged; D009754:Nuts; D013375:Substance Withdrawal Syndrome / Q000453:epidemiology; D019966:Substance-Related Disorders / Q000453:epidemiology*; D013577:Syndrome; D014029:Tobacco Use Disorder / Q000453:epidemiology
keywords: Areca nut; arecoline; betel-quid; dependence; psychoactive ingredient; tobacco