Areca nut dependence among chewers in a South Indian community who do not also use tobacco

Aims Previously reported research suggests a dependence syndrome for areca nut use, though well-designed studies are virtually non-existent. The goal of this study was to examine evidence of areca dependence in a sample of areca-only (i.e. no tobacco) chewers using modified measurement scales. Design A purposive sample of chewers, identified via local informants and advertisements, was surveyed from January to March of 2005. Setting Six villages in Dakshina Kannada District, Karnataka State, India. Participants Fifty-nine daily areca chewers who do not also currently use any form of tobacco. Measurements Questionnaires included modified versions of the Fagerstrom Tolerance Questionnaire, Cigarette Dependence Scale (CDS-5) and the Smokeless Tobacco Dependence Scale (STDS). Additional questions assessed demographic characteristics and patterns of use. Findings Approximately half of respondents reported 1-3 chews/day (mean = 1.9; SD = 0.98). The average number of chewing episodes/day was 4.4 (SD = 3.4) and the average number of nuts/day was 1.2 (SD = 1.1). Users' typical chew lasts up to 20 minutes and includes spitting out the juices and rinsing the mouth with water. Overall, the levels of reported dependence symptoms were quite low, but approximately 44% of chewers endorsed at least one of the following items: continued use despite illness or mouth wounds, difficulty refraining from chewing in forbidden places, or craving during periods of abstinence. Approximately 15.4% of chewers reported at least one intentional quit attempt and a subset had summary scores indicative of dependence (13.6% had scores > 16 on the CDS-5 and 5.3% had scores > 11 on the STDS). Dependence scores were positively correlated with frequency of chews/day. Conclusions The symptoms of dependence observed in a subset of areca-only chewers warrant further investigation. Next steps should include well-controlled laboratory evaluation of dependence features.