Betel-quid dependence domains and syndrome associated with betel-quid ingredients among chewers: an Asian multi-country evidence

Aims 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. Design An intercountry Asian Betel-quid Consortium study. Setting Six Asian general communities in Taiwan, Mainland China, Indonesia, Malaysia, Sri Lanka and Nepal. Participants Six multi-stage random samples of BQ chewers in the Asian Betel-quid Consortium study (n=2078). Measurements All chewers were evaluated for BQ dependence using the DSM-IV and ICD-10 criteria. Findings 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%, P0.001). 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.