Background: Areca nut (AN) is a carcinogenic substance consumed by roughly 600 million individuals worldwide with increasing popularity in Guam. In response, a cessation program was developed and implemented in Guam and Saipan. However, to improve its delivery, it is necessary to understand the reasons influencing recruitment and participation, such as why a chewer may not want to quit or join a cessation program.Objective: To explore barriers inhibiting chewers from quitting AN chewing and from participating in a cessation program.Methods: Nine individual and group discussions were facilitated with a convenience sample of 17 chewers and nonchewers in Guam in 2017. The mean age of the participants was 36.4 years. Recurring themes relating to reasons for not quitting and not joining a cessation program were extracted.Results: Results produced 3 general categories -Sociocultural, Behavioral, and Accessible. Each category encompasses different attributes concerning reasons not to quit chewing (e.g. addiction, enabling community, or belief that AN is harmless), and reasons influencing lack of participation in a cessation program (e.g. time, transportation, or relatability).Conclusions: Current findings suggest chewers are unaware of the harmful effects of AN. Also, they may not comprehend the purpose of a cessation program. In addition, the likelihood of chewers participating in a cessation program is influenced by their level of comfort with the program and personnel, and whether a program addresses their time and transportation limitations.
Areca nut, the seed of the Areca catechu L. palm evaluated to be a Group 1 carcinogen, is still chewed by 10-20% of the world population. It is often chewed with Piper betle L. leaf and other ingredients such as slaked lime and tobacco, to form a betel quid. Globally, areca nut/betel quid is the fourth most commonly used psychoactive substance after tobacco, alcohol, and caffeine. Unlike tobacco cessation, systematic research on areca nut/betel quid cessation is rare. The negative health effects associated with areca nut/betel quid consumption warrant the need for an evidence-based cessation program. Consequently, the Betel Nut Intervention Trial (BENIT) was initiated in August 2016. The BENIT is a randomized, controlled, superiority trial designed to test the efficacy of an intensive areca nut/betel quid cessation program, and to quantify the efficacy through bio-verification. The trial is ongoing in Guam and Saipan in the Mariana Islands. Adult areca nut/betel quid chewers, 18 years and older who include tobacco in their betel quid, are being enrolled into the trial. Those enrolled are assessed for the primary outcome (chewing status) and the secondary outcome (saliva bio-verification) at baseline, at 22 days, and at 6 months. The areca nut/betel quid chewers randomized into the control arm receive an educational booklet only. The areca nut/betel quid chewers randomized into the intervention arm receive the educational booklet and a 22-day cessation program modeled after a smoking cessation program and led by trained facilitators. To date, 224 chewers have been enrolled into the BENIT. The current quit percentages are 18% in the experimental group and 8% in the control group, though these results may change as the trial progresses. The BENIT is designed to provide evidence of the efficacy of a cessation program to help areca nut/betel quid with tobacco chewers to quit chewing. Although the current intervention trial focuses on Guam and Saipan, it has the potential for greater regional and global importance. TRIAL REGISTRATION: Clinical Trial # NCT02942745. Citation Format: Yvette C Paulino, Lynne R Wilkens, Patrick P Sotto, Adrian A Franke, Crissy T Kawamoto, Jade SN Chennaux, Ana J Mendez, Lynette F Tenorio, Grazyna Badowski, Pallav Pokhrel, Thaddeus A Herzog. Introduction of a randomized controlled trial on areca nut/betel quid cessation: The Betel Nut Intervention Trial (BENIT) [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C081.
(1) Background: Cyanobacteria produce a wide range of secondary metabolites, including tumor-promoting hepatotoxins. We recently reported evidence of an independent association between oral cyanobacteria and hepatocellular carcinoma in a U.S. population. We sought to characterize the nature, sources, and health correlates of cyanotoxin exposure in the U.S. Pacific Island territory of Guam, which has a high incidence of liver cancer. (2) Methods: Seventy-four adult males and females were enrolled in a cross-sectional study to quantify cyanotoxins in saliva, urine, and blood and their correlation with health behaviors, medical history, and environmental exposures. Plant samples were collected from locations throughout the island. Microcystin/nodularin (MC/NOD), cylindrospermopsin (CYN), and anabaenopeptin (AB) were measured in biospecimens and in plant extracts by ELISA. (3) Results: Overall, among study participants MC/NOD were detected in 53.9% of saliva, 7.5% of urine, and 100% of serum.; CYN in 40.0% of saliva, 100.0% of urine, and 70.4% of serum; AB in 30.8% of saliva, 85% of urine, and 92.6% of serum. Salivary MC/NOD levels were significantly higher in individuals using municipal tap water as their primary source of drinking water; both salivary and urinary MC/NOD levels were higher in those not using store-bought/commercial water. Urine MC/NOD levels were highest among individuals consuming fruits and vegetables exclusively from local sources. Urine MC/NOD levels were elevated in individuals with hypertension and hyperlipidemia and salivary MC/NOD in those with recent alcohol consumption. Cyanotoxins were prevalent in plant samples including MC/NOD (46.6%), CYN (35.1%), and AB (51.7%). (4) Conclusions: Our study provides evidence that exposure to cyanobacterial hepatotoxins, including tumor promoters, may be prevalent in Guam and may originate from environmental sources. Population-based epidemiologic studies are needed to investigate the role of cyanotoxins in liver cancer development.
Betel nut from the Areca catechu palm tree, chewed alone or as a quid wrapped in Piper betle leaf, is the 4th most widely used addictive substance globally, primarily in parts of Asia and the Pacific. Betel nut chewing is an independent cause of cancers of the oral cavity and esophagus and has been linked to other malignancies. We evaluated 16S rRNA in oral cavity swabs and saliva obtained from 122 adults (64 current betel nut chewers, 37 former chewers, 21 never chewers) in Guam. Cyanobacteria was detected at 90-fold higher abundance in oral samples from current betel nut compared to both former and never chewers. Cyanobacteria was also the predominant bacterial taxa detected in Areca catechu nuts and Piper betle leaves.16S sequence data were evaluated using PICRUSt to predict gene families and to generate a composite metagenome. AntiSMASH 5.0 was used for the analysis of gene marker data corresponding to secondary metabolites. Cyanotoxins, including microcystins, nodularins, and cylindrospermopsin, as well as other secondary metabolites were identified as putative secondary metabolites. Subsets of oral and plant samples evaluated via ELISA confirmed the presence of these metabolites. The identification of these cyanotoxins in this population suggests their possible contribution to betel nut-associated carcinogenesis. Citation Format: Brenda Y. Hernandez, Xuemei Zhu, Patrick Sotto, Yvette Paulino. Betel nut chewing, oral Cyanobacteria, and exposure to cyanotoxins [abstract]. In: Proceedings of the AACR Special Conference on the Microbiome, Viruses, and Cancer; 2020 Feb 21-24; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2020;80(8 Suppl):Abstract nr A11.
Background: Areca nut and betel quid (ANBQ) chewing is a widespread carcinogenic habit. The BENIT (ClinicalTrials.gov - NCT02942745) is the first known randomized trial designed for ANBQ chewers. Methods: We compared intensive behavioral treatment intervention condition (IC) with control condition (CC) in the BENIT and included a 5-stage early stopping rule. We report the primary analysis at stage 3. English literate adults in Guam and Saipan who self-identified as ANBQ chewers with tobacco were enrolled between August 2016 and August 2020. IC participants (n=88) received five in-person sessions over 22 days and a brochure containing quitting advice. CC participants (n=88) received only the brochure. Participants were assessed at baseline and day-22 follow-up. Self-reported chewing status at day-22 was determined by a composite of two survey items with disparate wording and response options for cross-verification. Results: Cessation rates were 38.6% (IC) and 9.1% (CC). Proportional hazards regression revealed a p=0.0058, which met the Stage 3 criteria for significance and an estimated reduction in ANBQ chewing for IC compared to the CC of 71% (95% CI: 41%-88%). Conclusion: Robust self-reported intervention effects at day-22 suggests that intensive cessation programs such as BENIT should be further developed and implemented on a larger scale.
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