Despite the increasing population of betel nut chewers, Guam and its neighboring islands do not have a program dedicated solely to quitting betel nut chewing.

On Thursday, a group of researchers from the University of Guam/University of Hawaii Cancer Center Partnership to Advance Cancer Health Equity unveiled the results from the Betel Nut Intervention Trial (BENIT) – their latest study, which could be the model for future prevention strategies.

Yvette Paulino, UOG associate professor of health science, is one of the principal investigators for BENIT.

Paulino said the study explored the effectiveness of a cessation program designed specifically for betel nut chewers. “It is the only behavioral clinical trial that is going on right now. We are just testing to see if it works,” she said.

Paulino said prevention initiatives on Guam currently use tobacco use cessation models in the absence of a betel nut-focused program.

“If we are successful with BENIT, then it is something that we can package and we can share with our community partners,” Paulino said. These partners include the Guam Department of Public Health and Social Services, the Guam Department of Education, and the Guam Behavioral Health and Wellness Center, she added.

Educating students

Cathy Castro, the vice chairwoman of the Guam Comprehensive Cancer Control Coalition, said one thing resonated while working with GDOE on educating students on nicotine addiction.

"Many of them that have tobacco addiction also are using the betel nut," Castro said. "There is a strong correlation to it."

“I’m quite sure that it is a cultural issue, but the interesting part of it is that many of the kids don't understand the harmful effects of it,” Castro said.

Castro said the coalition is interested in working with the team behind BENIT.

Betel nut chewing is a massive global health problem, according to Paulino.

The nut contains the world’s fourth most used psychoactive substance. Around 600 million people worldwide practice betel nut chewing. While it is commonly practiced in many Asian and Pacific countries, betel nut chewing poses a greater risk for multiple disease conditions, including oral cancer.

In her presentation, Paulino pointed out that betel nut was deemed an oral carcinogen in 1985 and 2004.

In terms of a prevalence rate, Guam is at 11 percent, based on the results from the most recent Behavioral Risk Factor Surveillance System Survey, according to Paulino. “It means that out of a hundred people, 11 of them would be betel nut chewers,” she added.

Meanwhile, the Commonwealth of the Northern Mariana Islands has a prevalence rate of 23.9 percent, which is double the rate for Guam.

Results of trial

Thaddeus Herzog, the co-principal investigator from the University of Hawaii, said the study involved 324 betel nut chewers from Guam and Saipan.

To be included in the study, the individual must be a self-described betel nut chewer. He or she must have chewed betel nut for at least three years, and at a rate of at least three days per week. The individual must chew a quid consisting of areca nut, slaked lime, betel leaf, tobacco and/or other optional ingredients.

The Guam and Saipan participants were divided equally between an intervention group and a control group. The intervention group was provided with a “Quitting Betel Nut” booklet and was required to participate in an intensive betel nut cessation program. The control group was provided with only the booklet.

The intervention program included five intensive sessions over the span of 22 days, with an additional follow-up session after six months. The first day started with a discussion of health risks associated with betel nut chewing, and introduction to self-monitoring and logs of triggers.

According to Herzog, at the end of 22 days, the intervention group had a quit rate of 15.5 percent, in comparison with the control group, which registered 9.1 percent.

At the end of the six-month follow-up session, the intervention group had a 40 percent quit rate, while the control group registered 21.4 percent.

Prior to BENIT, Herzog said the team conducted preliminary studies, including surveys among betel nut chewers on Guam. The team found that betel nut chewers and cigarette smokers were similar in terms of addiction levels.

Herzog said the preliminary study also found that many of the betel nut chewers are interested in quitting. Chewers may have tried to quit but did not have a clear idea of how and when to quit, he explained.

On Thursday, the presenters also noted research gaps addressed by the UOG and UHCC consortium. Aside from BENIT, the team has been involved in research using saliva samples to establish chewer status and other betel nut-related studies.