This article is based on information in a nationwide survey that was carried out to determine the prevalence of oral mucosal lesions (OML) in Malaysia. Among the information collected was the prevalence of risk habits for OML such as smoking, betel quid chewing and alcohol consumption. This paper thus focuses on the betel quid chewing habit and explores the possible factors that influence the inception and cessation of this habit.
Usually logistic regressions are used to identify the related factors for commencement and cessation of betel quid chewing habit. A limitation to this approach would be participants' age. A younger participant is less likely to have chewing habit and may develop the habit at a later age. This is why an increasing chewing prevalence rates in older ages was always found. The advantage of survival analysis on censored events can be used to overcome this situation. From the Kaplan-Meier plots, it is possible to find the changes on proportions of chewing habit over years of age, and proportions of keeping chewing habit over the chewing years. Using the recall time duration from a cross sectional survey data could also be a limitation to this study, since recall bias can easily arise.
The habit of betel quid chewing among Malaysians is more prevalent among females (see Additional file 1
). This trend is also evident among other South-east Asian populations such as among the Cambodians [17
]. However, in most societies, where this habit is still highly practiced, such as in India [18
], Taiwan [13
] and Solomon Islands [12
] the habit is more commonly practiced among the males compared to females. The trend of concurrently practicing more than one risk habit was also found in this population (see Additional file 1
). This finding is in concordance with other studies which found that the practice of betel quid chewing is usually accompanied by the practice of other risky habits such as smoking and alcohol consumption [20
]. This practice of multiple risk habits was also found to be more common among males, which is in line with other populations that practiced betel quid chewing.
Apart from the difference in gender distribution of this habit, another variation that can clearly be seen in this multiethnic population is the difference in the distribution of this habit among the different ethnic groups (see Additional file 1
). For the males, betel quid chewing was predominantly seen among the 'others' group while for the females, it was found to be most commonly practiced among the Indians, which is the third largest ethnic group in Malaysia. Interestingly, based on the report by the Malaysian National Cancer Registry [23
] for the year 2003-2005, cancer of the oral cavity is among the top ten types of cancers among the Indians, while it is not evident among the other ethnic groups. The higher prevalence of this habit among Indians is also in concordance to the findings from an earlier epidemiological survey done by Hirayama et al. [24
It is noted that from this present study, the results showed that there were no obvious years of ages where more participants tend to develop chewing habit (Figure ). However, it can be observed that there is a large decrease in male current chewers after 15 to 25 years of chewing (Figure ). Many factors are thought to influence the inception of this behaviour. A study among adolescents in Taiwan cited the reasons for starting the habit as curiosity, keeping warm and peer pressure [25
] while another study quoted the initiation of the habit was as a way to pass the time, tension in the family and boredom [26
]. This survey found that females were less likely to stop quid chewing habit as compared to males (see Additional file 2
) which corroborates an earlier finding on a sample of Taiwanese adults [11
]. This could be attributed to the fact that the female chewers in this population are housewives residing in plantations and were from low socioeconomic status where they face boredom, financial or social problems in the family and also peer pressure where betel quid chewing is considered as a traditional cultural norm, thus contributing to the low cessation rate among the females.
In this multiethnic population, cessation of betel quid chewing habit was more significantly seen among the Chinese for both males and females (see Additional file 2
). This scenario is most probably due to the fact that this habit is rare among the Chinese, therefore creating a conducive factor providing a more supportive environment for cessation as compared to the other ethnic groups.
This study identified gender, age, ethnicity and smoking history as the factors that influence the development and cessation of this habit. Females were found to be less likely to quit the habit. This finding is in line with the results from a Taiwan study where females were found to have a lower cessation rate than males [11
]. Those aged more than 40 years were found to be significantly more likely to start (see Additional file 3
) and also less likely to quit the habit (see Additional file 4
). This could be attributed to the fact that this habit is more prevalent among those in the older generation. Furthermore, the foul-smelling breath associated with betel quid chewing [18
] might be the reason why the younger generation avoids the behaviour. As for smoking history, those with current and past history of smoking were more likely to start chewing habit (see Additional file 3
) while ex-smokers were more likely to quit the habit (see Additional file 4
). This finding is in concordance with an earlier study among the Taiwanese which found that smokers are 10 times more likely to become a quid chewer while ex-smokers were twice as likely to quit the habit [20
The cessation of the quid chewing habit is also influenced by the frequency of chewing and the type of quid chewed. Cessation is significantly more likely among those in the lowest category of chewing frequency who chewed less than 5 quids per day (see Additional file 4
). This is in concordance with the finding by Lin et al. [13
] in Taiwan where those who are chewing smaller amount of quids per day are more likely to quit their habit. Cessation was also less likely for those chewing quids containing areca nut and tobacco (see Additional file 4
). This might be attributed to the contents of arecoline in the areca nut which is a para-sympathomimetic agent that stimulates a sense of well-being, heightened alertness and reduction of tension [27
] and the nicotine content in tobacco which is an addictive substance that creates dependency, making it difficult for consumers to stop the habit.