Perceive Stress and Betel Quid Dependence Associated with Reasons for Betel Quid Chewing: A Mixed Methods Study

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This study’s purpose was to identify the correlates of reasons for betel quid (BQ) chewing. Methods : We adopted a mixed-methodsdesign design. The study was conducted between October 2021 and August 2023 at a medical center of northern Taiwan. The Reasons for Betel-Quid Chewing Scale, Numeric Rating Scale, and Betel Quid Dependence Scalewere used to quantitatively assess reasons for betel quid chewing, stress, and betel quid dependence, respectively. Semi-structured questions were used to interview for qualitative data. Results : The most common reasons for betel quid chewing were stimulation, reinforcement, and social/cultural factors. Chewers who reported more pressure to chew were more likely to be younger, have less educational level, be employed, have greater stress, and have more betel quid dependence. Content analysis of qualitative data showed three themes: physical and psychological demands, peer pressure, and perceived greater effectiveness. Conclusion : Employment was the factor most commonly associated with reasons for betel quid chewing and with each construct. Study findings can help healthcare professionals understand reasons for betel quid chewing, thereby helping them educate chewers to cope with withdrawal symptoms and successfully quit. Betel quid Chewers Betel quid dependence Culture Mixed-method study INTRODUCTION Betel quid (BQ), chewed for its psychoactive effects, is a known carcinogen with a negative impact on health [ 1 ]. Globally, 600 million people worldwide chew BQ. BQ chewing has significant geographic variation, with high prevalence in South Asia, East Africa, and the Pacific region, including Taiwan [ 2 ]. Of the approximately 600,000 chewers in Taiwan, the majority are male. BQ chewing has been linked to poor oral hygiene, oral premalignant lesions, metabolic syndrome, obesity, hypertension, diabetes, cardiovascular disease, and dependence [ 3 – 5 ]. BQ chewing may result from habit, dependence, culture, or social triggers [ 6 , 7 ]. The reasons for BQ chewing vary. In a review of the literature, Athukorala et al. [ 8 ] found that the reasons for BQ chewing included social influence, lack of awareness, stress, and a dependence syndrome. Sotto et al. [ 9 ] found that chewers’ reasons not to quit chewing were addiction, the belief that BQ is harmless, and the presence of an enabling community. Singhvi et al. [ 10 ] reported that chewers’ reasons for the habit of BQ chewing were related to the social environment and the secondarily stimulating effect of the betel nut. Wang et al. [ 11 ] reported that adolescent chewers’ reasons for starting the habit were peer pressure, keeping warm, and curiosity. The study by Murphy et al. [ 12 ] revealed that socio-cultural reasons were important for BQ chewers. Reported factors related to reasons for BQ chewing include lower education level [ 13 ], longer duration of BQ chewing [ 13 ], more chews per day [ 14 ]., shorter choice reaction time [ 15 ], negative mood [ 13 ], working group [ 16 ], rural residence [ 16 ], BQ users as close friends [ 16 ], and a positive attitude toward BQ chewing [ 16 ]. Based on the literature review, we assume that adult current chewers chew BQ for reasons related to stress, BQ withdraw, social/culture concerns, or other unidentified considerations. Although several studies have investigated this topic, most were in adolescent [ 11 , 17 , 18 ] or Taiwan aboriginal populations [ 19 ]. However, little research has investigated the factors affecting BQ chewing behavior in Taiwanese adults [ 20 ]. Therefore, the purposes of this study were (1) to explore the characteristics of perceive stress, BQ dependence, and reasons for BQ chewing; (2) to determine the factors related to reasons for BQ chewing; and (3) to explore the chewers’ experience of reasons for BQ chewing in Taiwanese adult BQ chewers. METHODS Design and sample This study was a part of a survey study with mixed methods design, exploring the oral health status, anxiety, betel quid dependency, and oral-related quality of life among BQ users (CMRPG3J1181). This study employed a mixed methods design, including both a quantitative and qualitative approach, to examine the characteristics of perceive stress, BQ dependence, and factors related to reasons for BQ chewing in chewers. Participants were recruited using convenience sampling from the otorhinolaryngology outpatient department of a medical center in northern Taiwan from October 2021 to August 2023. The inclusion criteria were: (1) age ≥18 years; (2) having a BQ chewing habit for more than three years and a current chewer (at least one BQ per day for 6 months); (3) visiting the otolaryngology clinic for oral mucosal screening; and (4) ability to communicate in Mandarin or Taiwanese through speaking, reading, or writing. Ethics approval and consent to pa rticipate All eligible participants agreed to participate in the study and provided informed consent after receiving an explanation of the research purposes and procedures. The study obtained approval from the Institutional Review Board of Chang Gung Medical Foundation (Number: 201900801B0C501), ensuring compliance with ethical guidelines and protocols. Participants signed the inform consent form before data collection. Data collection For quantitative data collection, chewers were referred from the otolaryngology clinic where they had gone for oral mucosal screening. Chewers who met the inclusion criteria were invited by a research nurse to fill in the quantitative survey of this study. Participants filled out a set of questionnaires by self-report before they visited the physician and had an oral mucosal screening. For qualitative data collection, from every nine chewers who participated in the quantitative study, one was invited to join the qualitative study. The interview was conducted by a lead researcher of this study, who had completed qualitative research training and had more than 10 years’ experience in BQ cessation care. Participants were singly interviewed in a consultation room for approximately 30–40 minutes. Instruments Reasons for Betel-Quid Chewing Scale (RBCS) The Reasons for Betel-Quid Chewing Scale (RBCS) was used to assess chewers’ motivation for BQ chewing. The 10-item RBCS includes 3 subscales: reinforcement construct (2 items), social/cultural construct (4 items), and stimulation construct (4 items). Each item is scored on a scale of 0 (not important) to 4 (extremely important), with a higher score indicating more important reasons for BQ chewing [21]. Previous studies have demonstrated that the RBCS had satisfactory psychometric characteristics [20,21]. In the present study, the Cronbach’s α was 0.93. Numeric Rating Scale (NRS) The Numeric Rating Scale (NRS), used to assess perceive stress related to life, is a single item; response is made on a scale from 0 (no stress at all) to 10 (worst stress imaginable) points [23]. A score of ≤3 points is mild, 4–6 points is moderate, and ≥7 points indicates severe perceived stress [24,25]. The NRS is a simple, easy to administer, and comprehensive measure, with proven sensitivity to assess personal perception [26]. In this study, the Cronbach’s α value for the NRS was 0.90. Betel Quid Dependence Scale (BQDS) BQ-related withdrawal symptoms were assessed using Chinese-language version of the Betel Quid Dependence Scale (BQDS), developed by Lee et al. [27] based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition for substance dependence [27]. The BQDS consists of 16 items in 3 domains: physical and psychological urgent need (7 items), increasing dose (5 items), and maladaptive use (4 items). Each item is scored 0 (no) or 1 (yes), for a total score ranging from 0 to 16. A higher score indicates higher BQD. A previous study has shown acceptable psychometric properties of the Chinese BQDS [28]. In this study, the Cronbach’s α value was 0.92. Demographic and betel quid (BQ)-related characteristics form A form was developed to collect the demographic and BQ-related characteristics of chewers. It included the demographic characteristics of age, gender, marital status, educational level, type of occupation, ethnicity, and rurality of residence. BQ-related characteristics included years since beginning BQ chewing, times per day of chewing, additive ingredients (nut, lime, leaf, other), type of BQ chewed (with alcohol, tobacco, or both), betel nut fee per day (in New Taiwan Dollars, NTD), and resource providing BQ (self, family, friends). Qualitative interviews The qualitative interview was guided by semi-structure questions, which was developed according to the literature review [8–11]. The interview questions included: (1) What was the motive for beginning BQ chewing?; (2) What are the reasons for BQ chewing?; and (3) What is the feeling after BQ chewing? Data analysis Quantitative data analysis SPSS 26.0 for Windows (IBM Corp., Armonk, NY, USA) was used to analyze quantitative data, including demographic and BQ-related characteristics, perceived stress level, BQ dependence, and reasons for BQ chewing. Multiple regression analysis was used to assess the variables associated with reasons for BQ chewing. Pearson’s product-moment coefficient was used to examine the relationships between reasons for BQ chewing (dependent variable) and the selected independent variables. Independent variables included age, education level, religion (no vs. yes), employment (no vs. yes), perceived stress, and BQ dependence. Q ualitative data analysis Content analysis [29] was used to analyze qualitativedata. Rigor The rigor of the qualitative research included credibility, confirmability, dependability, and transferability [30]. For credibility, none of the researchers provided clinical care for any of the chewers. Interviews were guided by the interview questions according to the comprehensive literature review. To be faithful to participants, their original statements were recorded without adding or subtracting text. To ensure confirmability, the data was analyzed by two researchers independently [31] and two individual group discussion were held to ascertain the findings. Two individual participants were invited to review the accurate and interpretive notes in order to present the key points of their experience [31]. For dependability, the sampling, interview (verbal and non-verbal data), and data analysis were documented consistently and rigorously [31]. For transferability, the process of research design, data collection, and data analysis were clearly recorded [31]. RESULTS Demographic and BQ-related characteristics In all, 150 chewers were involved in this study. Chewers’ mean age was 51.58 (standard deviation [SD] = 10.27) years. All chewers were male (100%). The majority of chewers were living with a partner (96.7%), educated at the junior high school level (25.3%) or senior high school level (45.3%), were skilled workers (38.0), were Hoklo Taiwanese (70.7%), and lived in an urban area (40.0%). Most chewers had chewed BQ for more than 10 years (63.4%); of these, more than half (32.7%) chewed more than 20 pieces per day. Most chewers reported that the most common added ingredient was leaf (61.4%), chewed BQ only (53.5%), purchased their own BQ (89.1%), and were motived to attempt BQ cessation (84.7%). The mean years of chewing was 31.83 (SD =11.82), the average BQ cost per day was 166.07 (SD = 120.70) NTD, which most (89.1%) provided themselves (Table 1). Degree of p erceived stress, BQ dependence, and r easons for BQ chewing Chewers’ level of perceived mean stress (NRS) was 4.60 (SD = 1.14). Based on the NRS classification, 12.0% (n=18) of chewers perceived mild stress, 69.3% (n=104) perceived moderate stress, and 18.7% (n=28) perceived severe stress. The mean betel quid dependence (BQDS) score was 7.40 (SD = 4.04). The mean reasons for betel-quid chewing (RBCS) score was 2.30 (SD = 0.72). Mean scores for the subscales were: reinforcement, 2.29 (SD = 0.83), social/cultural reasons, 2.18 (SD = 0.73), and stimulation, 2.43 (SD=0.92) (Table 2). Factors associated with reasons for BQ chewing Chewer-related factors associated with more important reasons for BQ chewing were: younger age (b= −0.150), a lower level of educational attainment (b= −0.186), being employed (b= 0.258), having greater perceived stress (b= 0.419), and more BQ dependence (b= 0.179). These 5 factors explained 34.8% of the total variance in reasons for BQ chewing. In terms of the subscales, the most important reinforcement reasons for BQ chewing were younger age (b= −0.191) and greater perceived stress (b= 0.331). These 2 factors explained 16.9% of the total variance in reinforcement. The most important social/cultural reasons were being employed (b= 0.259) and having greater perceived stress (b= 0.427). These 2 factors explained 29.3% of the total variance in social/cultural reasons. The most important reasons for stimulation were having a lower level of educational attainment (b= −0.171), being employed (b= 0.228), and having greater perceived stress (b= 0.337). These 3 factors explained 28.5% of the total variance in stimulation (Table 3). Qualitative results Three themes were extracted from the content analysis of the qualitative data. These included demanding physical and psychological conditions, perceiving peer pressure, and perceived greater effectiveness. The themes and sub-themes are summarized in Table 4. Theme 1: Demanding physical and psychological conditions Chewers stated that BQ craving and withdrawal symptoms led to BQ seeking behavior. Chewers often used BQ as a reward for completing work or tasks. Some of the chewers expressed: “When I stop [having] access to BQ, I felt unable to concentrate, having a headache, and tension,” “I chewed BQ when I deal with difficult situations,” and “I treated myself when I did a good work.” Theme 2: Perceived peer pressure Participants perceived peer pressure at work, particularly those whose closest friends or co-workers had a significant relationship with BQ use. The reasons for BQ chewing were associated with workplace-based peer networks. Typical responses included: “My co-workers provided BQ, when taking a break at work,” “I perceived stress from my peer[s,] [who] encourage to chew, providing BQ for chewing,” and “[I felt] sorry to refuse, worry about feeling ashamed.” Theme 3: Greater effective ness Chewers also stated that some of the compounds in BQ trigger brain and stimulation reactions, resulting in changes in the body. The chewers used the following expressions regarding this theme: “When I chewing BQ, I felt [my] body was warming,” “The ingredient of BQ helped me concentrating on one thing,” and “After BQ chewing, I felt greater power, strength, and endurance during a workout.” DISCUSSION In the present study, 69.3% of chewers perceived their level of stress as moderate and 18.7% perceived it as severe. These findings support those of previous studies [8,13], which reported that chewers had negative moods and greater perceived stress. Most of the subjects in this study were employed and more than half had chewed BQ for more than 10 years. Our findings suggest that clinical nurses should assess chewers’ stressors and help enhance their coping strategies, to help chewers develop positive methods of relieving stress. Chewers in the present study reported that the most important reasons for BQ chewing were: “stimulation,” “reinforcement,” and “social/cultural factors.” These findings support those of a previous study [21], which reported that the crucial reasons for BQ chewing were related to stimulation, reinforcement, and social/cultural factors. Most of the subjects in our study were motivated to quit BQ chewing. These findings may reflect that chewers feel exhausted from work or life, and use BQ to refresh or revive themselves. Chewers may therefore face a dilemma: they feel the need for the “lift” associated with BQ use but at the same time recognize the value of quitting chewing. To help chewers achieve successful cessation, clinical nurses should assess chewers’ attitudes, concerns, and beliefs about quitting chewing while also educating them on how to cope with withdrawal symptoms from BQ chewing. Results of the present study also showed that chewers who reported a higher level of BQ dependence were more likely to express greater importance in their reasons for BQ chewing. The agreement of this finding with the results of prior studies supports the assumption that the ingredients of BQ stimulate the default, frontal-parietal, and occipital regions of brain, causing within- and between-network disconnection and leading to awareness. The effect on brain function of chronic BQ dependence is mild and associated with BQ seeking behaviors [32]. Previous studies have also found that chewers experienced BQ dependence, tolerance, and the stimulating effect of the betel nut [8,10]. More than 90% of chewers in our study were employed in manual labor. Therefore, BQ cessation care involves exercise training, such as aerobic exercise, stretching exercise, or resistance exercise, to improve physical fitness. Results of the present study revealed that chewers who were employed were more likely to report stronger reasons for BQ chewing and higher scores for all constructs of reasons for BQ chewing, except reinforcement. Peer pressure from co-workers to chew BQ is a part of the social identity associated with Chinese culture. Based on our findings, healthcare providers should educate BQ users in developing refusal skills, to increase their ability to refuse co-workers’ invitation to join in BQ chewing activities. Chewers in our study stated that their reasons for BQ chewing included demanding physical and psychological conditions, maintaining friendships, and becoming more effective. Similar results were obtained in studies performed in other countries [7–10]. However, in this study, 84.7% of chewers were motived to quit chewing BQ. BQ dependence and socio-cultural issues were factors that influenced chewers to continue to use BQ. It is crucial to understand the needs of BQ chewers who want to quit and develop case-based BQ cessation programs, possibly using virtual reality simulation technology. Limitations and strengths This study had several limitations. First, the sample consisted of chewers from a single institute receiving oral mucosal screening; the study participants may have been homogenous in BQ-related characteristics. Future studies should expand participant recruitment to other areas in order to represent the comprehensive scope of Taiwan BQ chewers. Second, in the present study, we did not consider the barriers to quitting BQ chewing. Future studies should consider the barriers to and available of BQ cessation programs, to understand how these factors affect the reasons for BQ chewing. Finally, chewers’ lifestyle variables were not included, and these may affect the self-reported reasons for BQ chewing. Future studies should explore the correlations between BQ habits and lifestyle factors. CONCLUSION We found the most common reasons for BQ chewing were reinforcement, social/cultural pressure, and stimulation. Chewers who reported greater importance for their reasons for BQ chewing were more likely to be younger, have a lower educational level, be employed, have higher levels of stress, and have more BQ dependence. Content analysis of qualitative data showed three themes: physical and psychological demands, peer pressure, and perceived greater effectiveness. Chewers have misconceptions about BQ use and barriers to quitting. Clinical nurses should strive to strengthen positive behaviors and attitudes towards to BQ cessation with continual reinforcement. Abbreviations BQ: betel quid BQDS: betel quid dependence scale NT: New Taiwan Dollars NRS: Numeric Rating Scale SD: standard deviation RBCS: reasons for betel-quid chewing scale Declarations Ethics approval and consent to participate. (Human) Ethics approval and consent to participate. The study was reviewed and approved by the Institutional Review Board of Chang Gung Medical Foundation in Taiwan (Number: 201900801B0C501), and all methods were performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants before data collection. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available from the corresponding author. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the authors with the permission of the Chang Gung Medical Foundation in Taiwan. Competing interests The authors declare that they have no competing interests. Funding This study was founded by Chang Gung Memorial Hospital Research Program (grant number CMRPG3J1181) in Taiwan. Authors’ contributions All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/)]: • substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; • drafting the article or revising it critically for important intellectual content. Study design: SEC and SCC; Data collection and analysis: SEC, MHH, CJK, and SCC; Manuscript preparation: SEC and SCC. Acknowledgements We greatly appreciate the support of the participants and the hard work of the researchers during this study. The authors would like to thank Convergence CT for assistance with English editing during development of the manuscript. 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Nursing research: generating and assessing evidence for nursing practice. 10th ed. Philadelphia: PA: Lippincott Williams & Wilkins. 2016. Zeqiang L, Huang X, Liu Z, Guo S, Sariah A. Brain Imaging and Behavior. A multivariate pattern analysis of resting-state functional MRI data in Naïve and chronic betel quid chewers. Indianapolis. 2021;15(3): 1222–1234. doi:10.1007/s11682-020-00322-6 Tables Tables 1 to 4 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files TablessubmitBMCOralHealth.docx Cite Share Download PDF Status: Published Journal Publication published 01 Nov, 2024 Read the published version in BMC Oral Health → Version 1 posted Editor assigned by journal 10 Jul, 2024 Submission checks completed at journal 08 Jul, 2024 First submitted to journal 02 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4677025","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":325157743,"identity":"269efd54-209d-4a7d-9e8e-7b81f7966e4d","order_by":0,"name":"Su-Erh Chiu","email":"","orcid":"","institution":"Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Su-Erh","middleName":"","lastName":"Chiu","suffix":""},{"id":325157744,"identity":"154f19b9-98d5-4e43-be43-6ddec97f5710","order_by":1,"name":"Mei-Hui Hsu","email":"","orcid":"","institution":"Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mei-Hui","middleName":"","lastName":"Hsu","suffix":""},{"id":325157745,"identity":"d90ff21b-08a4-48e3-8037-97a7e95eaf95","order_by":2,"name":"Chung-Jan Kang","email":"","orcid":"","institution":"Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chung-Jan","middleName":"","lastName":"Kang","suffix":""},{"id":325157746,"identity":"6b97ee9c-c31f-470b-bf9d-08886395155c","order_by":3,"name":"Shu-Ching Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIiWNgGAWjYDACCQYGZgYDBgZ+NEEitEg2QAV4IIIGBLQAgcEBYrXIz+4x/FxQcMdu8/k1Bgw/fh22t2dgPnibh+FPYgMOLQZ3zhhLzzB4lrztxhsDxt6+w4k9DGzJ1jwMBri1SOSYMfMYHE42u3F2AzNjz+EEHgYeM2mgllxcWuRnQLUYz4Bosedh4P+GVwvDDYgWOwP+3g3MDD8OM/Yw8LDh1WJwI61YGqglQeIG/4eDvQ3piT2H2Ywt5xgY1+N2WPLGzzx/Dtvz9x9LfPDjj7U9e3vzwxtvKuSMcbkLBhIbJBIYDjC2McCiiZAGBgZ7Bv4DQOoPYZWjYBSMglEw8gAAINhTrltMrO0AAAAASUVORK5CYII=","orcid":"","institution":"Chang Gung University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Shu-Ching","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-07-03 02:14:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4677025/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4677025/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-024-05093-w","type":"published","date":"2024-11-01T16:20:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68207063,"identity":"3ea38afc-07b4-46ff-92a9-2c844d93dd22","added_by":"auto","created_at":"2024-11-04 16:34:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":505506,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4677025/v1/37a22508-2bef-423d-94b5-3e6eaee51eda.pdf"},{"id":61472142,"identity":"fe471b55-cafc-41bb-a294-10a8212c6fe4","added_by":"auto","created_at":"2024-07-31 07:01:08","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":54224,"visible":true,"origin":"","legend":"","description":"","filename":"TablessubmitBMCOralHealth.docx","url":"https://assets-eu.researchsquare.com/files/rs-4677025/v1/d08ba3fe9528e033047c6486.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePerceive Stress and Betel Quid Dependence Associated with Reasons for Betel Quid Chewing: A Mixed Methods Study \u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eBetel quid (BQ), chewed for its psychoactive effects, is a known carcinogen with a negative impact on health [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Globally, 600\u0026nbsp;million people worldwide chew BQ. BQ chewing has significant geographic variation, with high prevalence in South Asia, East Africa, and the Pacific region, including Taiwan [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Of the approximately 600,000 chewers in Taiwan, the majority are male. BQ chewing has been linked to poor oral hygiene, oral premalignant lesions, metabolic syndrome, obesity, hypertension, diabetes, cardiovascular disease, and dependence [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. BQ chewing may result from habit, dependence, culture, or social triggers [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe reasons for BQ chewing vary. In a review of the literature, Athukorala et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] found that the reasons for BQ chewing included social influence, lack of awareness, stress, and a dependence syndrome. Sotto et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] found that chewers\u0026rsquo; reasons not to quit chewing were addiction, the belief that BQ is harmless, and the presence of an enabling community. Singhvi et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] reported that chewers\u0026rsquo; reasons for the habit of BQ chewing were related to the social environment and the secondarily stimulating effect of the betel nut. Wang et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] reported that adolescent chewers\u0026rsquo; reasons for starting the habit were peer pressure, keeping warm, and curiosity. The study by Murphy et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] revealed that socio-cultural reasons were important for BQ chewers. Reported factors related to reasons for BQ chewing include lower education level [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], longer duration of BQ chewing [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], more chews per day [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]., shorter choice reaction time [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], negative mood [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], working group [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], rural residence [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], BQ users as close friends [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], and a positive attitude toward BQ chewing [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on the literature review, we assume that adult current chewers chew BQ for reasons related to stress, BQ withdraw, social/culture concerns, or other unidentified considerations. Although several studies have investigated this topic, most were in adolescent [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] or Taiwan aboriginal populations [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, little research has investigated the factors affecting BQ chewing behavior in Taiwanese adults [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Therefore, the purposes of this study were (1) to explore the characteristics of perceive stress, BQ dependence, and reasons for BQ chewing; (2) to determine the factors related to reasons for BQ chewing; and (3) to explore the chewers\u0026rsquo; experience of reasons for BQ chewing in Taiwanese adult BQ chewers.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eDesign and sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study\u0026nbsp;was a part of a survey study with mixed methods design, exploring the\u0026nbsp;oral health status, anxiety, betel quid dependency, and\u0026nbsp;oral-related quality of life among BQ users (CMRPG3J1181).\u0026nbsp;This study employed a\u0026nbsp;mixed methods\u0026nbsp;design, including both a\u0026nbsp;quantitative and qualitative\u0026nbsp;approach,\u0026nbsp;to examine\u0026nbsp;the characteristics of perceive stress, BQ\u0026nbsp;dependence, and\u0026nbsp;factors related to\u0026nbsp;reasons for BQ chewing in chewers. Participants were recruited using convenience sampling from the otorhinolaryngology\u0026nbsp;outpatient department of\u0026nbsp;a medical center in northern Taiwan\u0026nbsp;from October 2021 to August 2023. The inclusion criteria were: (1) age ≥18 years; (2)\u0026nbsp;having a BQ chewing habit for more than three years and a current chewer (at least one BQ per day for 6 months); (3) visiting the otolaryngology clinic for oral mucosal screening; and (4) ability to communicate in Mandarin or Taiwanese through speaking, reading, or writing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to pa\u003c/strong\u003e\u003cstrong\u003erticipate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;All eligible participants agreed to participate in the study and provided informed consent after\u0026nbsp;receiving an\u0026nbsp;explanation of the research purposes and procedures.\u0026nbsp;The study obtained approval from the\u0026nbsp;Institutional Review Board of\u0026nbsp;Chang Gung Medical Foundation\u0026nbsp;(Number:\u0026nbsp;201900801B0C501), ensuring compliance with ethical guidelines and protocols. Participants signed the inform consent form before data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor\u0026nbsp;quantitative\u0026nbsp;data collection,\u0026nbsp;chewers were referred from the otolaryngology clinic where they had gone for oral mucosal screening. Chewers who met the inclusion criteria were\u0026nbsp;invited\u0026nbsp;by a research nurse\u0026nbsp;to fill in the\u0026nbsp;quantitative survey of\u0026nbsp;this study.\u0026nbsp;Participants filled out a\u0026nbsp;set of questionnaires by self-report\u0026nbsp;before they visited the physician and had an oral mucosal screening.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor qualitative data collection,\u0026nbsp;from every nine chewers who participated in the quantitative study, one was invited to\u0026nbsp;join the\u0026nbsp;qualitative study.\u0026nbsp;The interview was conducted by a lead researcher of this study, who had completed qualitative research training and had more than 10 years’ experience in BQ cessation care. Participants were singly interviewed in a consultation room for\u0026nbsp;approximately 30–40\u0026nbsp;minutes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstruments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eReasons for Betel-Quid Chewing Scale (RBCS)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;Reasons for Betel-Quid Chewing Scale (RBCS)\u0026nbsp;was used to assess chewers’ motivation\u0026nbsp;for BQ chewing. The 10-item RBCS\u0026nbsp;includes 3 subscales:\u0026nbsp;reinforcement construct\u0026nbsp;(2 items), social/cultural construct\u0026nbsp;(4 items), and stimulation construct\u0026nbsp;(4 items).\u0026nbsp;Each item is scored on a scale of 0 (not important) to 4 (extremely important), with a higher score indicating more important reasons\u0026nbsp;for BQ chewing\u0026nbsp;[21].\u0026nbsp;Previous studies have demonstrated that the RBCS had satisfactory psychometric characteristics\u0026nbsp;[20,21].\u0026nbsp;In the present study, the Cronbach’s α was 0.93.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNumeric Rating Scale (NRS)\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Numeric Rating Scale (NRS),\u0026nbsp;used to assess perceive stress related to life, is a single item; response is made on a scale from 0 (no stress at all) to 10 (worst stress\u0026nbsp;imaginable)\u0026nbsp;points\u0026nbsp;[23]. A score of ≤3 points is mild, 4–6 points is moderate, and ≥7 points indicates severe perceived stress\u0026nbsp;[24,25]. The NRS is a simple, easy to administer, and comprehensive measure, with proven sensitivity to assess personal perception\u0026nbsp;[26].\u0026nbsp;In this study, the Cronbach’s α value for the NRS was 0.90.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBetel Quid Dependence Scale (BQDS)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBQ-related withdrawal symptoms\u0026nbsp;were assessed using\u0026nbsp;Chinese-language version of\u0026nbsp;the\u0026nbsp;Betel Quid Dependence Scale (BQDS),\u0026nbsp;developed by Lee et al.\u0026nbsp;[27]\u0026nbsp;based on\u0026nbsp;the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition for substance dependence\u0026nbsp;[27].\u0026nbsp;The BQDS\u0026nbsp;consists of 16 items in 3 domains:\u0026nbsp;physical and psychological urgent need (7 items), increasing dose (5 items), and maladaptive use (4 items).\u0026nbsp;Each item is\u0026nbsp;scored\u0026nbsp;0 (no) or 1 (yes),\u0026nbsp;for a\u0026nbsp;total score ranging from 0 to 16. A higher score indicates\u0026nbsp;higher BQD. A previous study has shown acceptable psychometric properties of the Chinese\u0026nbsp;BQDS\u0026nbsp;[28].\u0026nbsp;In this study, the Cronbach’s α value was 0.92.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDemographic and betel quid (BQ)-related characteristics form\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA form was developed to collect the demographic and BQ-related characteristics of chewers. It included the demographic characteristics of age, gender, marital status, educational level, type of occupation, ethnicity, and rurality of residence. BQ-related characteristics included years since beginning BQ chewing, times per day of chewing,\u0026nbsp;additive\u0026nbsp;ingredients (nut, lime, leaf, other), type of BQ chewed (with alcohol, tobacco, or both), betel nut fee per day (in New Taiwan Dollars, NTD), and resource providing BQ (self, family, friends).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQualitative interviews\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative interview was guided by semi-structure questions, which was developed according to the literature review\u0026nbsp;[8–11]. The interview questions included: (1) What was the motive for beginning BQ chewing?; (2) What are the reasons for BQ chewing?; and (3) What is the feeling after BQ chewing?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;data\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eanalysis\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSPSS 26.0\u0026nbsp;for Windows (IBM Corp., Armonk, NY, USA) was used to\u0026nbsp;analyze\u0026nbsp;quantitative\u0026nbsp;data, including demographic and BQ-related characteristics,\u0026nbsp;perceived stress level,\u0026nbsp;BQ\u0026nbsp;dependence, and reasons for\u0026nbsp;BQ\u0026nbsp;chewing.\u0026nbsp;Multiple regression analysis\u0026nbsp;was used to assess the variables associated with\u0026nbsp;reasons for\u0026nbsp;BQ\u0026nbsp;chewing. Pearson’s product-moment coefficient was used to examine the relationships between\u0026nbsp;reasons for\u0026nbsp;BQ\u0026nbsp;chewing\u0026nbsp;(dependent variable) and the selected independent variables. Independent variables included age, education level, religion\u0026nbsp;(no vs. yes), employment\u0026nbsp;(no vs. yes), perceived stress, and BQ\u0026nbsp;dependence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQ\u003c/strong\u003e\u003cstrong\u003eualitative data\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eanalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContent analysis\u0026nbsp;[29]\u0026nbsp;was used to\u0026nbsp;analyze\u0026nbsp;qualitativedata.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRigor\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe rigor of the qualitative research included credibility, confirmability, dependability, and transferability [30]. For credibility, none of the researchers provided clinical care for any of the chewers. Interviews were guided by the interview questions according to the comprehensive literature review. To be faithful to participants, their original statements were recorded without adding or subtracting text. To ensure confirmability, the data was analyzed by two researchers independently [31] and two individual group discussion were held to ascertain the findings. Two individual participants were invited to review the accurate and interpretive notes in order to present the key points of their experience [31]. For dependability, the sampling, interview (verbal and non-verbal data), and data analysis were documented consistently and rigorously [31]. For transferability, the process of research design, data collection, and data analysis were clearly recorded [31].\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eDemographic and BQ-related characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn all, 150 chewers were involved in this study. Chewers’ mean age was 51.58 (standard deviation [SD]\u0026nbsp;= 10.27) years. All chewers were male (100%). The majority of chewers were living with a partner\u0026nbsp;(96.7%), educated at the junior high school level (25.3%) or senior high school level (45.3%), were skilled workers (38.0), were Hoklo Taiwanese (70.7%), and lived in an urban area (40.0%).\u0026nbsp;Most chewers had chewed BQ for more than 10 years (63.4%); of these, more than half (32.7%) chewed more than 20 pieces per day. Most chewers reported that the most common added ingredient was leaf (61.4%), chewed BQ only (53.5%), purchased their own BQ (89.1%), and were motived to attempt BQ cessation (84.7%). The mean years of chewing\u0026nbsp;was 31.83 (SD =11.82), the average BQ cost per day was 166.07 (SD = 120.70) NTD, which most (89.1%) provided themselves\u0026nbsp;(Table 1).\u003c/p\u003e\n\u003cp\u003e\u0026lt;Table 1\u0026gt;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDegree of p\u003c/strong\u003e\u003cstrong\u003eerceived stress,\u003c/strong\u003e\u003cstrong\u003eBQ dependence, and r\u003c/strong\u003e\u003cstrong\u003eeasons for BQ chewing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChewers’ level of perceived mean stress (NRS) was 4.60 (SD = 1.14).\u0026nbsp;Based on the NRS classification, 12.0% (n=18) of chewers perceived mild stress,\u0026nbsp;69.3% (n=104) perceived moderate stress, and 18.7% (n=28) perceived severe stress.\u0026nbsp;The mean betel quid dependence\u0026nbsp;(BQDS)\u0026nbsp;score\u0026nbsp;was 7.40 (SD = 4.04). The mean reasons for betel-quid chewing (RBCS)\u0026nbsp;score\u0026nbsp;was 2.30 (SD = 0.72). Mean scores for the subscales were: reinforcement, 2.29 (SD = 0.83), social/cultural reasons, 2.18 (SD = 0.73), and stimulation, 2.43 (SD=0.92) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u0026lt;Table 2\u0026gt;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors associated with reasons for BQ chewing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChewer-related factors associated with more important reasons for BQ chewing were: younger age (b=\u0026nbsp;−0.150), a lower level of educational attainment (b=\u0026nbsp;−0.186), being employed (b= 0.258), having greater perceived stress (b= 0.419), and more BQ\u0026nbsp;dependence\u0026nbsp;(b= 0.179). These 5 factors explained 34.8% of the total variance in reasons for BQ chewing.\u0026nbsp;In terms of the subscales,\u0026nbsp;the most important reinforcement reasons for BQ chewing were\u0026nbsp;younger age (b=\u0026nbsp;−0.191) and greater perceived stress (b= 0.331). These 2 factors explained 16.9% of the total variance in reinforcement. The most important social/cultural reasons were being employed (b= 0.259) and having greater perceived stress (b= 0.427). These 2 factors explained 29.3% of the total variance in\u0026nbsp;social/cultural reasons. The most important reasons for stimulation\u0026nbsp;were\u0026nbsp;having a lower level of educational attainment (b=\u0026nbsp;−0.171), being employed (b= 0.228), and having greater perceived stress (b= 0.337). These 3 factors explained 28.5% of the total variance in\u0026nbsp;stimulation (Table 3).\u003c/p\u003e\n\u003cp\u003e\u0026lt;Table 3\u0026gt;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree themes\u0026nbsp;were extracted from the content analysis\u0026nbsp;of the qualitative data. These included\u0026nbsp;demanding physical and psychological conditions, perceiving peer pressure, and perceived greater effectiveness. The themes and sub-themes are summarized in Table 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDemanding physical and psychological conditions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChewers stated that BQ craving and\u0026nbsp;withdrawal symptoms led to BQ\u0026nbsp;seeking behavior. Chewers often used BQ as a reward for completing work or tasks. Some of the chewers expressed: “When I stop [having] access to BQ, I felt unable to concentrate, having a headache, and tension,”\u0026nbsp;“I chewed BQ when I deal with difficult situations,” and\u0026nbsp;“I treated myself when I did a good work.”\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePerceived peer pressure\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants perceived peer pressure at work, particularly those whose closest friends or co-workers had a significant relationship with BQ use. The reasons for BQ chewing were associated with workplace-based peer networks. Typical responses included:\u0026nbsp;“My co-workers provided BQ, when taking a break at work,” “I perceived stress from my peer[s,] [who] encourage to chew, providing BQ for chewing,”\u0026nbsp;and “[I felt] sorry to refuse, worry about feeling ashamed.”\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eGreater effective\u003c/strong\u003e\u003cstrong\u003eness\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eChewers also stated that some of the compounds in BQ trigger brain and stimulation reactions, resulting in changes in the body.\u0026nbsp;The chewers used the following expressions regarding this theme: “When I chewing BQ, I felt [my] body was warming,” “The ingredient of BQ helped me concentrating on one thing,” and “After BQ chewing, I felt greater power, strength, and endurance during a workout.”\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lt;Table 4\u0026gt;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn the present study, 69.3% of chewers perceived their level of stress as moderate and 18.7% perceived it as severe. These findings\u0026nbsp;support those of previous studies\u0026nbsp;[8,13], which reported that chewers had negative moods and greater perceived stress. Most of the subjects in this study were\u0026nbsp;employed and more than half had chewed BQ for more than 10 years.\u0026nbsp;Our findings suggest that clinical nurses should assess chewers’ stressors and help enhance their coping strategies, to help chewers develop positive methods of relieving stress.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Chewers in the present study reported that the most important reasons for BQ chewing\u0026nbsp;were: “stimulation,” “reinforcement,” and “social/cultural factors.” These findings support those of a previous study\u0026nbsp;[21], which reported that the crucial reasons for BQ chewing were related to\u0026nbsp;stimulation, reinforcement, and social/cultural factors.\u0026nbsp;Most of the subjects in our study were motivated to quit\u0026nbsp;BQ chewing. These findings may reflect that chewers feel exhausted from work or life, and use BQ to refresh or revive themselves.\u0026nbsp;Chewers may therefore face a dilemma: they feel the need for the “lift” associated with BQ use but at the same time recognize the value of quitting chewing. To help chewers achieve successful cessation, clinical nurses should assess chewers’ attitudes, concerns, and beliefs about quitting chewing while also educating them on how to cope with withdrawal symptoms from BQ chewing.\u003c/p\u003e\n\u003cp\u003eResults of the present study also showed that\u0026nbsp;chewers who reported a higher level of BQ dependence\u0026nbsp;were more likely to express greater importance in their reasons for BQ chewing. The agreement of this finding with the results of prior\u0026nbsp;studies supports the assumption that the ingredients of BQ stimulate\u0026nbsp;the default, frontal-parietal, and occipital regions of brain, causing within- and between-network disconnection and leading to \u003cem\u003eawareness.\u003c/em\u003e The effect on brain function of chronic BQ dependence is mild and associated with BQ seeking behaviors\u0026nbsp;[32].\u0026nbsp;Previous studies have also found that chewers experienced\u0026nbsp;BQ dependence, tolerance, and the\u0026nbsp;stimulating effect of the betel nut\u0026nbsp;[8,10].\u0026nbsp;More than 90% of chewers in our study were employed in\u0026nbsp;manual\u0026nbsp;labor. Therefore, BQ cessation care involves exercise training, such as\u0026nbsp;aerobic exercise, stretching exercise, or resistance exercise, to improve physical fitness.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Results of\u0026nbsp;the present study revealed that chewers who were employed were more likely to\u0026nbsp;report stronger reasons for BQ chewing and higher scores for all constructs of reasons for BQ chewing, except reinforcement. Peer pressure from co-workers to chew BQ is a part of the social identity associated with Chinese culture.\u0026nbsp;Based on our findings, healthcare providers should educate BQ users in developing refusal skills, to increase their ability to refuse co-workers’ invitation to join in BQ chewing activities.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;Chewers in our study stated that their reasons for BQ chewing included\u0026nbsp;demanding physical and psychological conditions, maintaining friendships, and becoming more effective.\u0026nbsp;Similar results were obtained in studies performed in other countries\u0026nbsp;[7–10]. However,\u0026nbsp;in this study,\u0026nbsp;84.7% of chewers were motived to quit chewing BQ. BQ dependence and socio-cultural issues were factors that influenced chewers to continue to use BQ. It is crucial to understand the needs of BQ chewers who want to quit and develop case-based BQ cessation programs, possibly using virtual reality simulation technology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and strengths\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study had several limitations. First, the sample consisted of chewers from a single institute receiving oral mucosal screening; the study participants may have been homogenous in BQ-related characteristics. Future studies should expand participant recruitment to other areas in order to represent the comprehensive scope of Taiwan BQ chewers. Second, in the present study, we did not consider the barriers to quitting BQ chewing. Future studies should consider the barriers to and available of BQ cessation programs, to understand how these factors affect the reasons for BQ chewing. Finally, chewers’ lifestyle variables were not included, and these may affect the self-reported reasons for BQ chewing. Future studies should explore the correlations between BQ habits and lifestyle factors.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWe found the most common reasons for BQ chewing were reinforcement, social/cultural pressure, and stimulation. Chewers who reported greater importance for their reasons for BQ chewing were more likely to be younger, have a lower educational level, be employed, have higher levels of stress, and have more BQ dependence. Content analysis of qualitative data showed three themes: physical and psychological demands, peer pressure, and perceived greater effectiveness. Chewers have misconceptions about BQ use and barriers to quitting. Clinical nurses should strive to strengthen positive behaviors and attitudes towards to BQ cessation with continual reinforcement.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBQ:\u0026nbsp;betel quid\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBQDS:\u0026nbsp;betel quid dependence scale\u003c/p\u003e\n\u003cp\u003eNT: New Taiwan Dollars\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNRS: Numeric Rating Scale\u003c/p\u003e\n\u003cp\u003eSD:\u0026nbsp;standard deviation\u003c/p\u003e\n\u003cp\u003eRBCS: reasons for betel-quid chewing scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate. (Human)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate.\u0026nbsp;The study was reviewed and approved by\u0026nbsp;the Institutional Review Board of\u0026nbsp;Chang Gung Medical Foundation\u0026nbsp;in Taiwan\u0026nbsp;(Number:\u0026nbsp;201900801B0C501), and all methods were performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants before data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author. Restrictions apply to the availability of these data, which were used under license for this study. Data are available from the authors with the permission of the\u0026nbsp;Chang Gung Medical Foundation in Taiwan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was founded by Chang Gung Memorial Hospital Research Program\u0026nbsp;(grant number\u0026nbsp;CMRPG3J1181)\u0026nbsp;in Taiwan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/)]:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e• substantial contributions to conception and design, acquisition of data or analysis and interpretation of data;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e• drafting the article or revising it critically for important intellectual content.\u003c/p\u003e\n\u003cp\u003eStudy design: SEC and SCC; Data collection and analysis: SEC, MHH, CJK, and SCC; Manuscript preparation: SEC and SCC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe greatly appreciate the support of the participants and the hard work of the researchers during this study. The authors would like to thank Convergence CT for assistance with English editing during development of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eIARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Betel-quid and areca-nut chewing and some areca-nut derived nitrosamines. \u003cem\u003eIARC Monographs\u003c/em\u003e on the Identification of \u003cem\u003eCarcinogenic Hazards\u003c/em\u003e to Humans. 2004;85:1\u0026ndash;334.\u003c/li\u003e\n \u003cli\u003eCenters for Disease Control and Prevention. Betel quid with tobacco (Gutka). Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/ smokeless/betel_quid/index.htm.\u003c/li\u003e\n \u003cli\u003eAung AA, Soe Zin SN, Ko Ko A, Thet AC. The association between betel quid chewing and metabolic syndrome among urban adults in mandalay district of Myanmar. 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J Clin Diagn Res. 2016;10(11):ZC15\u0026ndash;ZC18. doi:10.7860/JCDR/2016/21010.8789\u003c/li\u003e\n \u003cli\u003eWang PW, Lin HC, Yeh YC, Liu TL, Yen CF. The relation of substance use with different levels of depressive symptoms and the moderating effect of sex and age in Taiwanese adolescents. Compr Psychiatry. 2012;53(7): 1013\u0026ndash;1020. doi:10.1016/j.comppsych.2012.02.010\u003c/li\u003e\n \u003cli\u003eMurphy KL, Liu M, Herzog TA. Confirmatory factor analysis and structural equation modeling of socio-cultural constructs among chamorro and non-chamorro micronesian betel nut chewers. \u003cem\u003eEthn\u003c/em\u003e\u003cem\u003eHealth. 2019;\u003c/em\u003e24(6):724\u0026ndash;735. doi:10.1080/13557858.2017.1346177\u003c/li\u003e\n \u003cli\u003eSariah A, Pu W, Xue Z, Liu Z, Huang X. Reduced cortical thickness in the right caudal middle frontal is associated with symptom severity in betel quid-dependent chewers. \u003cem\u003eFront in Psychiatry. 2020;\u003c/em\u003e11:654. doi:10.3389/fpsyt.2020.00654\u003c/li\u003e\n \u003cli\u003eBhat SJS, Blank MD, Balster RL, Nichter M, Nichter M. Areca nut dependence among chewers in a South Indian community who do not also use tobacco: areca nut topography and dependence. Addiction.2010;105(7):1303\u0026ndash;1310. doi:10.1111/j.1360-0443.2010.02952.x\u003c/li\u003e\n \u003cli\u003eKong L, Zeng C, Yuan F, Liu S, Wang D, Jiang C, Zhan Z, Qian Z, Zhu X. Dysfunction of the prefrontal cortex in betel-quid-dependent chewers. \u003cem\u003eFront Psychiatry. 2020;\u003c/em\u003e11:558367. doi:10.3389/fpsyt.2020.558367\u003c/li\u003e\n \u003cli\u003eSaing KK, Lwin KT, Hlaing T. Factors associated with betel quid chewing among adolescents living in Nattalin township, Bago region, Myanmar. Int J Comm Med Public Health. 2022;9(7):2829\u0026ndash;2838.\u003c/li\u003e\n \u003cli\u003eLiu TL, Yen JY, Ko CH, Huang MF, Wang PW, Yeh YC, Yen CF. Associations between substance use and body mass index: moderating effects of sociodemographic characteristics among Taiwanese adolescents. Kaohsiung Med Sci. 2010;26(6):281\u0026ndash;289. doi:10.1016/S1607-551X(10)70041-3\u003c/li\u003e\n \u003cli\u003eWang, S.C., Tsai, C.C., Huang, S.T., \u0026amp; Hong, Y.J. (2003). Betel nut chewing and related factors in adolescent students in Taiwan. \u003cem\u003ePublic Health, 117\u003c/em\u003e(5), 339\u0026ndash;345. https://doi.org/10.1016/S0033-3506(03)00082-9\u003c/li\u003e\n \u003cli\u003eLin CF, Wang JD, Chen PH, Chang SJ, Yang YH, Ko YC. Predictors of betel quid chewing behavior and cessation patterns in Taiwan aborigines. BMC Public Health. 2006;6:271. doi:10.1186/1471-2458-6-271\u003c/li\u003e\n \u003cli\u003eYap SF, Ho PS, Kuo HC, Yang YH. Comparing factors affecting commencement and cessation of betel quid chewing behavior in Taiwanese adults. BMC Public Health. 2008;8:199. doi:10.1186/1471-2458-8-199\u003c/li\u003e\n \u003cli\u003eLittle MA, Pokhrel P, Murphy KL, Kawamoto CT, Suguitan GS, Herzog TA. The reasons for betel-quid chewing scale: assessment of factor structure, reliability, and validity. BMC Oral Health. 2014;14:62. doi:10.1186/1472-6831-14-62.\u003c/li\u003e\n \u003cli\u003eMurphy KL, Liu M, Herzog TA. The Reasons for Betel Quid Chewing Scale (RBCS) for ex-chewers: Assessment of factor structure, reliability, validity and measurement invariance across gender in a Guamanian sample. Subst Use Misuse. 2022;57(4):522\u0026ndash;530. doi:10.1080/10826084.2021.2019781\u003c/li\u003e\n \u003cli\u003eMcCaffery M, Beebe A. Pain: clinical manual for nursing practice. Mosby, St. Louis. 1989.\u003c/li\u003e\n \u003cli\u003eBoonstra AM, Stewart RE, K\u0026ouml;ke AJ, Oosterwijk RF, Swaan JL, Schreurs KM, Schiphorst Preuper HR. Cut-off points for mild, moderate, and severe pain on the Numeric Rating Scale for pain in patients with chronic musculoskeletal pain: Variability and influence of sex and catastrophizing. Front Psychol. 2016;7:1466. doi:10.3389/fpsyg.2016.01466\u003c/li\u003e\n \u003cli\u003eZelman DC, Dukes E, Brandenburg N, Bostrom A, Gore M. Identification of cut-points for mild, moderate and severe pain due to diabetic peripheral neuropathy. Pain. 2005;115(1\u0026ndash;2):29\u0026ndash;36. doi:10.1016/j.pain.2005.01.028\u003c/li\u003e\n \u003cli\u003eWilliamson A, Hoggar B. Pain: review of three commonly used Pain Rating Scales. J Clin Nurs. 2005;14(7):798\u0026ndash;804.\u003c/li\u003e\n \u003cli\u003eLee CY, Chang CS, Shieh TY, Chang YY. 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Philadelphia: PA: Lippincott Williams \u0026amp; Wilkins. 2016.\u003c/li\u003e\n \u003cli\u003eZeqiang L, Huang X, Liu Z, Guo S, Sariah A. Brain Imaging and Behavior. A multivariate pattern analysis of resting-state functional MRI data in Na\u0026iuml;ve and chronic betel quid chewers. \u003cstrong\u003eIndianapolis. 2021;15(3):\u0026nbsp;\u003c/strong\u003e1222\u0026ndash;1234. doi:10.1007/s11682-020-00322-6\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Betel quid, Chewers, Betel quid dependence, Culture, Mixed-method study","lastPublishedDoi":"10.21203/rs.3.rs-4677025/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4677025/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eAims\u003c/strong\u003e: Social culture concerns and BQ dependence maybe the potential reasons for BQ chewing. This study’s purpose was to identify the correlates of reasons for betel quid (BQ) chewing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: We adopted a mixed-methodsdesign design. The study was conducted between October 2021 and August 2023 at a medical center of northern Taiwan. The Reasons for Betel-Quid Chewing Scale, Numeric Rating Scale, and Betel Quid Dependence Scalewere used to quantitatively assess reasons for betel quid chewing, stress, and betel quid dependence, respectively. Semi-structured questions were used to interview for qualitative data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The most common reasons for betel quid chewing were stimulation, reinforcement, and social/cultural factors. Chewers who reported more pressure to chew were more likely to be younger, have less educational level, be employed, have greater stress, and have more betel quid dependence. Content analysis of qualitative data showed three themes: physical and psychological demands, peer pressure, and perceived greater effectiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Employment was the factor most commonly associated with reasons for betel quid chewing and with each construct. Study findings can help healthcare professionals understand reasons for betel quid chewing, thereby helping them educate chewers to cope with withdrawal symptoms and successfully quit.\u003c/p\u003e","manuscriptTitle":"Perceive Stress and Betel Quid Dependence Associated with Reasons for Betel Quid Chewing: A Mixed Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-31 07:01:03","doi":"10.21203/rs.3.rs-4677025/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2024-07-10T11:02:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-08T09:23:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2024-07-03T02:11:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aa1edc5f-eb20-4a56-abed-52f9b9c54904","owner":[],"postedDate":"July 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-04T16:27:08+00:00","versionOfRecord":{"articleIdentity":"rs-4677025","link":"https://doi.org/10.1186/s12903-024-05093-w","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2024-11-01 16:20:20","publishedOnDateReadable":"November 1st, 2024"},"versionCreatedAt":"2024-07-31 07:01:03","video":"","vorDoi":"10.1186/s12903-024-05093-w","vorDoiUrl":"https://doi.org/10.1186/s12903-024-05093-w","workflowStages":[]},"version":"v1","identity":"rs-4677025","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4677025","identity":"rs-4677025","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}