Introduction

The areca nut is commonly referred to as betel nut, because it is often chewed while wrapped in betel leaves1. Betel quid (BQ) and areca nuts products are typically a mixture of areca nuts and hydrated lime wrapped in betel leaves with added flavorings2. All throughout the world, about 600 million people are areca nut users3,4. In China, Hunan Province has one of the highest prevalence rates (64.5–82.7%) of areca nut chewing5. A major reason for this is that Xiangtan in Hunan Province is a major centre for areca nut processing. Moreover, The BQ chewing habit in Hunan consists of dried husks and areca nuts, which are sold as industrially packaged, areca nut-based products. The age range of people chewing areca nut in Hunan is very wide. A study investigated the chewing of areca nut among primary and secondary school students in Hunan Province and found that the frequency of chewing areca nut was 12.4%6.

As an important herbal medicine, areca nut exhibits therapeutic potential for a wide range of illnesses, including depression, abnormalities of the digestive system, and parasitic infections7,8,9,10. However, many studies have shown that the ingredients of areca nut are potentially harmful11,12. Adverse effects of chewing areca nut include cytotoxicity and genotoxicity, carcinogenicity (especially oral cancer), oral submucous fibrosis (OSF), and addiction dependence7,8,13,14,15. Areca nut has been classified as an independent Group 1 human carcinogen16. BQ chewing is closely associated with oral precancerous lesions, leukoplakia and OSF and has exhibited significant dose response17. However, according to the results of a survey in Hunan Province published in 2008, most respondents did not know that chewing areca nut could induce oral cancer18.

Due to the prevalence of areca nut chewing in Hunan Province, China, the incidence of oral cancer is particularly high, posing a serious threat to public health19,20,21. Few studies have explored the current situation of areca nut chewing among university students and their perceptions and attitudes towards areca nut22. The aim of our study was to figure out how often the students use areca nut or areca nut products at Central South University in Changsha, Hunan, as well as to identify any potential risk factors.

Methods

Participants and study design

In this cross-sectional study, we distributed an anonymous self-reported questionnaire to students of Central South University in Changsha by sending links to class groups or club groups on WeChat (the dominant social platform among Chinese college students) in March 2023. We compiled the items in our questionnaire to make them relevant to our research population based on prior studies23,24 and the epidemiology of areca nut usage in China25. Surveys were administered via Questionnaire Stars (www.wjx.cn), a certified online data collection platform compliant with China’s cybersecurity regulations (GB/T 35273 − 2020). Participants accessed the survey through unique links. Upon accessing the link, participants first viewed a mandatory disclosure statement: “Dear student, thank you for participating in this survey on areca nut use among contemporary university students. Your responses will be used solely for academic research. All data are anonymized; no personal identifiers (e.g., name) are collected. You may close the browser at any time to withdraw. Submission of this questionnaire implies informed consent. We appreciate your honest and careful responses.” The exclusion criteria are as follows: (1) incomplete questionnaire, (2) the duration of questionnaire filling without under 60 s. If a questionnaire met any of the exclusion criteria, it would be unaccepted.

Materials

The questionnaire was called College students’ knowledge, attitudes and use of areca nut. The questionnaire included three parts: general characteristics, knowledge and attitudes toward areca nut chewing, usage and addiction to areca nut. This questionnaire consisted of 42 items (the Supplemental Data 1). General characteristics included age, gender, academic year, and cost of living per month, etc. An extra 15 questions were listed to discover more about respondents’ knowledge and attitudes toward areca nut chewing. Then we asked the students the following question, “Do you have a tendency to chew areca nut?“. When participants chose “Yes”, they were required to answer further 19 questions designed to gauge the respondents’ usage of areca nut. If they replied “No”, questions about the use of areca nut would be skipped.

Statistical analysis

The invalid questionnaires were excluded on the platform of Questionnaire Stars. The final data was then downloaded and analyzed in SPSS (version 26.0). The qualitative data are described as frequencies and percentages (%), while quantitative variables are described as means and standard deviations (SD). Chi-square analysis was employed to compare the basic statistics and other characteristics of the areca nut chewing group and the non-chewing group. Continuous variables were compared with the Student’s t-test. Binary logistic regression analysis was conducted to examine the effect of students’ basic statistical information on areca nut chewing. In this logistic regression analysis, areca nut chewing is regarded as a dependent variable, while gender, age, and other basic characteristics were considered as covariates. The statistical significance of the study was determined at p-value less than 0.05, and the test of significance used was two-sided. In addition, “Generally agreed”, “Relatively agreed”, and “Completely agreed” were considered as agreed.

Results

Basic characteristics of the participants

1692 questionnaires were returned in total. After excluding incomplete questionnaires and short questionnaires (less than 60 s), 1417 questionnaires (83.74%) remained. There were 715 males (50.5%) and 702 females (49.5%), with a mean age of 21.35 years (SD = 1.62). A total of 317 participants (22.4%) reported a habit of areca nut chewing. Among them, 271 (85.5%) were males and 46 (14.5%) were females (p < 0.05). They varied across academic years, with percentages of 29.30% among freshmen, 48.10% among sophomores, 23.3% among juniors, 9.40% among seniors, and 5.1% among graduate students (p < 0.05). A statistically significant difference was observed in areca nut chewing prevalence between medical students (27.9%) and non-medical students (15.7%) (p < 0.05), only children (34.4%) and non-only children (12.6%) (p < 0.05) and between urban students (26.3%) and rural students (17.3%) (p < 0.05). Besides, a noteworthy association was identified between parental education level (p < 0.05), as well as family atmosphere (p < 0.05), and areca nut chewing behavior. However, there was no significant difference in the proportion of chewing areca nut among students with different monthly living expenses (p = 0.29). In addition, since it is mainly men who chew areca nut, we conducted a stratified analysis of the differences in areca nut chewing among men with different home residence and found that there were no significant differences in areca nut chewing among men with different home residence (p = 0.05). Table 1 presents the basic characteristics of all the participants and as chi square analysis of the variations among groups.

Table 1 Basic characteristics of participants in this study.
Full size table

The habit of areca nut chewers

Among the study participants who chewed areca nut, 143 (45.1%) began chewing areca nut at an age younger than 18 years, and almost half of the participants had chewed areca nut for 2–3 years (n = 158, 49.8%). Most of the areca nut chewers chew 3–5 areca nuts per day (n = 113, 35.6%), followed by 6–8 areca nuts per day (n = 99, 31.2%), and 36 people chewed 9 or more areca nuts per day (11.4%). 143 areca nut chewers chew areca nut for 30 min to an hour daily (45.1%), and 103 (32.5%) spent 20 to 50 yuan on chewing areca nut in the past six months. Figure 1 shows the characteristics of the habit of areca nut chewers.

Fig. 1
figure 1

The habits of areca nut chewers. (A) Number of areca nut chews per day. (B) How long you chew areca nut each day. (C) The number of years of chewing areca nut. (D) The average monthly cost of buying areca nut in the last six months.

Full size image

Risk factors of chewing areca nut

The results of bivariate logistic regression analysis (Table 2) showed that home residence (p = 0.95) and family atmosphere (p = 0.41) had no significant effect on areca nut chewing. Meanwhile, increasing age (OR = 1.46, 95%CI: 1.31–1.63, p < 0.05), male sex (OR = 5.31, 95%CI: 3.70–7.61, p < 0.05), and higher parents’ education level (OR = 1.31, 95%CI: 1.10–1.57, p < 0.05) were positively correlated with students’ use of areca nut. In addition, having siblings (OR = 0.40, 95% CI: 0.29–0.57, p < 0.05), and being in a higher academic year (OR = 0.38, 95% CI: 0.32–0.45, p < 0.05) were negatively correlated with the likelihood of a student using areca nut.

Table 2 Bivariate logistic regression analysis of ever areca nut use.
Full size table

Reasons for chewing areca nut

We designed a multiple-choice question (with a maximum of three options) to analyze the reasons why college students chew areca nut. The results showed that the majority of people chose to chew areca nut simply because of its good taste (n = 190). Secondly, environmental factors (including crowd mentality and social needs) accounted for the second major reason for chewing areca nut. Additionally, some people chew areca nut to refresh their minds (n = 149). Chewing areca nut has become a daily habit for 129 participants. Other factors contributing to chewing betel nuts include health benefits, keeping warm and quenching thirst (Fig. 2).

Fig. 2
figure 2

Reasons for chewing areca nut.

Full size image

Cognition and attitudes toward areca nut

The third part of questionnaire aimed to collect knowledge and attitudes toward areca nut. As many as 57.6% of the participants held the belief that chewing areca nut did not provide any benefits. Also, 74.3% of the respondents were aware of the World Health Organization’s classification of areca nut as a Group 1 carcinogen. A full 84.3% of respondents perceived a correlation between chewing areca nut and oral cancer, with 59.1% attributing the presence of the carcinogenic substance to areca nut itself. A substantial percentage (75.5%) conveyed their thought that oral cancer could be prevented. Additionally, 52.1% of individuals believed that areca nut possessed addictive properties. Most students thought using areca nut would produce the following undesirable outcomes: oral mucosal ulcer (69.2%), impaired taste function (63.6%), restriction of mouth opening (58, 3%), cancer of oral mucosa (71.3%), and serious tooth abrasion (65.1%). It is significant that 73.7% of them obtained information on health risks of areca nut through TV or Internet. In addition, 50.3% of the students considered that teenagers should be banned from chewing betel quid. To some extent, most participants thought areca nut advertisements should be forbidden and all shops or supermarkets selling areca nut need to be regulated. However, only 30.4% fully agreed that they would persuade those around them not to chew areca nut or to chew less. Further details were presented in Table 3.

Table 3 Knowledge and attitudes regarding areca nut among university students.
Full size table

Discussion

This cross-sectional study focused on the knowledge, attitudes, and practices of chewing areca nut among Central South University students in Changsha, Hunan. According to the survey, we found that male students were more likely to have areca nut compared with female students, which was consistent with previous studies26,27,28,29. Young and adult women might not enjoy it since areca nut stained teeth, thus affecting aesthetics. We also found that with the improvement of students’ grades, the use of areca nut in college students decreased significantly. This may reflect increased autonomy in health decisions or exposure to oral health courses.

In addition, only children were more likely to chew areca nut than non-only children. One possible explanation may be that the only child bears more attention from the parents, and the pressure of life and study is greater than that of a non-only child. In our survey, 76% of students using areca nut reported that there were other people who chewed areca nut nearby them. Students were more likely to chew areca nut if they were unable to refuse areca nut supplied by family or friends in previous research27,30. Meanwhile, chewing areca nut was considerably influenced by home address according to the chi-square analysis in our study. Among the students chewing areca nut, 66% of them were from metropolitan areas. However, when we conducted a stratified analysis of men with different home residences, no significant statistical differences were found. The logistic regression analysis also revealed a contradictory result that there was no statistical significance about the role of home address on areca nut chewing. We suspect that it is because the chi-square analysis did not control for the percentage of males in urban and rural areas, but our logistic regression did. Therefore, logistic regression shows the real situation. According to an Indian study with a sample size of 74,037 individuals aged 15 and older, consumption of areca nut was higher in urban than in rural areas26. Conversely, another survey discovered that areca nut chewing was more common in less urbanized areas28. Future multi-regional studies should examine how variations in areca nut product types and location-specific accessibility influence consumption patterns. Furthermore, our survey supported that as parents’ education levels rose, their children obtained more chances to chew areca nut. This might due to the phenomenon that the higher the education levels the parents had, the greater the expectations of the parents exerted on their children. As the stress on the children became greater, they were more likely to chew areca nut for psychological comfort. It has been found that areca nut users often experience emotional distress, such as anxiety, depression, and distress related to areca nut dependence31. Therefore, reducing the burden on college students is critical, while we also advocate that students relieve their stress more healthily by developing other interests or playing sports. A higher rate of areca nut chewing was observed in studies with children with parents experiencing failed marriages24. In addition, if either of the parents chewed areca nut, it was easier for their children to pick up this habit as teenagers32,33,34,35.

In our study, the level of knowledge among these students regarding areca nut and oral cancer was high. The World Health Organization defines areca nut as a Group 1 carcinogen, and more than two-thirds of the participants (74.3%) were aware of this fact. This was significantly higher than that of the results from another survey in China, revealing that only 30.6% of participants recognized areca nut’s carcinogenicity20. However, there were still a large number of participants choose to chew areca nut. We believe there are three mutually reinforcing driving factors: Firstly, Hunan province is the largest processing area of areca nut in the country, which makes it very easy for people to purchase areca nut. Secondly, peer pressure also plays an important role. Crowd mentality and social needs constitute a large part of the reasons why people chew areca nuts. Last but not least, the underestimation of addiction is also a very important part: although 84.3% of people are aware of oral cancer risks, there were still 40.6% of participants chew areca nut due to their daily habit. This suggests knowledge alone is insufficient where environmental exposure and social reinforcement are pervasive. Unlike previous studies that revealed a low level of knowledge regarding the carcinogenic effects of areca nut35,36, 84.3% of participants in our study were aware that areca nut was associated with oral cancer and 75.5% of them realized that oral cancer could be prevented. It may be because oral cancer was widespread as reported in scientific research. According to the results of a cluster-randomized controlled trial, oral visual screening could be a worthwhile initiative for oral cancer surveillance, and the screening had the potential to decrease the mortality of oral cancer17,37. In addition, it could be the primary prevention effort to reduce areca nut use. However, there were many barriers to oral mucosal screening, including a lack of a physician recommendation, high cost and lack of public transport, emotional barriers (avoidance of cancer information and fear), embarrassment, fear of the procedure or report, living in a rural area, and insufficient resources38,39,40. What’s more, a systematic review and meta-analysis including 11 studies indicated that betel quid and areca nut chewing was closely associated with poor prognosis of patients with oral cancer19. Unlike the warning labels on tobacco products by the Tobacco Products Directive (from the WHO Framework Convention on Tobacco Control)41, many areca nut product packaging or sale websites provide no information about the carcinogenic effects and risks of oral cancer. It might be difficult to get the support of the government to control arecanut because it may be earning taxes from arecanut products, but is important to keep trying hard42.

In terms of how participants perceived the addictive properties of areca nut and its products, 52.1% of participants believed that the areca nut itself was addictive, while 29.6% thought that the added substances were. It has been found that there are seven psychoactive alkaloids in the areca nut with arecoline being the main one, and the rest are arecaidine, guvacine, guvacoline, isoguvacine, arecolidine, and homoarecoline43,44. Arecoline was supposed to be the principal hazardous component in arena nuts, and its primary side effects were genotoxicity, oral submucous fibrosis, and oral squamous cell carcinoma (OSCC)45. In the aspect of the oral hazards of consuming areca nut, the majority (71.3%) of the students chose oral mucosa cancer and more than half of the students chose oral ulcer (69.2%), severe tooth wear (65.1%), gustatory dysfunction (63.6%), or hard to open the mouth (58.3%). Our results showed that college students had a certain awareness of the oral hazards of chewing areca nut. Some previous studies found a higher prevalence of dental caries and oral candida in BQ users than in non-users46,47. Community-based oral care education should also be warranted to improve oral health and oral hygiene48. As the results of a global systematic review based on 62 studies, the brain, heart, lungs, gastrointestinal tract, and reproductive systems were among nearly all of the human body’s organs that were affected by areca nut consumption20. There is a pressing need for policymakers to acknowledge areca nut as a dangerous food ingredient. To control the commercial manufacturing of areca nuts, strict restrictions are required. Chewing areca nut can also disrupt basic medical procedures, such as tracheal intubation and preoperative airway assessments due to oral submucous fibrosis caused by areca nut chewing49.

There are many ways to know about the health hazards of areca nut. According to the findings of our survey, most participants (73.7%) received health-related information about areca nut from television and the Internet. This suggested that the ways to spread knowledge about areca nut could be in line with the preference of contemporary young people who were more inclined to receive knowledge through video. Some platforms offer online courses about the dangers of betel quid and areca nut, such as the Pacific Open Learning Health Net (POLHN)50. It has the potential to be adopted in China and other countries to improve the understanding of areca nut in student groups. Moreover, health education enables students to better resist the use of areca nut. A study was designed to explore the effect of preventive health education intervention in the knowledge, attitudes, practice of areca nut chewing, and self-efficacy in resisting areca nut chewing for adolescent students. It confirmed the importance of health education programs in dealing with the health risks of areca nut chewing for the risk group students51. All these results can guide us to design a well-fitting publicity campaign about the hazards of areca nut for students in the future and educational intervention measures on how to stop using areca nut.

The results of our study also indicated that college students maintained a relatively consistent view towards the dimension of supervision and restriction of areca nut. The majority of the participants held the positive attitude towards banning or restricting chewing areca nut by teenagers (73.4%), areca nut advertisements in major media (67.2%) and selling areca nut in shops or supermarkets (87.2%), suggesting that college students were looking forward to strengthening the restriction of areca nut use. Moreover, a large amount of online data demonstrated that the general public held a negative attitude toward the chewing habit. According to the findings of the questionnaire from residents in Zhuzhou City, most of the responders (74.3%) suggested that controlling and managing areca nut industries was necessary20. Under such a context, the government needs to formulate appropriate policies to balance public proposals, suggestions and areca nut industry development.

There are several limitations in our study. Firstly, the sample size of our study was limited, so the results might not be representative of Chinese university students. Secondly, online surveys may be more difficult to ensure data quality compared with face-to-face interviews. That might cause the main information bias of our study.

Conclusion

The binary logistic regression analysis in this study found that gender, academic year, parental education level, and being an only child may affect the habit of areca nut chewing among college students. Among all participants, the majority of students believed that areca nut had addictive substances and carcinogenicity, especially for oral cancer, and most of them approved that oral cancer can be prevented.