The adverse health effects associated with areca (betel) nut use include oral and oropharyngeal cancer, oral premalignant lesions and conditions (oral leukoplakia and submucous fibrosis), gum disease and addiction (1, 2). Chewing areca nut is widespread in south Asia and in the Pacific region (3). A study in Papua New Guinea has reported that areca nut use is highly prevalent among adults in Melanesia (4). In Taiwan, China, where the habit is practised widely, particularly in the aboriginal areas (5), many reports suggest that this chewing habit starts at a young age (6-9).
Guam, the Commonwealth of the Northern Mariana Islands (CNMI), Republic of Palau, the Federated States of Micronesia and the Republic of the Marshall Islands belong to the geographical area of Micronesia which covers a large portion of the central and western Pacific Ocean. Apart from their geographical separation from Melanesia and Polynesia, the Micronesians are distinct in their physical appearance. In addition, each island group represents a unique culture with specific customs.
Together Guam and the CNMI form the Northern Mariana Island chain which extends in a north-south direction between the equator and Japan. The CNMI is an unincorporated territory of the USA and consists of 14 principal islands, three of which are inhabited. Saipan, 12.5 miles long and 5.5 miles wide, is the CNMI's largest island and is home to 90% of its population (about 58 000 people in 1995). The indigenous ethnic group are the Chamorro people, who comprise approximately 60% of the population. In the late nineteenth century a migration of islanders from the Caroline Islands (now the Federated States of Micronesia) occurred. The descendants of these immigrants are called Carolinians. Due to the proximity of the CNMI to Asia, there is also a large representation of other racial groups such as Chinese, Filipinos, Japanese and people from the Republic of Korea.
Areca nut use among the inhabitants of Guam has been reported to be widely prevalent (10). In Guam, areca nut (pugua) chewing is an old tradition, particularly among Chamorro people (the indigenous people of Guam and Saipan) (http:// ns.gov.gu/pugua.html). Most of the chewers in the islands surrounding Micronesia use the soft immature nut, split open and filled with lime (calcium hydroxide) and wrapped with piper betel leaf. Chamorros traditionally chewed the hard mature nut with lime with or without the leaf. The chewing habits among adolescents in Micronesia have not been reported. We conducted a cross-sectional study on high-school students in Saipan with the objective of describing the prevalence, correlates of use, reasons for chewing and reasons for disliking the habit, and to characterize the associated clinically detectable oral mucosal lesions.
Materials and methods
On Saipan there are three public high schools with a total of 2415 students of whom 1186 are female and 1229 are male. Several small private high schools, all religion-based, were excluded from the study. Permission to undertake the study in the three schools was obtained from the school authorities. Information about the study and consent forms were sent to the parents and legal guardians by schoolteachers and collected prior to the study. Participation was voluntary. All consenting students (with the signed consent of their parent(s) or guardian(s)) who attended the school on the days of the examinations and were physically present in the science classroom in each school at the time of the visits by the research team participated in the study. The mean age of the high-school students was 16 years (range 14-18 years).
During 2004, the three schools were visited by a dentist who acted as a screener and a registered dental hygienist who administered the questionnaire to the participants. The 15 item questionnaire was self-completed by students during class time under the supervision of the dental hygienist. …