RESEARCH ARTI CLE Open Access

Alcohol, betel-nut and cigarette consumption are

negatively associated with health promoting
behaviors in Taiwan: A cross-sectional study
Su-Er Guo
1
, Tung-Jung Huang
2
, Jui-Chu Huang
3
, Ming-Shyan Lin
4
, Rei-Mei Hong
5
, Chia-Hao Chang
5
and Mei-Yen Chen
5*
Abstract
Background: Oral cancer is the 2
nd
most common cause of death due to cancer in the south-western coastal
region of Taiwan; the standardized mortality of oral cancer is higher than elsewhere in the world. According to the
evidence, alcohol, betel-nut and cigarette (ABC) consumption cause oral, nasopharyngeal and related cancers. This
study describes the relationships between ABC consumers and health promoting behaviors among community
adults living around an area with a high prevalence of oral cancer.
Methods: A population-based, cross-sectional study design was conducted in oral cancer epidemic areas in
south-western coastal Taiwan in 2010, 6,203 community residents over 20 years of age participated.
Demographic data, ABC habits, and health-promoting behaviors were explored. A logistic regression analyses
were used to identify factors associated with ABC consumers.
Results: A high percentage of participants consumed alcohol, betel-nut and cigarettes. Betel-nut and cigarette
consumers took low levels of exercise, adopted a poor diet, and had poor oral hygiene. After adjusting for
potential confounders, the logistic regression model indicated that middle aged males of poor education and
low economic status, who did not exercise regularly and had poor oral hygiene, were more likely to chew
betel quid and smoke cigarettes.
Conclusions: It has identified that BC consumers are negatively associated with health promoting behaviors.
Further research is required to understand the reasons why the subjects consume ABC, and explore ways to
prevent initiation and enhance cessation of ABC habits in this population.
Keywords: Alcohol, Betel-nut, Cigarette, Nursing-led community health, Health promotion, Oral cancer
Background
Nurse-led health promotion program to prevent chronic
disease and related cancers
Each year the International Council of Nurses (ICN)
provides a theme or mission on International Nurses
Day for global nursing reflection and direction. During
the last 5 years (20082012) themes have concerned
serving communities, with nurses leading primary health
care, chronic care and closing the gap from evidence to
action [1]. These missions motivated community nurses
in Taiwan to actively participate in providing health pro-
motion programs, cooperating with public health nurses,
school health nurses and faculty members from the
schools of nursing to take a leading role concerning
community health development. The World Health
Organization (WHO) has said that chronic diseases,
such as heart disease, stroke, cancer, chronic respiratory
diseases and diabetes, correspond to 63% of all deaths in
the world [2]. Alcohol and cigarettes contribute to these
chronic diseases [3], and ABC consumption causes oral
cancer [4]. In this study, the authors found that the in-
cidence of oral cancer is 123-fold higher in ABC con-
sumption, compared to non-ABC consumption [4].
* Correspondence: meiyen@gw.cgust.edu.tw
5
College of Nursing & the Chronic Diseases and Health Promotion Research
Center, Chang Gung University of Science and Technology, No. 2, Chia-pu
Rd. West Sec, Putz City, Chiayi County 61363, R.O.C. Taiwan
Full list of author information is available at the end of the article
2013 Guo et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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Twenty years ago, 10% Taiwanese over 15 years old were
ABC users [5]. In particular, betel nut trees became a
significant agricultural product in Taiwan [6]. Therefore,
reducing ABC consumption is increasingly important in
promoting health.
According to ICD-10, oral cancer in the south-western
coastal region of Yunlin County is ranked as the 2
nd
most
common cause of death from cancer in males, and its
standardized mortality rate (34/100,000) is higher than
that of the Taiwanese nation (14.9/100,000) and through-
out the rest of the world [7]. Some of the mechanisms
and specific risk factors associated with developing can-
cer remain unknown. However, the majority of factors
associated with oral cavity-related cancers, including
the oral sub-mucosa, tongue and nasopharynx, are re-
lated to alcohol, betel quid (areca nut) chewing and
cigarette smoking [8-11]. Of these 3 habits, chewing
betel quid, widespread in Southern Asian populations,
is the major factor that causes oral cancer [10,12]. This
habit is common in Taiwanese adolescents and adults
with a poor educational level, and in minority popula-
tions in rural areas [12].
According to the mission of ICN, nurses are expected
to serve communities and lead community health facil-
ities. Therefore, this research team conducted a longitu-
dinal study, based on community health assessment
through a health promotion program, with the aim of
reducing ABC consumption.
Issues of ABC
Over-consumption of alcohol harms health and social
relationships, and, according to [13], excess alcohol con-
sumption results in 2.5 million deaths every year. It can
result in cardiovascular diseases, liver cirrhosis, hyper-
tension, diabetes, dyslipidemia, abdominal obesity, meta-
bolic syndrome, various cancers and several psychosocial
related issues [14]. Numerous studies show that alcohol
consumption is strongly associated with morbidity, mor-
tality, and social problems in developing and developed
countries [1,14,15].
Chewing betel quid is significantly associated with
adverse health effects, including oral and pharyngeal
cancer, sub-mucosal fibrosis, gum disease, obesity,
metabolic syndrome, hypertension and cardiovascular
mortality [8,12,13]. Betel quid chewing is a common
habit in Southern Asian populations, e.g. Malaysia,
India, Pakistan, Sri Lanka, Myanmar, Thailand and
Taiwan [8], and its contribution to the development of
oral sub-mucosal fibrosis and oral cancer confirmed
[9,16]. Retrospective studies indicated that many betel
quid users combine this with alcohol consumption and
cigarette smoking [7]. Cigarette smoking is responsible
for several adverse cardiovascular and respiratory out-
comes [17,18]. Combined with betel quid chewing it
also has a significant contribution (86.5%) to the risk of
oral leukoplakia and oral sub-mucosal fibrosis [16].
Despite numerous studies reporting that the mechan-
ism of ABC habits are associated with oral cancer, those
that focus on combining ABC habits with adopting
health promoting behavior in areas with a high preva-
lence of oral cancer are scarce. The purpose of this art-
icle, therefore, has been to outline the first phase of a
longitudinal study and decide whether ABC is associated
with poor health promotion.
Methods
Design, sample and setting
This study is the first part of the longitudinal study of
health promotion for community health development
lead by nursing faculty members (HPCHN) around
areas in south-western coastal Yunlin County, Taiwan,
where oral cancer is endemic. Using a descriptive cross-
sectional design, this community-based survey was
implemented every Monday to Saturday from October
2010 to September, 2011. Of 47,798 residents living in 27
villages, the response rate was 14.5% (6,911). The partici-
pants were selected by convenience sampling at the vil-
lages in the south-western coastal areas. The inclusion
criteria were adults: (1) aged 20 years and over, (2) fully
independent in managing their daily lives, (3) able to
complete the questionnaires in Mandarin or Taiwanese
dialects either by self-administration or at interview,
without serious mental problems, (4) able to walk to a
community center or the corporate private hospital, and
(5) who agreed to sign an informed consent before being
enrolled in the study. A total of 6,203 community resi-
dents participated.
Procedure and ethical considerations
This study was conducted with a corporate private hos-
pital (135 beds) through the community health screening
program, and approved by the institutional review board
ethical committee (Chang-Gung Memorial Hospital Eth-
ics Committee No 99-2501B). The interviewing proce-
dures and privacy protection were explained to the
participants by the research assistants. There were 2
stages in the set-up: (1) A systematic literature reviews
needed to draw up the first version of the questionnaire.
ABC were used as the major keywords to search
PubMed, Ovid and the Chinese database from 1980 to
2011. (2) Face and content validity was judged to be
good (CVI = 0.900.92) by a panel of 5 experts - public
health and health education faculty members, metabolic
physicians, and nursing faculty members teaching health
promotion. Some items within the instruments were re-
vised according to the experts suggestions.
All research assistants were trained for 4 hours by the
investigators. Research assistants were senior nursing
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students in a Post-RN Bachelor of Nursing Degree Pro-
gram who held registered nursing license and received 2
consequent training programs, each of 2 hours duration.
In session 1, we focused on understanding research
background and practicing interview skills. In session 2,
20 research assistants were grouped into 10 pairs to pre-
test and be familiar with all items of the questionnaire.
Finally, research assistants were divided 2 groups to
interview each elder and a 90% correct rate of inter-rater
reliability was confirmed among the 10 pairs. The ques-
tionnaire consisted of 2 sections and the characteristics
of the participant, as described below.
Instruments
ABC habits were measured using 5 questions: (A) do
you drink alcohol? Participants were classified as less
consumption if they had never drank alcohol or had
not drank for one year, or regular consumption if they
were currently drinking; (B) do you chew betel-nut?
Participants were classified as less consumption if they
had never chewed betel-nut or no longer chewed, or
regular consumption if they were currently chewing
one quid or more per day [4]; (C) do you smoke ciga-
rettes? Participants were classified as less consumption
if they rarely or never smoked or regular consumption
if they were a current smoker one cigarette or more
per day [4]; (D) when did you begin to consume alco-
hol, betel nut chewing or smoke cigarettes? if partici-
pants answered that they no longer partook of these 3
habits, they were asked question (E). How long is it
since you quit drinking alcohol, betel nut chewing or
smoking cigarettes?
Health-promoting behavior was measured using 5
items including physical activity, requiring participants
to answer the questions: (A) do you take regular exer-
cise? Participants were classified as not often if their
answer was never or sometimes, or often if they usu-
ally exercised for >30 min per day, 3 times per week,
or 150 minutes per week. (B) Vegetable and fruit
habits: do you have 3 portions of vegetables and 2
portions of fruit every day? The answer was classified
as not often if they answered never or sometimes,
and as often if they usually had at least 3 portions or
one and half bowl-sized portions of vegetables, and at
least 2 portions or one bowl-size of fruit >5 days per
week. (C) Regular dental check-up behavior: do you
generally go to the dental clinic for a check up every
half-year? the answer was classified as not regular if
the answer was never or more than one year before
visiting a dentist, or regular if they answered that
they attended regularly or at least within half a year.
(D) Teeth brushing behavior: do you think that you
should brush your teeth after meals? the answer was
classified as incorrect if they did not brush their teeth
after meals and use dental floss at least once per day,
or correct if they brushed their teeth after meals and
used dental floss at least once per day. (E) Frequency
of brushing teeth: how many times do you brush your
teeth per day?
Participants characteristics were obtained through
structured questions relating to age (year of birth), gen-
der, marital status, economic status (3 levels were cate-
gorized as good, fair/not bad, poor/bad), and educational
attainment (receiving educational year or graduated
school level).
Statistical analysis
Analysis was conducted using SPSS 17 statistical soft-
ware (SPSS INC., Chicago, IL). Coded data were
subjected to range and manual checks for accuracy. To
compare personal factors or health promoting behavior
in various ABC consumption groups, the Chi-square
statistic for testing equality of proportions or rates was
used. Final models using binary logistic regression for
analyzing betel-nut and cigarette consumption were
chosen, based on likely and relevant confounders after
univariate analysis (candidate correlates were excluded
from the final analyses if p > 0.05 in the univariate ana-
lysis with outcome variable). Statistical significance was
set at p < 0.05.
Results
Demographics and health related behavior
According to the statistics on household registration,
the total of adult residents living in the 27 villages
was 47,798 [19]. As several worked out of these
townships, the baseline questionnaire was sent to
6,911 residents; 708 (10.2%) were not recruited to
this study due to being too young, and others were
rejected as they were unavailable for interview. Of
the remaining 6,203 participants, 83.4% had lived in
the community for >20 years and 57% were female
(3,501). The mean age was 49.4 (SD = 16.4, range
2095) years, with 78% (4,819) being in the range
from 20 to 64 years. More than half (3552, 58%)
were not educated past middle school. The majority
(78%) was married, 39% had no occupation, and
25.1% worked in farming or fishing. Twenty-one per-
cent (1,268) rated their economic status as poor and
difficult, while 78% considered it average.
More than one-third of the participants (2,153; 35%)
reported that they regularly consumed alcohol, 17%
(1,017) chewed betel-nut and 26% (1,576) smoked ciga-
rettes. Furthermore, 14% (872) reported regularly con-
suming betel-nut and cigarettes, and 9% (522) regularly
consumed ABC. The beginning mean (median, range)
age of using ABC was 23 (20, 1271), 24 (21, 1365),
and 21 years of age (21, 1071), respectively.
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ABC consumption is associated with personal factors and
health promoting behavior
There were few differences between the personal factors
and health promoting behavior in the alcohol, betel-nut
chewing and cigarette smoking groups. Table 1 shows
that subjects at study entry who consumed alcohol regu-
larly were predominantly male (p < 0.001), with a high
school or college education (p < 0.001), below 64 years of
age (p < 0.001), with good or fair economic status (p <
0.001), often adopting physical activity (p < 0.01), not
consuming vegetable and fruit (p < 0.001), not attending
regular dental check-ups (p < 0.001) and brushed their
teeth infrequently (t = 5.4, 95% CI = 0.08 ~ 0.17, p <
0.001). The characteristics and factors associated with
Table 1 Demographic characteristics, health promoting behaviors and alcohol, betel-nut and cigarette consumption
Variables Alcohol Betel-nut Cigarette
Consumption N (%)
Less
1
/Regular
2
Less
1
/Regular
2
Less
1
/Regular
2
Mean, median, range 23, 20, 12 ~ 71 24, 21, 13 ~ 65 21, 20, 10 ~ 71
Gender
2
=906.7***
2
=1077.1***
2
=1636.4***
Female 2880 (83.7) 560 (16.3) 3394 (97.8) 75 (2.2) 3283 (94.8) 180 (5.2)
Male 1160 (46.8) 1319 (53.2) 1780 (67.3) 866 (32.7) 1332 (49.8) 1341 (50.2)
Educational level
2
=267.6***
2
=147.7***
2
=131.8***
<=middle school 2542 (76.8) 770 (23.2) 2849 (82.5) 606 (17.5) 2652 (76.7) 804 (23.3)
=high school 658 (54.2) 557 (45.8) 1002 (79.4) 260 (20.6) 810 (63.7) 462 (36.3)
> = college 807 (59.6) 546 (40.4) 1288 (94.8) 70 (5.2) 1124 (82.3) 242 (17.7)
Age (years)
2
=257.5***
2
=29.1***
2
=57.0***
20 ~ 39 1229 (59.1) 852 (40.9) 1826 (86.6) 283 (13.4) 1541 (72.5) 585(27.5)
40 ~ 64 1683 (66.9) 832 (33.1) 2167 (81.7) 484 (18.3) 1945 (73.4) 705 (26.6)
65~ 1138 (85.1) 200 (14.9) 1193 (87.0) 178 (13.3) 1141 (82.9) 235 (17.1)
Economic status
3

2
=20.7***
2
=36.9***
2
=16.1***
Good 80 (70.8) 33 (29.2) 103 (88.8) 13 (11.2) 93 (80.2) 23 (19.8)
Fair/not bad 3091 (66.8) 1537 (33.2) 4092 (85.9) 673 (14.1) 3646 (76.2) 1137 (23.8)
Poor/bad 795 (73.8) 282 (26,2) 892 (78.8) 240 (21.2) 802 (70.8) 330 (29.2)
Physical activity
4

2
=8.3**
2
=15.5***
2
=14.1***
Not often 2138 (69.9) 919 (30.1) 2630 (82.8) 545 (17.2) 2332 (73.2) 853 (26.8)
Often 1912 (66.5) 965 (33.5) 2556 (86.6) 400 (13.5) 2295 (77.4) 672 (22.6)
Vegetable and fruit
2
=34.1***
2
=25.5***
2
=50.6***
Not often 3506 (67.2) 1709 (32.8) 4536 (84.0) 863 (16.0) 4019 (74.2) 1400 (25.8)
Often 447 (79.3) 117 (20.7) 528 (92.0) 46 (8.0) 502 (87.6) 71 (12.4)
Dental check-up
2
=27.2***
2
=51.6***
2
=23.7***
Not regular 2158 (71.4) 863 (28.6) 2583 (81.8) 574 (18.2) 2309 (73.0) 852 (27.0)
Regular
5
1584 (64.8) 859 (35.2) 2203 (88.7) 280 (11.3) 1963 (78.6) 533 (21.4)
Tooth brush
2
=0.4
2
=38.4***
2
=19.3***
Incorrect 2967 (68.0) 1395 (32.0) 3754 (82.9) 775 (17.1) 3356 (73.8) 1193 (26.2)
Correct 1083 (68.9) 489 (31.1) 1432 (89.4) 170 (10.6) 1271 (79.3) 332 (20.7)
Tooth brush
6
t value = 5.4*** t value = 7.0*** t value = 8.2***
(mean, sd) 1.82 (0.7) 1.69 (0.6) 1.80 (0.7) 1.60 (0.7) 1.82 (0.7) 1.62 (0.6)
95% CI .08 ~ .17 .15 ~ .27 .16 ~ .26
1
Less consumption: The amount of ABC consumption was never or less or quit more than one year.
2
Regular consumption: The amount of ABC consumption was more than recommended by medical experts.
3
Self-perceived economic status.
4
Often: regular physical activity at least 30 minutes per day or 150 minutes a week.
5
Regular: dental check up/per half year, which coverage by National Health Insurance.
6
Mean frequency of tooth brush per day and 95% confidence interval.
* p < .05 ** p < .01 *** p < .001.
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betel-nut chewing or cigarette smoking were comparable
(Table 1).
Table 2 shows that betel-nut and cigarette consump-
tion was associated with males (
2
=1761.2, p < 0.001)
that had received less education (
2
=169.9, p < 0.001),
aged between 4064 (
2
= 44.5, p < 0.001), had poor eco-
nomic status (
2
= 34.4, p < 0.001), did not often adopt
physical activity (
2
= 20.1, p < 0.001), did not often con-
sume vegetable and fruit (
2
= 56.3, p < 0.001), did not
regularly have dental check-ups (
2
= 44.4, p < 0.001) and
brushed their teeth infrequently (
2
= 32.9, p < 0.001).
The mean frequency of tooth brushing per day in the
betel-nut and cigarette group was significant less than
the other 2 groups (F = 38.6, p < 0.001, Table 2).
Correlation of betel nut and cigarette consumption
The logistic regression model (Table 3) indicated that
males were 9.8 times more likely have indulge in BC
Table 2 Betel nut and/or cigarette consumption associated with personnel factors and health promoting behaviors
Variables Number of betel-nut and/or cigarette consumption
1

2
0 1 2
B
3
user: 17% C
4
user: 26% BC user: 14%
Gender 1761.2***
Female 3228 (93.4) 206 (6.0) 23 (0.7)
Male 1214 (46.1) 670 (25.5) 748 (28.4)
Educational level 169.9***
<=middle school 2517 (73.2) 448 (13.0) 472 (13.7)
=high school 784 (62.4) 238 (18.9) 235 (18.7)
> = college 1113 (82.1) 182 (13.4) 60 (4.4)
Age (years) 44.5***
20 ~ 39 1513 (72.2) 327 (15.6) 257 (12.3)
40 ~ 64 1854 (70.3) 391 (14.8) 393 (14.9)
65~ 1086 (79.3) 160 (11.7) 124 (9.1)
Economic status 34.4***
Good 89 (76.7) 18 (15.5) 9 (7.8)
Not bad 3522 (74.2) 674 (14.2) 551 (11.6)
Difficult/very bad 759 (67.5) 168 (14.9) 198 (17.6)
Physical activity
2
20.1***
Not often 2242 (71.0) 458 (14.5) 457 (14.5)
Often 2211 (75.0) 420 (14.2) 317 (10.8)
Vegetable and fruit 56.3***
Not often 3858 (71.8) 813 (15.1) 706 (13.1)
Often 494 (86.4) 40 (7.0) 38 (6.6)
Dental check-up 44.4***
Not regular 2199 (70.0) 479 (15.2) 463 (14.7)
Regular 1911 (77.1) 334 (13.5) 233 (9.4)
Tooth brush- 32.9***
Incorrect 3209 (71.2) 670 (14.9) 630 (14.0)
Correct 1244 (77.9) 208 (13.0) 144 (9.0)
Frequency of tooth brush F = 38.6***
(mean, SD) 1.83 (0.7) 1.64 (0.6) 1.58 (0.6) Scheffe
95% CI 1.80 ~ 1.85 1.58 ~ 1.70 1.53 ~ 1.64 0 > 1 > 2
1
0 = none habit of betel-nut or cigarette consumption, 1 = one habit of betel-nut or cigarette, 2 = both habits of betel-nut and cigarette.
2
Often: regular physical activity at least 30 minutes per day or 150 minutes a week.
3
B = betel-nut.
4
C = cigarette.
* p < .05 ** p < .01 *** p < .001.
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consumption than females (OR = 9.77, p < 0.001). Partici-
pants with middle and high school education were 1.65
(p < 0.001) and 2.5 (p < 0.001) times more susceptible to
betel-nut and cigarette consumption regularly than those
with a college education, respectively. Those aged 4064
were 1.85 times (p < 0.01) more susceptible to regular
betel-nut and cigarette consumption than those aged
over 65, although there was a relationship between vege-
table and fruit intake and BC consumption in univariate
analysis (Table 2). However, after controlling other con-
founders, vegetable and fruit intake was not an import-
ant correlate in the logistic regression model. Subjects
that were less physically active, did not attend regular
dental check-ups, and incorrectly brushed their teeth
were 1.25, 1.29 and 1.42 times more susceptible to BC
habits than others, respectively.
Discussion
The findings indicate a high prevalence of ABC con-
sumption among adult community residents around
areas with a high incidence of oral cancer. Regular users
of betel quit and cigarettes are associated with low social
economic status and adopting a less health promoting
lifestyle. ABC consumption was also significantly associ-
ated with males.
High prevalence of ABC consumption among adult
residents around high oral cancer areas
This study did not use random sampling, but a signifi-
cantly higher percentage of ABC consumption, com-
pared with national data, was identified. The prevalence
of ABC consumption was identified in 35%, 17%, and
26% of participants, respectively. In addition, when
considering the gender difference, males that regularly
consumed ABC were 53.2%, 32.7% and 50.2%, respect-
ively. These numbers were higher than the nation-wide
percentages among both genders. In males aged over
18 years, the prevalence of current ABC behavior was
18.8, 13.0 and 35.0%, respectively [10]. These differences
may be due to location and professions. Most people
who live in south-western coastal Yunlin County are
farmers and fishermen. Based on the finding of Lee et al.
[20], the highest prevalence of betel quid chewing and
cigarette smoking in Taiwan is in agriculture or fisheries.
This study also found that 14% regularly consumed
both betel quid and cigarettes, and 9% consumed A, B
and C regularly. This finding is similar to Ko et al. [5],
which shows that, despite the Taiwan government
conducting several strategies during the last two de-
cades, problems persist.
To compare these habits with other countries, Ghani
et al. [8] reported that in Malaysian adults 8.2% were
betel quid chewers, a habit that was more prevalent
among females. Females >40 years old with Indian ethni-
city and a history of smoking were likely to develop a
quid chewing habit. Despite betel nut and cigarette con-
sumption, the prevalence of alcohol consumption is
similar to Germany and South Korea. Donath et al. [21]
found higher alcohol consumption in rural than urban
areas in Germany, and Chung et al. [22] found that of
the males, 90% are likely to drink excess alcohol in
South Korea.
The age of starting to use ABC was very young - 12 years
old for drinking alcohol, 13 for betel nut chewing and 10
for smoking cigarettes. Moreover, many betel nut users be-
come cigarette smokers and alcohol drinkers. In the last
10 years, the Taiwan government incorporated several
strategies to reduce the prevalence of ABC consumption,
including legislation to increase the price or tax [7].
However, it is unknown why western coastal adults liv-
ing around areas with high incidence of oral cancer par-
take of these 3 unhealthy habits. Do they know the
etiology and mechanism(s) of oral cancer associated with
ABC? Do the health and education policies penetrate
into rural areas and the socially economic disadvantaged
Table 3 The logistic regression of betel-nut and cigarette
consumption and associated factors
Variables Odds ratio 95% CI P
Gender
Male 2.28 9.77 8.08 ~ 11.82 <.001
Female*
Educational level
<=middle school .50 1.65 1.25 ~ 2.18 <.001
=high school .91 2.49 1.93 ~ 3.22 <.001
> = college*
Age (years)
20 ~ 39 .85 2.34 1.72 ~ 3.19 <.001
40 ~ 64 .61 1.85 1.45 ~ 2.34 <.001
65 ~ *
Economic status
Poor/bad .56 1.75 0.93 ~ 3.29 .08
Fair/not bad .26 1.30 0.72 ~ 2.34 .39
Good *
Physical activity
Not often .22 1.25 1.04 ~ 1.49 .013
Often*
Dental check-up
Not regular .31 1.29 1.02 ~ 1.63 .001
Regular*
Tooth brush
Incorrect .35 1.42 1.12 ~ 1.80 .004
Correct*
Note: * as reference.
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community residents? This may suggest that to understand
more fully the complexity of consumption of ABC; investi-
gators need to develop and use sensitive measures that can
capture the multidimensional aspects of ABC behavior in
these areas.
Participants who chewed betel-nut and consumed cig-
arettes tended to be male, less well educated, middle-
aged, with poor economic status and an unhealthy life
style (Table 2). These findings are similar to the results
of Shieh et al. [23] who described the prevalence of
chewing betel-nut and cigarette smoking in the general
population 18 or more years of age in Chiayi city, a
south-western coastal city of Taiwan. Based on this find-
ing, the researchers will develop culturally and linguistic-
ally competent health education materials for this group
in the future.
This study shows an inconsistent finding in the logis-
tic regression model that alcohol users tend to have a
better education, higher economic status, adopt more
physical activity and receive regular dental check-ups.
This phenomenon could be due to the questionnaire
not including measuring and quantifying alcohol type,
such as the brands of wine they drank, although beer is
popular nation-wide with the percentage of alcohol be-
ing below 5%. Small volumes of alcohol may have posi-
tive effects on health [15]. The consequence could
explain the false higher figure of alcohol consumption
in this study. Therefore, we suggest a further study to con-
sider the issue of health literacy and adequate ABC infor-
mation, culture-oriented educational material or adapted
language-sensitive pamphlets, and that it should take the
alcohol type into account for middle aged community resi-
dents in regions with a high prevalence of oral cancer.
More specific health promotion programs are necessary
initiated in the western coastal rural areas
Comparing the data with nationwide statistics, partici-
pants exercised (56.5 vs. 48%) and used dental floss (55.4
vs. 39%) less often than the general population [7]. Betel
nut and cigarette users also used dental floss signifi-
cantly less (9.0%) and took less exercise (14.5%) than
those without these 2 habits (Table 2). Oral health and
exercise are recognized as important health-related be-
havior conducive to good mental and physical well-being
[7,13]. Experts recommend brushing teeth often or at
least twice a day, flossing teeth daily and regularly at-
tending dental check-ups every 6 months [13]. Profes-
sional oral health resource and access to dental services
are limited in rural areas. Therefore, community nurses
should conduct health promoting programs related to
the low cost, but effectiveness, of oral hygiene and phys-
ical activity through community-based health develop-
ment, specifically for the social economic minority and
males in rural areas.
In March 1995, Taiwans national health insurance
(NHI) program was set up with the goal of providing
high quality, affordable healthcare to all (NHI covers
99% of the population) [24]. However, in the last 5 years,
financial difficulties and conflicts between government
and the public led to the NHI program becoming un-
stable. Enhancing health promoting programs might re-
duce the health-related incidence of chronic disease.
Furthermore, national statistics showed that life expect-
ancy in Yunlin County is 3 years less in males compared
with Taiwan population (73.4 vs. 76.1 years) [24]. It is
common for men to die at a younger age than women
worldwide [1], but the average is 6 years in Taiwan (76.1
vs. 82.6 years) [24].
Several studies have indicated that it is not only the
male gender that is associated with these 3 kinds of be-
havior [22,25], but that socioeconomic inequalities are
important [10,26,27], with poor education, low economic
status and living in rural areas being associated with
ABC use [21,26]. Our findings indicate that 4.5% (122)
of alcohol, 13.4% (360) of betel nut, and 13.3% (357) of
cigarette users reported abstinence for >1 year. There-
fore, it is possible to initiate health promoting programs
to reduce the prevalence of ABC behaviors if the ap-
propriate and cultivated culture-tailed strategies are
used. Physical inactivity is a modifiable risk factor for
several chronic conditions and a leading cause of pre-
mature mortality. An increasing proportion of adults
worldwide do not engage in a level of physical activity
sufficient to prevent or alleviate these adverse effects
[13]. It is time, therefore, that we had nurse-led pri-
mary healthcare with an emphasis on health promoting
strategies for disadvantaged people living in high
behaviour-related cancer areas.
A few limitations must be considered when interpreting
our findings. First, the cross-sectional nature of the data
poses a limitation and prevents the inference of causal rela-
tionships. Second, self-reporting often underestimates true
alcohol intake; and because there were more women par-
ticipants in this study, the prevalence of ABC users might
have been an underestimate. Third, several unaccounted
factors (i.e., exposure to media messages about tobacco or
alcohol or betel-nut, price or cost of ABC, psychiatric dis-
orders, and use of other substances) could have affected
the residents ABC behavior.
Conclusion
This is the preliminary outcome of a nursing facultys lon-
gitudinal cohort study that cooperated with a multidiscip-
linary research team in an area of high prevalence of
behavior-related cancer. It has identified that a high per-
centage of community adults living around the western
coastal region regularly consumed ABC. Betel-nut and
cigarette users were usually male, middle aged, with a poor
Guo et al. BMC Public Health 2013, 13:257 Page 7 of 8
http://www.biomedcentral.com/1471-2458/13/257
attitude to health promoting behavior. Betel nut chewers
are likely to smoke and drink, and usually do not take
part in regular physical activity and have poor oral hy-
giene. Further research is required to understand the
reasons why the subjects consume ABC, and explore
ways to prevent initiation and enhance cessation of ABC
habits in this population.
Competing interests
The authors hereby declare that there were no competing interests.
Authors contributions
SEG: Conceptualization of the study, study design, data analysis, discussion
and editing of the final draft for publication. TJH: Conceptualization of the
study and data collection. JCH: Data collection. MSL: Data collection. RMH:
Editing of the final draft for publication. CHC: Data analysis. MYC:
Conceptualization of the study, study design, proposal writing, data analysis,
discussion and editing of the final draft for publication. All authors read and
approved the final manuscript.
Acknowledgments
The study was supported by a grant from the Taiwan Formosa Plastic
Company (FCRPF 690011). We also thank all participants living around the
western coastal region in Yunlin County who helped in the success of this
study.
Author details
1
College of Nursing, Chang Gung University of Science and Technology
(CGUST); Director of the Chronic Diseases and Health Promotion Research
Center, CGUST, Chang Gung, Taiwan.
2
Chang Gung Memorial Hospital,
Yunlin, Taiwan.
3
Division of Endocrinology and Metabolism, Department of
Internal Medicine, Chang Gung Memorial Hospital, Yunlin, Taiwan.
4
Division
of Cardiology, Department of Internal Medicine, Chang Gung Memorial
Hospital, Yunlin, Taiwan.
5
College of Nursing & the Chronic Diseases and
Health Promotion Research Center, Chang Gung University of Science and
Technology, No. 2, Chia-pu Rd. West Sec, Putz City, Chiayi County 61363, R.O.
C. Taiwan.
Received: 9 August 2012 Accepted: 12 March 2013
Published: 21 March 2013
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doi:10.1186/1471-2458-13-257
Cite this article as: Guo et al.: Alcohol, betel-nut and cigarette
consumption are negatively associated with health promoting
behaviors in Taiwan: A cross-sectional study. BMC Public Health 2013
13:257.
Guo et al. BMC Public Health 2013, 13:257 Page 8 of 8
http://www.biomedcentral.com/1471-2458/13/257