Scientific letter
Consumption of the tobacco-betel-calcium hydroxide mixture, among Spanish students
Consumo de la mezcla tabaco-betel-hidróxido cálcico entre estudiantes españoles
Nansi López-Valverde, Antonio López-Valverde
, BegoñaGarcía García Cenador
Corresponding author
Departamento de Cirugía, Universidad de Salamanca, Salamanca, Spain
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All associated manners of consuming tobacco are associated with different types of cancer.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Multiculturalism and the migratory phenomena both in Spain and in other European Union (EU) countries are giving rise to the host country's population adopting certain habits and customs from immigrants.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A large number of Asian immigrants settled in the central area of Spain, Madrid and the metropolitan area during the economic expansion of the 1990s.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The industrialised areas of Catalonia, the Basque Country, Andalusia and Castilla-León also experienced this type of immigration.</p><p id="par0030" class="elsevierStylePara elsevierViewall">This type of immigration includes citizens from Pakistanis and Northern India, specifically from the region of Punjab, habitual consumers of chewing tobacco. This tobacco is mixed with betel nut, flavouring and calcium hydroxide as an ‘excipient’.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Each ingredient in this blend – except the flavourings (usually cardamom and cinnamon) – are considered carcinogenic. Furthermore, calcium hydroxide could provoke certain types of oral submucosal fibrosis and irritative hyperplasia, which, according to the International Agency for Research on Cancer (IARC), can predispose consumers of these products to certain types of oral carcinomas.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Although in these countries the mixture is sold and consumed pre-prepared, it is easy to prepare oneself, since its components can be easily obtained in Europe. Betel nut, the seed of the betel palm tree, is a low-priced stimulant that can be easily purchased online.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We conducted five surveys in five vocational training centres in the centre, north, south, east and west of Spain, in the cities of Madrid, Bilbao, Seville, Tarragona and Salamanca. A total of 125 male and female students answered the surveys, all of them were students studying Oral Hygiene; there were 25 students per centre and they were aged between 18 and 27.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The survey was totally anonymous and asked participants their sex, age and whether they consumed tobacco – either pre-prepared, a mixture of betel-tobacco or both.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Before requesting the student complete the survey, they were informed of its purpose.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Our study found that in the study population, five males and two females – representing 5.6% of the total sample – consumed the tobacco-betel-calcium hydroxide mixture (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">33% of females and 29% of males aged between 14 and 18 smoke cigarettes in Spain; this figure is one of the highest in the EU.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Nicotine consumed in its traditional form (inhaling cigarette smoke) has been considered a minor cholinergic stimulant; however, ‘smokeless chewing tobacco’ has received little attention in our country, probably due to its low consumption.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Betel nut is the fourth most consumed substance in the world, along with nicotine, ethanol and caffeine. Its nicotinic activity is based on its four main alkaloids: arecoline, arecaidine, guvacolina and guvacina. The combination of tobacco-betel-calcium hydroxide increases risks of morbidity and mortality from oral cancer.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">This preliminary study has shown us that there is a new way of consuming tobacco emerging in Spain, mainly imported from other countries.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Despite the small size of the sample, we believe that the medical and dental consequences of these new methods of consumption mean that carrying out more extensive studies and increasing warning campaigns for potential users is of interest.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: López-Valverde N, López-Valverde A, García Cenador B. Consumo de la mezcla tabaco-betel-hidróxido cálcico entre estudiantes españoles. Med Clin (Barc). 2019;152:160–161.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1101 "Ancho" => 1407 "Tamanyo" => 81315 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Percentage distribution of tobacco use in different groups (F, female; M, male).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mortality from smoking in developed countries 1950–2000, indirect estimation from National Vital Statistics" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R. 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Shafique" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s12889-017-4916-1" "Revista" => array:5 [ "tituloSerie" => "BMC Public Health" "fecha" => "2017" "volumen" => "17" "paginaInicial" => "913" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29183302" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015200000004/v1_201902100719/S2387020618305904/v1_201902100719/en/main.assets" "Apartado" => array:4 [ "identificador" => "43311" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015200000004/v1_201902100719/S2387020618305904/v1_201902100719/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020618305904?idApp=UINPBA00004N" ]
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