Chapter 80 - Attentional Biases for Betel Nut Cues

A betel nut (also called betel quid) usually consists of three major ingredients: a raw areca nut, slaked lime, and Piper betle inflorescence. The size of a betel nut is usually about 3 cm × 3 cm × 2 cm (Figure 1). The acidity of a raw areca nut can cause stomach problems after repeated intake. With high alkalinity, the slaked lime can neutralize this acidity. Arecoline (the primary alkaloid in raw areca nut) has been shown to act on the muscarinic and nicotinic acetylcholine receptors (Chu, 2001) and affect various cognitive functions (e.g., attention and memory) (Freo, Pizzolato, Dam, Ori, & Battistin, 2002; Ho & Wang, 2010, 2011). Back in the late nineteenth to early twentieth centuries, betel nut was popular among the nobles and the wealthy in Chinese society (S. Q. Wang, 1999). They would carry the small, delicate betel-quid bags (or boxes) with them and give betel nuts as presents on social occasions. Early Chinese medicine books and cookbooks declared great benefits from chewing betel nut, for example, chewing betel nut can facilitate digestion and ease hangover (S. H. Wang, 1861). In early Taiwan, the spiritualists in some aboriginal tribes would cast spells on the raw areca nuts, which were believed to represent human bodies in these tribes. However, during the Japanese colonial period (1895–1945), the use of betel nut was strictly prohibited. In the late twentieth century, when the betel nut was subjected to modern Western addiction theory and methodology, the dark side of the betel nut was gradually revealed. On the notorious dark side are the probable dependence symptoms betel nut chewers may develop in terms of Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) and International Classification of Diseases 10 (ICD-10) criteria (Benegal, Rajkumar, & Muralidharan, 2008; IARC, 2004; Lee et al., 2014; Li, Ho, Tang, & Chang, 2012; Winstock, 2002). Moreover, the chemical ingredients in a raw areca nut such as arecoline (the major alkaloid) and polyphenols have been identified as chemical carcinogens (IARC, 2004). In this chapter, we selectively review the literature regarding attentional biases in addictive behaviors in general and in betel nut chewers in particular. Attentional bias toward substance cues is an important issue in addiction development; it has been reported to be related to subjective craving (Field, Munafò, & Franken, 2009), impulsivity (Coskunpinar & Cyders, 2013), and treatment outcomes (Cox, Hogan, Kristian, & Race, 2002; Marissen et al., 2006). Lastly, we delineate a cognitive neuroscience approach to investigate various unexplored issues related to betel nut chewers, such as short-term memory (STM). Studies on these unexplored issues can facilitate our understanding of betel nut chewing. More effective treatments can be developed accordingly.