Table 2.

Reasons not to quit as perceived by chewers and nonchewers

	Chewer	Nonchewer
Sociocultural
Enabling Community	My boss actually gives me money […] Yeah from his wallet, how much you need, because he wants the job to be done. If you gather around with your friends or family, they instantly take out their betel nut and fix their chew. So you just sit there, ‘oh okay, I already quit.’ But then you’re like, ‘ah you know what, I just want to join in. Just this time,’ but then it goes on and on.	I know one person who quit betel nut, and then he went back to live with his family. His whole family chews so he began to chew again […] There’s no support to say ‘don’t chew.’ I guess like they grew up back there where everyone’s chewing, and like everyone is the same as everyone. Like it’s hard not to follow them.
Cultural Ideology	You’ve heard that phrase, ‘wisdom in the basket,’ […] That’s very true. That’s the time where you go into your basket to get out a betel nut, and you’re taking time to think about what you’re going to respond. Actually, if you chew and it stained your teeth, that’s what makes your teeth stronger.	Some of the patients that I’ve interviewed, they said that it’s been introduced to them as you as, you know, it’s part of their culture. I think living in the islands, it’s just a very enabling environment because you always have that scapegoat to blame it on culture.
Belief that Betel nut is Harmless	Personally, if I wanted to quit […] it’s the quitting of the tobacco that’s the issue […] So for me, it’s not really about the betel nut. The cigarette is the addicting part I hear it in a lot of the older people, and they say, ‘Well look at so and so. They’re 80 years old and they have all of their teeth, and they attribute that to […] when they say they were a chewer all their life.’	I think they don’t really see it happening. Like say a family unit, the grandfather may chew and then he passes [tradition] onto his grandkids. The grandkid say that they don’t see anything happening with the grandfather. So they think that it’s not a health issue. Based on my family, it’s like I feel they wouldn't want to quit. Like they do know you get cancer and everything, but it’s like it doesn’t change their [mind]. It’s like they don’t care and when it comes to cancer, it’s like they think it won’t happen to them.
Behavioral
Addictive	To me, it’s just like something better, you’re like addicted to. It’s kind of hard to stop My boss asked me, ‘How come you’re always carrying your bag with you?’ And I said, ‘Yeah because [it’s] my life.’ If you put the right combination, you know? The right amount of lime and cigarette. It’s just perfect. [It] turns out perfect.	They said they are trying very hard to stop, so that tells me that it’s, you know, an addiction, and they are having a difficult time with it. To them it is addictive. And even though people would tell them to stop chewing or their parents would tell them to stop, they keep on because they like the taste.
Euphoric	It gives me a high, that only betel nut can provide.	My family likes that aspect [taste] of it, and also gives them like a high effect.
Attentiveness	I work at night, so I got to have my betel nut. [It] keeps you awake. You stay up. It keeps you awake. Not like an energy drink. But it does keep you [awake] I think that’s also […] I used to always pick these guys at work in the middle of the night, and so I fix betel nut because it keeps me awake on the road.	Like what they tell me is that when they chew, it keeps them awake or something
Relaxing	I think it’s more of a chance to sit down. But there [work] I will be doing things then I stop and fix my chew. Maybe I use that as, like I take a break. If I don’t have betel nut, I’m pissed off. I’d rather be like, nobody’s going to talk to me.	It relaxes them. So it sort of like, makes them calm.
Habitual	It’s like, after a meal, breakfast, you want to chew betel nut.	I think it’s, it’s a habit for them.
Accessibility
Convenience of Betel nut	To me it’s much better. I have to sit where I’m at and chew, instead of smoke – I have to find a spot, go outside. I saw [someone] actually using Quest cards to purchase betel nut at one of the stores here […] and I didn’t know if that was a violation, or if that’s just not regulated to where it’s acceptable for that – the Quest card.	They can hide it a little better, or they think they can […] So I think betel nut is a little sneakier. They would say it’s available in any mom and pop store. That like a plastic bag of it is like only two (2) dollars or something. So it’s really cheaper than cigarettes. […] And some of them they can get from their neighbors.
Lack Information on Betel nut	You see a lot of advertisements in anti-smoking, but I don’t see advertisements on anti-chewing I don’t know that there is very much that I’ve seen [about betel nut] because I work with schools, and I don’t see very much in their curriculum that deals with this.	I’ve never learned about it. Like they tell you stay away from alcohol and those stuff, but not really betel nut I think it’s because they don’t find anything wrong with it, unless you point out the immediate risk of cardiovascular diseases, or like dental problems, or like the latest studies saying it has some carcinogen. But I don’t think it strikes them as something as important, they have to change their behavior.