Drug and Alcohol Dependence 113 (2011) 177–183 Contents lists available at ScienceDirect Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep Comparative epidemiology of betel nut use versus ecstasy use among Taiwanese adolescents: Findings from a national survey  Yen-Tyng Chen a , Chuan-Yu Chen b,c , Wei J. Chen a,c,d,∗ a Institute of Epidemiology, College of Public Health, National Taiwan University, 17 Xu-Zhou Road, Taipei 100, Taiwan b Division of Mental Health and Addiction Medicine, Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County 350, Taiwan c Department of Public Health, College of Public Health, National Taiwan University, 17 Xu-Zhou Road, Taipei 100, Taiwan d Department of Psychiatry, College of Medicine and National Taiwan University Hospital, National Taiwan University, 7 Chung Shan South Road, Taipei 100, Taiwan article info Article history: Received 21 January 2010 Received in revised form 16 July 2010 Accepted 29 July 2010 Available online 21 August 2010 Keywords: Adolescents Ecstasy Betel nut Youth Self Report Survey abstract Aims: To investigate whether variation may exist in betel nut- and ecstasy-involved adolescents in terms of sociobehavioral characteristics, the experience of psychoactive substance use, and behav- ioral/emotional problems. Methods: Students (n = 53,528) aged 12–18 sampled via stratified, multistage, random cluster sampling in 2004, 2005, and 2006 throughout Taiwan were categorized into four groups: betel nut- and ecstasy-naïve (n = 51,009), betel nut use only (n = 1965), ecstasy use only (n = 196), and use of both (n = 152). Participants completed a questionnaire with information on sociodemographic features, substance-use experiences, and the Chinese adaptation of the Youth Self Report. Results: Having a job, a larger weekly allowance, truancy, sexual experience, and externalizing behaviors were all in strong association with the involvement of either betel nut or ecstasy use. Compared with ecstasy-only users, betel nut-only users were more likely to be male, from the Eastern region of Taiwan, with initiation motivated by family members or friends, and having excess risks for Anxiety/Depression, Thought Problems, and Attention Problems. In contrast, ecstasy-only users were more likely to be female and involved in using other illegal drugs, with their initiation motivated by entertainment and with the drug use taking place in such settings. Conclusions: The variation in the experience of psychoactive substance use and behavioral problems for betel nut and ecstasy users suggests the existence of subgroups of drug-using adolescents in Taiwan. The identification of such heterogeneity may guide the efforts to reduce substance use and develop subgroup-tailored preventive programs. © 2010 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Psychoactive substance use among adolescents has become a major global public health issue (Bauman and Phongsavan, 1999; Toumbourou et al., 2007). The use of psychoactive substances in early life may not only increase the risk of physical problems but also hamper subsequent psychosocial development (Kandel et al., 1986). A series of reviews has summarized a broad spectrum of risk factors associated with adolescent substance use, including psy- chosocial correlates and emotional/behavioral problems (Brown, 2002; Deas and Brown, 2006; Hawkins et al., 1992). Moreover, there is evidence that drug-related heterogeneity may exist in etiological  Supplementary data tables are included with the online version of this article. Please see Appendix A. ∗ Corresponding author at: College of Public Health, National Taiwan University, 17 Xu-Zhou Road, Taipei 100, Taiwan. Tel.: +886 2 3366 8010; fax: +886 2 3366 8004. E-mail address: wjchen@ntu.edu.tw (W.J. Chen). factors, correlates, magnitudes of association, or underlying mech- anisms (Anthony et al., 1994; Chen et al., 2001; Degenhardt et al., 2001; Patton et al., 2007). To devise prevention programs specifi- cally targeting the population at risk, it is increasingly important to characterize the drug-specific distribution in the population and to assess drug-specific associations with potential risk factors. The practice of chewing betel nuts (Areca catechu), a tra- ditional psychoactive substance commonly used in the Indian subcontinent, large parts of south Asia, and Melanesia (Gupta and Warnakulasuriya, 2002), has spread by the migration of the East Asian population into areas such as South and East Africa (Warnakulasuriya, 2002), the United Kingdom (Farrand et al., 2001), and the United States (Changrani and Gany, 2005). In Tai- wan, despite the fact that the “Children and Youth Welfare Law” prohibits selling betel nuts to minors under the age of 18, betel nut has become the third most commonly used substance in adoles- cents, next to alcohol and tobacco cigarette. Recent national surveys reported that roughly 1.8–2.7% of middle school students (ages 12–15) and 3.3–7.3% of high school students (ages 15–18) have 0376-8716/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.drugalcdep.2010.07.018