Betel Nut Product Characteristics and Availability in King County, Washington: A Secret Shopper Study

Abstract

Background: The cultural practice of betel nut chewing with known detrimental health effects has become more geographically widespread through migration, and subsequently, global disease patterns have changed. Immigrants are at risk for oral health and multi system diseases due to continued patterns of betel nut use. Although legal in the U.S., little is known about the availability, purchasing patterns, and regulation of betel nut products. We documented the availability of betel nut and the consumer experience of buying betel nut in King County, Washington. Methods: We created a census sample of all Asian stores in King County, Washington through an internet search and in person store visits. We used a Secret Shopper design method to identify all stores that sold betel nut products and to document consumer experience and buying conditions of betel nut. We examined product pricing, labeling and marketing information of betel nut products purchased and developed a Product Information Score to evaluate products warning and consumer information properties. Results: Twenty-seven Asian stores (42%) sold betel nut products in King County. We identified 60 different types of betel nut products: 67% did not have warning labels, 22% had promotional advertising, 30% were marketed to children. No stores had warning signs about betel nut health risks, and all betel nut products without tobacco were available for self selection by consumers. Gutka was sold in 26% of stores and all gutka products were sold behind the counter. All regions of the Seattle metropolitan area contained stores that sold betel nut and regions of greater Asian population density had more betel nut stores. Conclusion: Betel nut is widely available, accessible, and inexpensive in King County, Washington. Stores inadequately warn consumers of betel nut health risks due to lack of in store warning signs, lack of age requirements for purchasing, easy access to most products, and limited product package warning information. Policy changes are needed to better regulate the betel nut market for consumer protection. Betel nut awareness campaigns are needed to promote prevention and cessation of betel nut use in order to reduce poor health outcomes among betel nut users.