Sample: Survey was conducted in 20 government primary and higher secondary schools with a total of 2846 students, among whom male and female were 1528 and 1318 respectively. The list of schools was prepared according to the information supplied by directorate of education, Jodhpur, Rajasthan, India. Schools were selected randomly in terms of gender, geographic area, level of urbanization, and Socioeconomic Status (SES). Around 50 schools were contacted for the study and each school’s principal was informed about its purpose, out of which 20 schools agreed to participate for the survey. Students were selected by stratified random sampling method based on age, gender, education and SES of parents. All the children enrolled along with their parents were given introduction regarding the survey so that they can understand the questionnaire and importance of the survey. Parents were personally interviewed by the team of surveyors to collect the data of SES. Parental consent and legal guardian consent was taken. A preliminary training was done prior to the main survey to provide practical experience in the methodology of study for the dental examiner. A pilot study was performed in all the enrolled schools and based on that final survey was planned. Visit to the school was made on pre-decided dates and all the students present on that day were examined. Children with the consent to participate in the survey were examined within their school.

Questionnaire: The questionnaire was structured on the basis of similar previous studies and modified after the conduction of the pilot study [5]. Questions included were subject’s demographic characteristics such as age, gender and education. The education of mother and father was divaricated into primary class, secondary class and senior secondary or completed high school. We then calculated a continuous financial score by asking how much money is spent per day on “Supari” (Areca nut). Onset of areca nut chewing habits and frequency of chewing were the other important variables that were noticed. Onset of habit was based on age at which it was started and was divided accordingly. Frequency of chewing and reasons for betel nut chewing were assessed like craving, tolerance, and a physiological withdrawal state when substance use is reduced or ceased. The expert of nut was entrenched as: own purchase, from parents, friends or other. Thereby, initiation of habit was divided into three categories namely by friends, by relatives or parents, or by advertisement and regarding awareness among school teachers, a straight forward question regarding detrimental health effects associated with nut use was also collected. However, the understanding of study by Group I students was questionable.

Ethical Aspects: The study was performed after approval from the Vyas Dental College and Hospital Review Board and each patient was recruited only after obtaining written informed consent.

Clinical Examination: In Group I subjects the questionnaire was filled by the examiner collecting the information from parents or guardians. When we didn’t get appropriate information and response from guardians these subjects were excluded from the study. Clinical examination was conducted on a school chair and lighting was provided by a halogen diving light. A sterile mouth mirror was used for tissue retraction. WHO criteria was used for the detection of oral mucosal lesions [6]. Parents or guardians were informed about the subject’s oral health. Inter-incisal distance was measured in millimeters using a sterile metal scale to record any limitation of mouth opening and graded according to Haider et al., system [7].

Statistical analysis was conducted using statistical software (Statistical Package for the Social Sciences Version 13.0; SPSS Inc, Chicago, Illinois, USA). Response value percentages were calculated for each question and for the lesion identified on the clinical examination. Discrete variables were analyzed using the Chi-square test. Pearson’s Correlation coefficient was used to measure linear correlation between two variables where 1 is total positive correlation, 0 is no correlation and -1 is total negative correlation. The p-value less than 0.05 were considered as a significant difference.

Data was collected from 2846 subjects among which 1528 were boys and 1318 were girls studying in rural schools in Western Rajasthan. Group I comprised of 1174 subjects with 625 boys and 549 girls; whereas, Group II had 1672 with 903 boys and 769 girls. The mean age of Group I and Group II children was 7.382 and 13.980 years respectively whereas mean age of total number of students who participated in the survey was 11.258 years. A total of 406 (34.5%) respondents from Group I and 1218 (72.8%) from Group II were addicted to areca nut and its products [Table/Fig-1]. The mean age of male and female chewers was 12.584 and 12.5 years respectively. Odds ratio for gender shows habit is 1.217 times more in males than females. A significantly higher frequency of areca nut chewing was observed in Group II subjects when compared to Group I subjects in both genders.

Parents (825 fathers and 799 mothers) of participants with areca nut chewing habit were evaluated for literacy level. An inverse relation was recorded between areca nut chewers and their parent’s education. Most of the parents of addicted subjects were uneducated or had not completed their primary education [Table/Fig-2].

In the present study we noticed that out of the various factors in initiation of habit, friends had significant influence followed by relatives. In few subjects advertisements of these products developed the craving to initiate the habits [Table/Fig-3]. Psycho-social aspects play an important role for maintenance of the habits. Most of the subjects consumed areca nut products for pleasure. A total of 22.03% males and 24.3% females believed that this habit is essential for social interaction, whereas less than 10% subjects felt the development of interest in the work [Table/Fig-4].

More than two third of the subjects were consuming 4 to 10grams of the areca nut products daily. Only12.5% males and 8.7% females were consuming more than 15grams of areca nut every day [Table/Fig-5]. Clinical examination of addicted subjects revealed 55 cases of OSMF, comprising of 39 males and 16 females. A total of 42 cases belonged to Stage II OSMF followed by Stage III (8 cases) and Stage I (5 cases) [Table/Fig-6].

Areca nut is a psychoactive substance which is available at low prices as compared to other similar substances like alcohol, tobacco and caffeine [8]. In the Indian states like Rajasthan, Gujarat, and Maharashtra these habits are rapidly increasing with severe oral health complications. Easy availability of these products near school premises has made younger ones addicted [9].

In present study we identified that areca nut chewing habit is more common in boys as compared to girls. A similar study considered that conservative culture of the society acts as a major inhibitor in adaptation of these habits in female. Girl’s consciousness regarding their health and aesthetics make them uncomfortable in purchasing tobacco products from shops. Frequency of areca nut consumption and duration are the major risk factor for oral cancer. Duration being more significant than frequency underlines the fact that younger the age of onset, more are the chances of potentially malignant lesions [10]. The lowest age for habit initiation in our study is 4 years which is comparable to cases reported in previous studies [11,12]. A progressive higher frequency of habit is found in early adolescent as compared to primary school children. One reason could be lack of parental consciousness, increase in the allowance for routine expenditure and influence of friends. Friends are the major initiators as they spell bound the children by drawing their attention on psychosocial aspects of areca nut chewing like pleasure, tension reliever, euphoria and development of interest in work after areca nut chewing [13]. The reason for increased incidence is low cost, easy availability and attractive packaging of areca nut products that has made number of people getting addicted to it. Some advertisements show areca nut chewing as a status symbol and is considered sacred in certain cultures so its consumption is unobjectionable [13]. The frequency of areca nut use is more among children of lower socioeconomic areas, and reason for that is peer pressure and lack of awareness which would increase the incidence in groups who are already deprived of quality health care.

Present study states that lower level of parental education has been associated with higher risk of initiation of this habit. Illiteracy of parents is related with the lack of awareness regarding the hazardous effects of these products on oral health and fails to prevent their children from engaging into the one [14,15]. Younger individuals get easily fascinated by their surrounding society which had a major impact on commencement of this habit in our study. The consumption of areca nut is socially and religiously acceptable in Asian community [16]. Father being the patriarch in our society inspires children by his addictive practice, especially one of chewing areca nut and unknowingly acts as one of the major offender for engaging child in this habit. This was almost similar to studies done by previous authors [17,18].

Areca nut is highly cytotoxic and genotoxic. Its continuous use can lead to OSMF [19]. Results of present study through light on this devastating disease as 3.38% of the students who were involved in areca nut chewing habit, developed OSMF. Most of the subjects having OSMF were in the habit of keeping areca nut product in the buccal vestibule and swallowing the contents after chewing. These findings further demonstrate that due to this style of chewing, fibrosis was more in buccal mucosa followed by soft palate and uvula [20].

In this survey, clinical examination revealed dominantly Stage II OSMF cases. As burning sensation and reduction in mouth opening started appearing and patients became alert. These students actively participated in the study so that they can get information of their current oral health status. Similar findings were observed by Tupkari in his study on 101 cases and he reported maximum cases belonging to Stage II and III [21]. These findings are cause of worry as it was an index of the youth developing this dreadful habit inadvertently with probability of developing oral lesions that have potential for malignant transformation [22]. Our subjects were unaware about the relationship between areca nut and OSMF. The clinically identified cases were referred to Vyas Dental College and Hospital for the management and follow-up.

In present study the data on prevalence of areca nut chewing habit and cause for this practice were collected at the same time which may be associated with temporal ambiguity. Although detailed instructions were provided to subjects before the survey but it may be possible that some questions were unclear to participants and influence the validity of data.

The present survey was an attempt to understand the factors responsible for initiation and progression of this habit in school age population. Lack of health consciousness among parents, influence of society and their customs have significant role in induction of habit. It is believed that children who are frequent chewers at early age will develop addiction and will continue this habit into their adult life, engaging themselves into a disease with highest malignant potential. In surveyed schools no oral health programs were conducted in relation to adverse effects of areca nut consumption. Present study statistics showed a worried outcome of these habits where we encounter higher prevalence of OSMF in early age. State and Central ministry of health and education should take serious steps for the cessation of these habits at primary level.