Literature Review of Betel Nut Use in Southeast Asia and The United States

Areca nut, sometimes called betel nut, is a nut that contains psychoactive substances. It is commonly used in Asia and South Asia, particularly in India, Pakistan, Taiwan, Sri Lanka, Thailand, Vietnam, and southern China (“Betel Quid and Areca Nut”). The nut can be prepared with other ingredients, leading to a number of products and names. Some include betel quid, paan, gukta, and mawa, to name a few. Each product is prepared slightly differently and contains a range of ingredients, though tobacco is the one of most concern. An estimated 600 million people chew areca nut, concentrated in South and Southeaster Asia (“Betel Quid and Areca Nut” n.d.). It is frequently combined with tobacco. It is more widely used by men, but it is also used by children as young as 12, leading to a long use cycle (Gupta and Ray 2004). Gupta and Ray (2003) illustrated that use of areca nut was ancient. Europeans introduced tobacco to South Asia during the 6th century. Tobacco was added to the ingredients of betel quid or pan, and it became quite popular and the most common use of smokeless tobacco in South Asia (Gupta and Ray 2003). Gupta and Ray (2003) also admit smokeless tobacco is more common than smoking tobacco in some parts of India, making the problem irregular and unique.

Gupta also points out that the practice is ancient and therefore socially acceptable. In India, between 3 and 40% of the population surveyed used some form of areca nut (Gupta and Ray 2004). Gupta and Warnakulasuriya (2002) found close to 100,000 users in Bombay, the largest of all cities surveyed. Nair et. al (2004) found that hundreds of millions of dollars were being spent on areca nut products, most of them also including tobacco, and most tobacco suppliers make some form of product (Gupta and Ray 2004).

Jend et. al conducted a review to assess the role of areca nut in associated chemical carcinogenesis. They noted that a strong causal association exists between betel quid use and oral mucosal diseases. These diseases include including leukoplakia, oral submucous fibrosis and oral cancer (Jeng et. al 2001). They note the most important event is the interaction of carcinogens and cellular macromolecules. They conclude more research is needed for understanding full chemical properties of betel nut.

Pankaj (2010) notes that India has an annual age standardized incidence of 12.5 per 100,000, and that oral cancer is 9.4% of all cancer. Pankaj notes that areca nut (betel nut) is a carcinogen that leads to submucus fibrosis and oral cancers. Heavy use of betel nut increases risk of cancer. Addition of alcohol or tobacco use with betel nut increases risk of cancer, including having between 40 and 195 times the risk for developing oral cancers. Mortality for elderly betel users is increased. Pankaj urges more legislative action to control betel nut use in India. Nair et. al (2004) found that a combination of tobacco, alcohol, and areca nut use are the predominant causes for oral cancers in Southeast Asia, Taiwan, and Papa New Guinea, and users have an increased mortality rate versus non-users. Gupta and Ray (2003) point out that tobacco use has increased over 50 years.

Nair et. al (2004) state the rise in development and onset of oral cancer, lesions and oral submucous fibrosis (OSF). The link these diseases and conditions to the carcinogens found in pan masala and gutkha, containing most of the already known carcinogens found in tobacco, including nitrosamines and nitrosonornicotine. Ranganathan (2004) studied 150 patients with OSF and determined all were caused by areca nut and pan masala, with duration of habit being more important than amount used. The majority of patients with OSF were between 21–40 years of age, suggesting fairly rapid onset and early use, and the predominant number of cases of OSF occurred in patients who also smoked and used alcohol, with the risk between men and women being virtually equal.

Merchant et. al (2000) studied oral cancer in Pakistan, citing it as the second most common cancer in women and third most common for males. Because of the known carcinogenic factors of tobacco and the combined use of areca nut and tobacco, the study found that users of just areca nut without tobacco are 100 times more likely to develop OSF than non-users. Data for users showed a majority of users had not attended school and were Urdu speaking (Merchant et. al 2000).

Warnakulasuriya (2009) looked at data related to cases of oral and oropharyngeal cancer including cancers that affected lip, tongue, mouth, oropharynx and other pharyngeal sites. The highest rates for these cancers are in South and Southeast Asia, with the cancer ranking fifth among men and women (Warnakulasuriya 2009). Pakistan and India ha the highest rates of lip cancer. Pakistan, India, and Brazil had the highest rates of tongue cancer.

According to the 2010 Census, Asian Indian immigration population increased 69.8%, Bangladeshi increased 202.9%, Taiwanese increased 67.6% and Pakistani increased 132.6% between 2000 and 2010. The Asian population is the fastest growing population of immigrants to the United States, with increases for all nationalities (Census 2010). Asian Indian groups are the second largest behind Chinese immigrants, with 3.18 million people. Bangladeshi immigrants number less than 150,000 but their growth rate is among the fastest group of Asian immigrants (Census 2010). Changrani et. al (2006) were the first to conduct a study about paan and gukta usage among Bangladeshi and Indian-Gujarati immigrants in the United States. Paan and gukta are products that contain betel nut and smokeless tobacco that are commonly used in India. The group cited that 80% of Bangladeshi immigrants in the United Kingdom used paan. In the United States, South Asian immigrants lead growth. New York City is a popular city for Indian and Bangladeshi immigrants, and paan and gutka are available in neighborhoods. The research found that Indian-Gujaratis decreased usage significantly. They did so for health reasons and because of living in a new culture. Bangladeshi immigrants used paan and gutka more frequently.

According to Auluck et. al (2009), “Therefore, the practice of areca nut chewing and the presence of oral precancerous, lesions are spreading from South Asia to the Western countries, with the potential of becoming a major public health issue.” Auluck’s study was conducted in Canada, but it is comparable to U.S.A. because trends are similar. Gupta and Ray (2004) found similar results in the study of South Asian immigrants to the United Kingdom. Blank et. al (2008) studied the availability of betel products in the United States. They found that a variety of products were available for purchase, were relatively inexpensive, and were inconsistent about the warning labels they carried. The research also noted that the ingredient list sometimes included a mix of Hindi and English (Blank et. al 2008). The market is currently unregulated, which raises questions about access and coordinated control of the products in the future. Changrani and Gany (2005) described paan and gutka as products containing areca nut and smokeless tobacco.

Much of the literature on areca nut use concurs. It is carcinogenic and leads to a number of well-documented health problems. Oral cancer is rising among people of India, Bangladesh, Pakistan and other countries in South Asia and reaching epidemic status. Areca nut contains alkaloids that are linked to cancer and are often used in combination with tobacco and alcohol. This increases overall risk factors by several times. Among immigrants to the United states, a significant portion of people from India, Bangladesh, and Pakistan among others still report use of areca nut. However, among Indians, the use dropped because the practice is a health hazard and also not acceptable in American culture. Still, as the population of immigrants rises, it is clear that the United States has little study or control of areca nut products.

References

Auluck, A., Hislop, G., Poh, C., Zhang, L. Rosin, M.P. (2009). Areca nut and betel quid chewing among south Asian immigrants to western countries and its implications for oral cancer screening. Rural and Remote Health, 9(1118). Accessed from http://www.rrh.org.au.

Blank, M., Deshpande, L., and Balster, R. (2008). Availability and characteristics of betel products in the U.S. Journal of Psychoactive Drugs, 4(3), 309–313.

Changrani, J., and Gany, F. (2005). Paan and gutka in the united states: An emerging threat. Journal of Immigrant Health 7(2), 103–108

Changrani, J., Gany, F., Cruz, G., Kerr, R., Katz, R. (2006). Pan and gutka use in the united states: A pilot study in bangladeshi and indian-gujarati immigrants in new york city. J Immigr Refug Stud., 4(1), 99–110.

Gupta, P. and Ray, C. (2003). Smokeless tobacco and health in india and south asia. Respirology 8, 429–431.

Gupta, P. and Ray, C. (2004). Epidemiology of betel quid usage. Annals Academy of Medicine 33(4), 32–36.

Gupta, P. and Warnakulasuriya, S. (2002). Global epidemiology of areca nut usage. Addition Biology 7, 77–83.

Jeng, J., Chang, M., Hah, L. (2001). Role of areca nut in betel quid-associated chemical carcinogenesis: Current awareness and future perspectives. Oral Oncology, 37, 477–492.

Merchant, A., Husain, S., Hosain, M., Fikree, F., Pitiphat, W., Siddiqui, A., Hayder, S. J., Daider, S.M., Ikram, M., Chuang, S. and Saeed, S. (2000). Paan without tobacco: An independent risk factor for tobacco. International Journal of Cancer 86, 128–131.

Nair, U., Bartsch, H., and Nair, J. (2004). Alert for an epidemic of oral cancer due to use of the betel quid substitutes gutkha and pan masala: A review of agents and causative mechanisms. Mutagenesis 41(4), 251–262. doi:10.1093/mutage/geh036

Pankaj, C. (2010). Areca nut or betel nut control is mandatory if india wants to reduce the burden of cancer especially cancer of the oral cavity. International Journal of Head and Neck Surgery 1(1), 17–20.

Ranganathan, K., Devi, M., Joshua, E., Kirankumar, K., and Saraswathi, T. (2004). Orla submucous fibrosdis: A case-control study in chennai, south india. Jourtnal of Oral Pathological Medicine 33, 274–277.

U.S. Census Bureau. (2010). United states census.

Warnakalasuriya, S. (2009). Global epidiology of oral and oropharyngeal cancer. Oral Oncology 45, 309–316.