Global usage of betel quid and areca nut
Globally, areca nut is among the most common addictions following tobacco, alcohol and caffeine. Its usage is very popular in India, Taiwan and parts of Southern China1. Its chronic use contributes significantly to the high incidence of oral cancer in these countries. With increasing immigration of Indians to the Western world, health professionals in the west should be aware of the habit and its consequences and so be prepared to face the challenges associated with the habit and resulting disease.
Studies from the US and UK have reported the persistence of areca nut chewing among immigrants from South Asia, resulting in increased rates of oral cancer in these new settlements2-7. Awareness of this practice should help health professionals to understand the relevance of oral cancer screening in this population.
Chewing habits and risk for oral cancer among South Asian immigrants
Areca nut is present in a number of chewing products, for example, paan (betel quid), gutka and paan masala (Table 1). These products contain lime, area nut and tobacco. Betel quid consists of a mixture of areca nut (with or without tobacco), slaked lime, catechu and several condiments according to taste, wrapped in betel leaf. While areca nut chewing may cause oral submucous fibrosis, its use along with tobacco can cause leukoplakia, which is also a premalignant lesion. Use of other condiments and ingredients in betel quid can cause lichenoid lesions8, the premalignant potential of which is not known.
Table 1: Areca nut chewing: its contents and practice
In the last few years small attractive and inexpensive sachets of betel quid substitutes have become widely available, are aggressively advertised and marketed and are consumed by the very young and old alike. These products have higher genotoxic and carcinogenic potential compared with conventional quids9. Chewing of these products usually starts at an early age (at approximately 13 to 15 years) and, by adulthood, most users are addicted to the habit10. Older adults are not alarmed by the fact that young children are indulging in this habit as they consider it a part of their normal life10. However, this practice often leads to addiction and, once the habit is formed, it persists after immigration.
Betel quid substitutes contain both carcinogens and genotoxic agents which have role in multistage progression of oral cancer11. Smokeless tobacco contains nitrosonornicotine and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone; areca nut contains arecoline and 3-(methylnitrosamino) propionitrile, while lime provides reactive oxygen radicals, each of which has a role in oral carcinogenesis9.
Chewing betel quid without tobacco is an independent risk factor for developing oral cancer12. When betel quid with tobacco is consumed with alcohol and smoking the relative risk increases 11-fold13. The risk of such interactions may be underestimated in some South Asian communities. For example, Sikhism and Punjabi religious beliefs prohibit alcohol and tobacco use14; however, there are reports of alcohol15 and tobacco consumption among them16.
Betel quid chewing seriously affects oral and periodontal health with higher oral hygiene index scores, increased periodontal pocket depth and bleeding causing poor oral hygiene17,18. There is not enough evidence to suggest that poor hygiene alone in absence of habits and other risk factors has a role in etiology of oral cancer.
It is important, however, to remember that the South Asian community is not homogenous, for it has people from diverse cultures who have distinct beliefs and practices. The extent of areca nut chewing varies among different religious groups and among first and second generation immigrants. A study from Leicester, UK, reported that areca nut chewing was most common among first generation Asian immigrants with the highest prevalence among Jains (28%) and Muslims (23%), followed by Hindus (18%). In second generation Asian immigrants, this practice was highest among Muslims (17%), followed by Hindus (13%) and Jains (12%)15.
It is interesting that the proportion of individuals chewing areca nut was reduced in generations subsequent to immigration. However it is a concern that the traditional habit of spitting out the contents of betel quid has also changed, and it is now being swallowed in Western countries. This change in habit may increase the risk of hypopharyngeal and esophageal cancer19.
Sociocultural reasons for chewing areca nut
Four factors form the foundation for the popularity of chewing areca nut and betel quid chewing: social acceptability, religious beliefs, perceived health benefits and addiction.
Areca (betel) nut is regarded by many Indians as a fruit of divine origin. It is considered an auspicious ingredient in Hinduism and is used along with betel leaf in religious ceremonies and when honoring individuals. Among the followers of the Hindu religion, areca nut (Supari) is considered a vital ingredient in the food for God (Bhagwan). In the absence of idols and other sacred images, the fruit (whole nut without its husk) is used while offering prayers. It is believed that God blesses the fruit which is then distributed to the followers20,21. With the religious and health beliefs regarding areca nut being so prevalent in many Indian cultures, areca nut is very commonly offered at important social gatherings and weddings21.
In addition to its religious connotations, areca nut is regarded by many people in South Asia as good for health, and it is used as a traditional ayurvedic medicine. It is used as an astringent, mouth freshener after meals; a taste enhancer, purgative and intoxicant; and for indigestion, impotence and gynecological problems, parasitic intestinal infection and for prevention of pregnancy-related morning sickness22.
Areca nut is often chewed in a betel quid and is used as a mildly euphoric stimulant because it contains relatively high levels of psychoactive alkaloids. Chewing also increases the capacity to work, causes a hot sensation in the body and heightens alertness. It is also used among the poor to avoid boredom and to suppress hunger20,22,23. A study in the United Kingdom (UK) reported that 42% of South Asian immigrants (from Bangladesh) chewed areca nut because it gave them a refreshing feeling and 35% because of its good taste; 29% used it as a snack, and others used it because it helped to relieve stress and was believed to strengthen the teeth and gums24.
Lack of awareness about areca nut as a risk factor for oral cancer
South Asian communities are generally not aware that areca nut chewing can cause oral cancer and that ceasing its use would reduce the likelihood of developing oral cancer15,25. A study in the UK showed that many Bangladeshi adolescents living in East London were unaware of the association between areca nut chewing and oral cancer24.
Reports also suggest that many shopkeepers selling these chewing products are not aware of any health risks and there are no restrictions placed on sale of these products to minors2. Those shopkeepers aware of health risks continue selling these products because it has become a multimillion dollar industry23.
Oral precancerous lesions in South Asian immigrants
Globalization and increased movement of people across boundaries has resulted in changes in the patterns of oral diseases. Historically, oral submucous fibrosis (a premalignant condition) was endemic and limited to South Asia and some parts of China and Taiwan. But with increasing numbers of South Asian immigrants in Western countries this pattern is changing. There were no case reports of oral submucous fibrosis in South Asian immigrants until the mid-1980s. Interestingly, this time period coincides with increased immigration from South Asia to these countries. Most reports have come from the UK, although there are some case reports from Canada, Germany, France, Australia and South Africa (Table 2). There is also a Canadian report of a child of Indian origin who developed oral pre-cancer at the age of 4 years, possibly due to early exposure to areca nut, as its consumption is socially accepted in the South Asian community at any age26. 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.
Table 2: Review of cases with oral precancerous lesions among South Asian immigrants3,4,6,7,15,25,26-35
Oral cancer rates among South Asians in many countries such as the UK36,37 and USA38 are higher than in the general population, and this may be attributable to the continuation of habits among South Asians after migration.
A descriptive study is in progress of oral cancer cases from the British Columbia (BC) Cancer Registry from 1980 to 2006, and our initial results suggest that age-adjusted incidence rates among South Asians are higher than the general population, at 5.63 (95% CI; 2.02-9.63) for South Asian men as compared with 4.32 (95% CI; 3.86-4.78) in the general male population and 4.41 (95% CI; 1.17-7.79) for South Asian women as compared with 2.73 (95% CI; 2.37- 3.08) in the general female population (authors' pers. data; 1980-2006). This translates to relative risks of 1.33 and 1.66 for South Asian men and women, respectively, as compared with the BC general population.
Although South Asian immigrants maintain higher rates of oral cancer as compared with the general population, these rates are still below the oral cancer rates in their home countries (for men, the age-adjusted incidence rate is 12.8 and for women, it is 7.5)39. These comparisons need to be interpreted with caution, however, because there are no national cancer registries and the incidence varies among different regions/ states in India.
Our observation that oral cancer frequently occurs in the cheek and gums of South Asians (authors' pers. data; 2006) is also consistent with this risk behavior. This finding has been reported elsewhere40,41.
Implications for oral cancer screening in South Asian Immigrant communities
Oral cancer is commonly found in India and this elevated risk is also brought to the west by its immigrants. A special report on Indian immigrants from census data suggests that the majority of immigrants from India to Canada come under family class immigration and not as business and independent skilled labor worker class42. Many of the Indian immigrants do not have proficiency in either of the Canadian official languages (English and French). Immigrants from India often choose to live on the outskirts of cities because the majority were engaged in agricultural and manufacturing industries. Data available for South Asian immigrants to BC showed that only 24% reported Vancouver as their intended destination, while the majority of Indian immigrants preferred to stay in the outskirts of Surrey and Abbotsford42. Few physicians are aware of the habits of betel quid chewing that may be practiced among immigrants living in rural and remote areas.
South Asian immigrants do not feel culturally safe and comfortable with visits to doctors and dentists of a different ethnic background and communication may be limited and sometimes ineffective43. Culturally insensitive behavior from the healthcare provider may offend immigrant patients, hampering healthcare delivery.
The concept of screening an otherwise healthy individual for asymptomatic disease is not a concept well understood by many South Asian immigrants44. In addition, those practicing potentially harmful oral habits may be less likely to participate in oral cancer screening initiatives; hence, special efforts may be required to reach these individuals. The screening examination provides an excellent opportunity for education about risk behaviors, including areca nut chewing, and interventions to help change such behaviors. Early signs of oral submucous fibrosis include blanching of oral mucosa, rigidity and fibrosis of tissues, restricted mouth opening and loss of cheek elasticity45 should be examined for while screening patients in this population.
In some of the South Asian communities, areca nut and betel quid (paan) chewing is a routine daily practice and an important component of social life and cultural identity. South Asians are now one of the largest minority groups in Canada with approximately 1 262 900 people, according to census reports46. It is important to study risk behaviors, beliefs, knowledge levels and oral health practices in this population. Further research is required to understand in depth the beliefs of people as they relate to this habit; as well as to enquiring into potential barriers and facilitators for participation in oral cancer screening, and discovering what educational messages should be made for health promotion and education among this community. This information is critical to developing and implementing health education programs appropriately targeted to the needs of the South Asian community. Healthcare providers must also be aware of these risk behaviors and alert to the presence of oral pre-cancerous lesions, such as oral submucous fibrosis, that are becoming important clinical findings in many Western countries.
Dr Auluck is a PORT (Psychosocial Oncology Research Trainee) Fellow supported by a grant from the Canadian Institutes of Health Research/National Cancer Institute of Canada.
1. Winstock ARTC, Warnakulasuriya KAAS, Peters TJ. A dependency syndrome related to areca nut use: some medical and psychological aspects among areca nut users in the gujrat community in the YK. Addiction Biology 2000; 5: 173-179.
2. Warnakulasuriya S. Areca nut use following migration and its consequences. Addiction Biology 2002; 7(1): 127-132.
3. Changrani J, Gany FM, Cruz G, Kerr R, Katz R. Paan and gutka use in the United States: a pilot study in Bangladeshi and Indian-Gujarati immigrants in New York City. Journal of Immigrant and Refugee Studies 2006; 4(1): 99-110.
4. Changrani J, Gany F. Paan and gutka in the United States: an emerging threat. Journal of Immigrant Health 2005; 7(2): 103-108.
5. Croucher R, Choudhury SR. Tobacco control policy initiatives and UK resident Bangladeshi male smokers: community-based, qualitative study. Ethnic Health 2007; 12(4): 321-337.
6. Farrand P, Rowe R. Areca nut use amongst South Asian schoolchildren in Tower Hamlets, London: the extent to which the habit is engaged in within the family and used to suppress hunger. Community Dental Health 2006; 23(1): 58-60.
7. Nunez-de la Mora A, Jesmin F, Bentley GR. Betel nut use among first and second generation Bangladeshi women in London, UK. Journal of Immigrant Minor Health 2007; 9(4): 299-306.
8. Avon SL. Oral mucosal lesions associated with use of quid. Journal of the Canadian Dental Association 2004; 70(4): 244-248.
9. Nair U, Bartsch H, Nair J. 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 2004; 19(4): 251-262.
10. Chandra PS, Mulla U. Areca nut: the hidden Indian 'gateway' to future tobacco use and oral cancers among youth. Indian Journal of Medical Science 2007; 61(6): 319-321.
11. Jeng JH, Chang MC, Hahn LJ. Role of areca nut in betel quid-associated chemical carcinogenesis: current awareness and future perspectives. Oral Oncology 2001; 37(6): 477-492.
12. Jacob BJ, Straif K, Thomas G et al. Betel quid without tobacco as a risk factor for oral precancers. Oral Oncology 2004; 40(7): 697-704.
13. Subapriya R, Thangavelu A, Mathavan B, Ramachandran CR, Nagini S. Assessment of risk factors for oral squamous cell carcinoma in Chidambaram, Southern India: a case-control study. European Journal of Cancer Prevention 2007; 16(3): 251-256.
14. Bradby H, Williams R. Is religion or culture the key feature in changes in substance use after leaving school? Young Punjabis and a comparison group in Glasgow. Ethnic Health 2006; 11(3): 307-324.
15. Vora AR, Yeoman CM, Hayter JP. Alcohol, tobacco and paan use and understanding of oral cancer risk among Asian males in Leicester. British Dental Journal 2000; 188(8): 444-451.
16. Gandhi G, Kaur R, Sharma S. Chewing Pan Masala and/or Betel Quid-fashionable attributes and/or cancer menaces? Journal of Human Ecology 2005; 17(3): 161-166.
17. Sumanth S, Bhat KM, Bhat GS. Periodontal health status in pan chewers with or without the use of tobacco. Oral Health Preventative Dentistry 2008; 6(3): 223-229.
18. Parmar G, Sangwan P, Vashi P, Kulkarni P, Kumar S. Effect of chewing a mixture of areca nut and tobacco on periodontal tissues and oral hygiene status. Journal of Oral Science 2008; 50(1): 57-62.
19. Nandakumar A, Anantha N, Pattabhiraman V, Prabhakaran PS, Dhar M, Puttaswamy K et al. Importance of anatomical subsite in correlating risk factors in cancer of the oesophagus--report of a case-control study. British Journal of Cancer 1996; 73(10): 1306-1311.
20. Williams S, Malik A, Chowdhury S, Chauhan S. Sociocultural aspects of areca nut use. Addiction Biology 2002; 7(1): 147-154.
21. Brownrigg H. Social and Ceremonial use of betel quid. In: H Brownwrigg (Ed.). Betel Cutters. London: Thames and Hudson, 1992; 25.
22. Strickland SS. Anthropological perspectives on use of the areca nut. Addiction Biology 2002; 7(1): 85-97.
23. Croucher R, Islam S. Socio-economic aspects of areca nut use. Addiction Biology 2002; 7(1): 139-146.
24. Prabhu NT, Warnakulasuriya K, Gelbier S, Robinson PG. Betel quid chewing among Bangladeshi adolescents living in east London. International Journal or Paediatric Dentistry 2001; 11(1): 18-24.
25. Shetty KV, Johnson NW. Knowledge, attitudes and beliefs of adult South Asians living in London regarding risk factors and signs for oral cancer. Community Dental Health 1999; 16(4): 227-231.
26. Hayes PA. Oral submucous fibrosis in a 4-year-old girl. Oral Surgery, Oral Medicine, Oral Patholology 1985; 59(5): 475-478.
27. Morawetz G, Katsikeris N, Weinberg S, Listrom R. Oral submucous fibrosis. International Journal of Oral and Maxillofacial Surgery 1987; 16(5): 609-614.
28. Hardie J. Oral submucous fibrosis. A review with case reports. Journal of the Canada Dental Association 1987; 53(5): 389-393.
29. Shah B, Lewis MA, Bedi R. Oral submucous fibrosis in a 11-year-old Bangladeshi girl living in the United Kingdom. British Dental Journal 2001; 191(3): 130-132.
30. Yusuf H, Yong SL. Oral submucous fibrosis in a 12-year-old Bangladeshi boy: a case report and review of literature. International Journal of Paediatric Dentistry 2002; 12(4): 271-276.
31. McGurk M, Craig GT. Oral submucous fibrosis: two cases of malignant transformation in Asian immigrants to the United Kingdom. British Journal of Oral and Maxillofacial Surgery 1984; 22(1): 56-64.
32. Reichart PA, Philipsen HP. [Oral submucous fibrosis in a 31-year-old Indian women: first case report from Germany]. Mund-, Kiefer- und Gesichtschirurgie 2006; 10(3): 192-196. (In German)
33. Oliver AJ, Radden BG. Oral submucous fibrosis. Case report and review of the literature. Australian Dental Journal 1992; 37(1): 31-34.
34. Vilmer C, Civatte J. [Oral submucous fibrosis. Review of the literature apropos of a case]. Annals of Dermatological Venereology 1986; 113(2): 107-112.
35. Seedat HA, van Wyk CW. Submucous fibrosis (SF) in ex-betel nut chewers: a report of 14 cases. Journal of Oral Pathology 1988; 17(5): 226-229.
36. Moles DR, Fedele S, Speight PM, Porter SR, dos Santos Silva I. Oral and pharyngeal cancer in South Asians and non-South Asians in relation to socioeconomic deprivation in South East England. British Journal of Cancer 2008; 98(3): 633-635.
37. Warnakulasuriya KA, Johnson NW, Linklater KM, Bell J. Cancer of mouth, pharynx and nasopharynx in Asian and Chinese immigrants resident in Thames regions. Oral Oncology 1999; 35(5): 471-475.
38. Liu L, Kumar SK, Sedghizadeh PP, Jayakar AN, Shuler CF. Oral squamous cell carcinoma incidence by subsite among diverse racial and ethnic populations in California. Oral Surgery, Oral Medicine, Oral Patholology, Oral Radiolological Endodontics 2008; 105(4): 470-480.
39. Kuruvilla J. Utilizing dental colleges for the eradication of oral cancer in India. Indian Journal of Dental Research 2008; 19(4): 349-353.
40. Sankaranarayanan R, Duffy SW, Padmakumary G, Day NE, Krishan Nair M. Risk factors for cancer of the buccal and labial mucosa in Kerala, southern India. Journal of Epidemiology and Community Health 1990; 44(4): 286-292.
41. Winn DM. Smokeless tobacco and cancer: the epidemiologic evidence. CA Cancer Journal Clinics 1988; 38(4): 236-243.
42. Statistics BC. Immigration highlights: special features of immigrants from India (Online) 2004. Available. http://www.bcstats.gov.bc.ca/pubs/immig/imm011sf.pdf (Accessed 12 April 2009).
43. Gordon HS, Street RL Jr, Sharf BF, Souchek J. Racial differences in doctors' information-giving and patients' participation. Cancer 2006; 107(6): 1313-1320.
44. Pearson N, Croucher R, Marcenes W, O'Farrell M. Dental service use and the implications for oral cancer screening in a sample of Bangladeshi adult medical care users living in Tower Hamlets, UK. British Dental Journal1999; 186(10): 517-521.
45. Auluck A, Rosin MP, Zhang L, Sumanth KN. Oral submucous fibrosis, a clinically benign but potentially malignant disease: report of 3 cases and review of the literature. Journal of the Canada Dental Association 2008; 74(8): 735-740.
46. Statistics Canada. The Daily. (Online) 2006. Available: http://www.statcan.ca/Daily/English/080402/d080402a.htm (Accessed 11 November 2008).