In 2022, it remains legal to sell an addictive carcinogen without a warning label in much of the world. The fibrous seed of the areca palm, more commonly known as “betel nut”, has been cultivated throughout the Asia-Pacific region for thousands of years. The nut is chewed but not swallowed. It is usually placed in the oral cavity, where arecoline, a nicotinic acid alkaloid, is absorbed transorally. People use the substance for a stimulating effect that improves alertness and, in some, produces mild euphoria. Although chewing habits vary widely, the nut is often eaten as a “quid”, along with tobacco, slaked lime and a plant leaf. According to frequently quoted estimates, there were 600 million betel nut users worldwide in 2002,1 which made arecoline from betel nut the fourth most widely abused drug after caffeine, nicotine and alcohol.1
In addition to being classified as a group 1 oral carcinogen by the International Agency for Research on Cancer, betel nut promotes non-malignant odontogenic diseases and is associated with a growing list of systemic conditions as well as pregnancy outcomes. unfavorable.1 Many chewers start using betel nut as teenagers, unaware of its harmful effects and lack knowledge about oral cancer. There is ample evidence to suggest that betel nut consumption and the incidence of oral cancer have increased dramatically across the Asia-Pacific region over the past few decades.
The causes of this problem are multiple. Contributing factors include insufficient access to medical care in areas where betel nut is chewed, socio-cultural traditions that promote its use, and low health literacy and fear of the medical system among affected populations. Policy makers in these regions have continually neglected to adopt public health initiatives that would address the production and use of betel nut – a billion dollar industry.
After completing an otolaryngology residency in 2018, I took a job in the Northern Mariana Islands, a remote American Commonwealth in the Western Pacific where betel nut is endemic. The burden of oral cancer linked to betel nut is surprisingly disproportionate to the size of the population. Many people diagnosed with oral cancer have low health literacy, show up late for treatment, and have poor outcomes. Although betel nut is widely available in markets and convenience stores, two stores selling exclusively betel nut products have recently opened to meet demand. In April, our Oral Cancer Awareness Month, we hear the following misleading announcement daily on public radio: “Did you know that adding tobacco to your chewing can increase your risk of getting oral cancer? stuffy ? Call this hotline to take the first step towards a tobacco-free life today.…” The implication is clear: go ahead and keep chewing, just avoid tobacco.
Several initiatives have been proposed to combat the local use of betel nut, including mandatory warning labels on betel nut products, government-funded trials of withdrawal strategies, screening efforts formalized and taxation programs. None of these proposals gained traction, in part due to resistance from local policymakers, some of whom are believed to have ties to the profitable betel nut industry. It took until 2016 for policymakers to pass a law banning the sale of betel nuts to minors, despite the well-known tendency to start chewing in adolescence.
With few exceptions, the story is no different elsewhere. Taiwan is perhaps the only country where betel nut is endemic to have made documented progress towards reducing its use. Since the implementation of numerous government-funded programs in the late 1990s – including nationwide awareness programs, weaning classes and incentives to grow alternative cash crops – Taiwan has seen reductions notable examples of betel nut use in several age groups.2 The country’s problems with betel nut, however, remain far from resolved; significant proportions of the working class continue to chew. Moreover, the betel trade has been largely sexualized in Taiwan: thousands of scantily clad people binlang teenage girls and 20s still peddle the product from see-through booths dotted along the highways.
Despite some success, Taiwan’s efforts to reduce betel nut use have not been replicated elsewhere, including neighboring regions with similar chewing histories. For example, even though public health experts predict a “humanitarian catastrophe” of around 250,000 new oral cancer diagnoses between 2016 and 2030 in Hunan province alone, Chinese politicians have not put in place a serious response to the use of betel nut.3 Indeed, during the Covid-19 pandemic, betel companies distributed free kits consisting of masks and betel.3 The products are available in many fruity flavors and advertisers promote them to the working class with colorful advertisements and catchy phrases. Sales in Hunan province increased by 10% annually.3 Finally, at the end of 2021, policymakers responded with a selective advertising ban, which did not include any provision requiring the disclosure of health risks.
Papua New Guinea, where around half of the population of 9 million chews betel nut, has the highest incidence of oral cancer in the world, according to estimates.4 In recent years, oral cancer mortality has increased from 15,000 to 25,000 deaths per year.4 In 2013, doctors and public health officials finally succeeded in getting lawmakers to pass an outright ban on selling and chewing betel nut in the capital city of Port Moresby, but the success was short-lived. . Those who wished to protect their sales protested, and the sale of betel nut products was later permitted in designated areas; booming sales persisted. Oral cancer has become the most common type of cancer among men in Papua New Guinea and the third most common among women. Many local experts predict that the burden of oral cancer in the country will continue to worsen.
The current situation is reminiscent of the mid-twentieth century, when the tobacco industry hid irrefutable health risks to protect sales. But in this case, substantial resources were mobilized to push the industry back – a process that took many years and was possible because wealthy and working people around the world smoked and were affected by tobacco’s harm to health. For the most part, only members of marginalized groups in the Asia-Pacific region chew betel. Betel nut consumers speak a range of dialects and have high rates of illiteracy.1 The reliance on English as the non-official language of health care is problematic and does not reliably facilitate the exchange of information between these regions and the medical community as a whole.
The data comes from Our World in Data, the Global Change Data Lab.
Recent data from India, the world leader in betel cultivation and consumption, does not suggest progress: production has fallen from around 250,000 metric tons per year in the 1990s to around 900,000 metric tons. in 2020 (see chart).5 Domestic cultivation is reinforced by favorable taxation and, with demand exceeding supply, the price per kilogram has more than doubled over the past 2 years.5 As in other regions where betel nut is endemic, consumption is concentrated among marginalized groups and the working class, with many people first using betel nut products during childhood or adolescence. .1 New Delhi’s latest response to this problem came in 2016, not as legislation, but as a request for Bollywood stars to refrain from endorsing betel nut products (which some have continued to argue). TO DO).5
Growing availability of betel nut in Asian markets across Europe and the Americas1 can ultimately make regulation politically feasible. These products are always cheap, are fairly easy to find in urban areas, and usually don’t come with a warning label. Once high-income people are exposed to the harms associated with betel nut consumption, it should become easier to foster meaningful awareness of the substance and its adverse effects. For now, however, the medical community is stuck on the outside, as a largely unregulated industry fuels a global health catastrophe – a painful reminder of how little progress has been made in addressing the stark health disparities between privileged and underprivileged populations. marginalized. Perhaps the famous neuroscientist Santiago Ramón y Cajal said it best in 1899: “Every disease has two causes. The first is pathophysiological; the second, politics.