In 2022, it is still legal to sell an addictive carcinogen without a warning label in much of the world. The fibrous seeds of the areca palm, known as “betel nut”, have been cultivated throughout the Asia Pacific region for thousands of years. The nut is chewed but not swallowed. It is usually placed in the buccal cavity, where the alkaloid arecoline based on nicotinic acid is absorbed orally. People use the substance for a stimulant effect that enhances alertness, and in some cases produces mild euphoria. Although chewing habits are highly variable, walnuts are often consumed “as ‘counter’” along with tobacco, stewed lemon, and leaf of the plant. According to frequently cited estimates, there were 600 million betel nut users worldwide in 2002,1 That made betel nut arecoline the fourth most popular 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 dental disease and is associated with a rapidly growing list of systemic conditions as well as adverse pregnancy outcomes.1 Many betel chewers start using betel nut in their teens, unaware of its harmful effects, and lack knowledge of 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 in recent decades.
The causes of this problem are multifaceted. Contributing factors include insufficient access to medical care in areas where betel nut is chewed, social and cultural traditions that promote its use, a low level of health education and fear of the medical system among the affected population. Policy makers in these areas have consistently ignored the adoption of public health initiatives that would tackle the production and use of betel nut—a billion-dollar industry.
After completing an otolaryngology residency in 2018, I accepted a job in the Northern Mariana Islands, a remote US Commonwealth country in the western Pacific where betel nut is prevalent. The burden of oral cancer associated with betel nut is strikingly disproportionate to population size. Many people diagnosed with oral cancer have low health literacy, delay treatment, and have poor outcomes. Although betel nut is widely available in the markets and corner stores, it has recently opened two stores that sell exclusively betel nut products to meet the demand. During April, Oral Cancer Awareness Month, we hear the following misleading advertisement daily on public radio: “Did you know that adding tobacco to your chewing gums can increase your risk of oral cancer? Call this hotline to take the first step toward a tobacco-free life today.. The meaning is clear: Go ahead and keep chewing, just skip the tobacco.
Several initiatives have been proposed to address the domestic use of betel nut, including mandatory warning labels on betel products, government-funded trials of cessation strategies, official screening efforts, and tax programs. None of these proposals gained traction, in part due to resistance from local policymakers, some of whom allegedly had links to the lucrative betel nut industry. It took policymakers until 2016 to pass a law banning the sale of betel nut to minors, despite the known tendency to start chewing during adolescence.
With a few isolated exceptions, the story is no different elsewhere. Taiwan may be the only betel nut endemic country that has documented progress toward reducing its use. Since the implementation of several government-funded programs in the late 1990s—including nationwide educational outreach, downtime courses, and incentives to plant alternative cash crops—Taiwan has seen a marked decline in betel nut use in many age groups.2 However, the country’s problems with betel nut are still far from resolved; Large proportions of the working class continue to chew food. Moreover, the betel nut trade has been widely sexualized in Taiwan: thousands of them wear tight clothes Binlang Girls in their teens and twenties still promote the product from the transparent booths scattered along the highways.
Despite some success, Taiwan’s efforts to reduce betel nut use have not been replicated elsewhere, including in neighboring regions with a similar chewing history. For example, even as public health experts predicted a “human catastrophe” of nearly 250,000 new oral cancer diagnoses between 2016 and 2030 in Hunan Province alone, Chinese politicians did not make a serious response to betel nut use.3 In fact, during the Covid-19 pandemic, betel nut companies distributed free kits consisting of masks and betel nut.3 The products are available in many fruit flavors, and advertisers promote them to working-class people using colorful advertisements and catchy phrases. Sales in Hunan Province grow by 10% annually.3 Finally, in late 2021, policymakers responded with a selective ban on advertising, which did not include any provision mandating disclosure of health risks.
It is estimated that Papua New Guinea, where nearly half of its 9 million people chew the betel nut, has the world’s highest rate of oral cancer.4 In recent years, the oral cancer mortality rate has jumped from 15,000 to 25,000 deaths annually.4 In 2013, doctors and public health officials eventually managed to persuade lawmakers to impose an outright ban on the sale and chewing of betel nut in the capital, Port Moresby, but the success was short-lived. Those wanting to protect their sales protested, and betel nut products were then allowed to be sold in designated areas; Booming sales continued. 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 country’s oral cancer burden will continue to worsen.
The current situation is reminiscent of the mid-20th century, when the tobacco industry hid irrefutable health risks to protect sales. But in this case, significant resources were mobilized to resist the industry – a process that took many years and was possible because both wealthy and working class people around the world smoke and are affected by the health harms associated with tobacco. For the most part, only members of marginalized groups in the Asia Pacific region chew betel nut. Betel nut consumers speak a range of dialects and have high rates of illiteracy.1 Reliance on English as the informal language of health care is problematic and reliably fails to facilitate the exchange of information between these areas and the medical community as a whole.
The data is from Our World in Data, the Global Change Data Lab.
Recent data from India, the world leader in betel nut cultivation and consumption, does not portend progress: production increased from an estimated 250,000 metric tons per year in the 1990s to around 900,000 metric tons in 2020 (see Graph).5 Domestic agriculture is promoted by favorable taxation, and with more demand than supply, the price per kilogram has doubled in the past two years.5 As in other betel nut endemic regions, consumption is concentrated among marginalized and working-class groups, with many people using betel nut products first 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 do).5
Availability of growing betel nut in Asian markets throughout Europe and the Americas1 It may eventually make regulation politically feasible. These products are always cheap, fairly easy to find in urban areas, and generally don’t come with a warning label. Once people with higher incomes are at risk of harms associated with betel nut use, it should become easier to promote purposeful awareness of the substance and its harmful effects. For now, however, the medical community is stuck outside as a largely unregulated industry fuels a global health catastrophe—a painful reminder of how little progress has been made toward tackling the stark health disparities among privileged and marginalized populations. Perhaps the famous neuroscientist Santiago Ramón y Cajal said it best in 1899: “Every disease has two causes. The first is pathophysiological. The second is political.”