WHO Library Cataloguing in Publication Data

Review of areca (betel) nut and tobacco use in the Pacific: a technical report.

1. Areca – adverse effects. 2. Tobacco, Smokeless. 3. Tobacco use disorder. 4. Pacific Islands.
5. World Health Organization Regional Office for the Western Pacific.

ISBN 978-92-9061-569-9 (NLM Classification: WM 290)

© World Health Organization 2012

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4 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

Contents
Executive summary .........................................................................................................................9

Introduction ......................................................................................................................................10

A Platform for Action ........................................................................................................................11

Legislation and policies ...................................................................................................................13

Governance and local enforcement ................................................................................................14

Public awareness, education, communication and advocacy .........................................................15

Alliance and partnerships ................................................................................................................17

Tobacco dependence treatment ......................................................................................................17

Surveillance and knowledge management ......................................................................................18

ANNEX 1. Betel Nut and Tobacco Use: Origin, History and Current Trends ...................................21

ANNEX 2. Health Concerns: Why is Betel Nut Use a Problem? .....................................................41

References ......................................................................................................................................51

Acknowledgements .........................................................................................................................67

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 5

6 Review of Areca (Betel) Nut and Tobacco Use in the Pacific
Executive summary
There is evidence to show that the frequency of betel nut use is increasing in the Western Pacific
Region and that its use is more frequently associated with the chewing of tobacco. Betel nut chewing
induces oral precancerous lesions that have a high propensity to progress. Betel nut itself has been
classified as a Group 1 carcinogen (carcinogenic to humans) by the International Agency for Cancer
Research (IARC). While it is clear that the use of betel nut alone is a threat to health, its combination
with tobacco greatly increases an individual’s risk of premature illness and death. In countries in
the Western Pacific Region where this is observed, betel nut and tobacco chewing has become a
significant public health problem.

With the entry into force of the WHO Framework Convention on Tobacco Control (WHO FCTC), there
has been increasing concern about the promotion of smokeless tobacco use. The groundwork for
this report began in 2006 when the Tobacco Free Initiative (TFI), the Western Pacific Regional Office,
commissioned the Secretariat of the Pacific Community (SPC) to review the use of betel (areca)
nut and tobacco in the Western Pacific Region. This was followed in August 2010 by a meeting
of national focal points in tobacco control from the countries that report high use of betel nut and
tobacco. Proposed actions have been mapped and linked to the Regional Action Plan for the TFI in
the Western Pacific Region (2010-2014). This document is envisioned as a supplement for countries
that wish to highlight specific tobacco control indicators and actions related to reduction of smokeless
tobacco use.

A major effort needs to be made to provide decision-makers with evidence of the serious harm caused
by betel nut chewing, with and without tobacco. Community-based strategies are also needed to
overcome cultural beliefs and practices that are barriers to sound public health measures that can
save lives and prevent unnecessary suffering from oral cancer and other diseases.

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 7

 Introduction
Use of tobacco is the leading preventable cause of death globally, killing up to one half of the people
who consume it. The health, social and economic burdens of tobacco use -- in all of its forms --
are devastating. The increasing use of tobacco with areca nut, commonly referred to as betel nut
throughout the Western Pacific, has played a significant role in the increased incidence of adverse
health effects in many countries of the Western Pacific Region. In particular, studies have linked
the high incidence of oral cancer in some western Pacific island countries to the concurrent use of
betel nut and tobacco. This high incidence of oral cancer is associated with significant morbidity
and mortality rates in some countries in the Region. The average worldwide mortality rate from oral
cancer, based on a five-year cumulative mortality rate, is less than 50%; however, mortality rates as
high as 67% and 80% have been reported for some countries in the Western Pacific Region.1

It is now well-established that the habitual use of betel nut alone can lead to serious adverse health
effects.2 The use of betel nut with tobacco is increasing in many countries because of the aggressive
marketing of tobacco products in combination with or alongside betel nut. Strong social norms also
encourage the combination of betel nut and tobacco. Of particular concern is evidence that the use
of betel nut and tobacco in some countries is increasing among youth and in some cases among
women.3

In response to this growing health threat, the TFI commissioned the SPC to undertake a review
of the use of betel nut and tobacco in the Western Pacific Region in 2006 and used the results to
formulate the Regional Action Plan. In August 2010, the TFI convened in Manila, Philippines, bringing
together international experts in tobacco control and focal points for tobacco from the countries in the
Western Pacific Region that are known to have high prevalence rates of betel nut and tobacco use.
The meeting provided participants with an opportunity to comment on and update the information
contained in the review conducted by the SPC and to formulate recommendations to reduce the
negative health consequences of betel nut and tobacco in the Region.

Those recommendations are presented in this addendum to the Regional Action Plan for the TFI in
the Western Pacific Region (2010-2014). The full review, including current trends in betel nut and
tobacco use in the Western Pacific Region, and a review of the current literature on the impact of betel
nut and tobacco use on health, are included as appendices to this report.

The Regional Action Plan calls on Member States to formulate and strengthen national coordinating
mechanisms and national action plans towards complete implementation of the WHO FCTC and sets
targets and indicators for different levels of intervention. It contains both qualitative and quantitative
indicators that are recommended to strengthen implementation of tobacco control strategies at the
regional and country levels. These indicators have been used to map the specific action objectives in
a Platform for Action Towards the Control of Betel Nut and Tobacco Use.

1
(Barton et al. 2001; Parkin et al. 2005; Carpenter et al. 2005)

2
IARC STRENGTHENS ITS FINDINGS ON SEVERAL CARCINOGENIC PERSONAL HABITS AND HOUSEHOLD
EXPOSURES, International Agency for Research on Cancer, World Health Organization, Lyon France; Press Release No.
196; November 2009,

3
Ysaol, Y., Chilton, J.I., Callahan, P. 1996 ‘A survey of betel nut chewing in Palau’, Journal of Micronesian Studies, Vol.4,
pps. 244-255.

8 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

The prevention and control of tobacco-chewing with betel nut poses some unique challenges since
the production and sale of betel nut are not regulated in most countries. Production of betel nut
is encouraged in some countries as a commodity for both local consumption and for export and
has become a significant source of income in some Pacific island countries. Therefore, addressing
supply-side issues for betel nut control will require multisectoral collaboration among ministries of
health and other sectors of government and community stakeholders.

This highlights the need for clear messages for both policy-makers and the public regarding the
dangers of betel nut and tobacco use. Meeting these challenges requires recognition of the magnitude
of the problem in each country and a mobilization of different sectors to take action. Participants at
the August 2010 meeting on betel nut and tobacco use have recommended the following set of Key
Messages to communicate the dangers of betel nut and tobacco use and to stimulate action for
effective measures to address this serious public health issue:

Key Messages for Prevention and Control of Betel Nut and Tobacco Use
• Chewing betel nut causes oral cancer.
• Adding tobacco to betel nut-chewing greatly increases the risk
of oral cancer.
• Measures need to be taken to discourage the use of betel nut
with or without tobacco.
• A set of effective measures to discourage betel nut and tobacco
use may include:
• Policies and legislation
• Education and advocacy
• Strategies to promote behavioural change
• Clinical services
• Surveillance and research
• Partnerships and alliances.

A Platform for Action

A clear framework for action that addresses both supply and demand for betel nut and tobacco products
is needed in order to reduce the current trends towards increased use of betel nut and tobacco in
the Western Pacific Region. The Platform for Action for the Control of Betel Nut and Tobacco Use,
shown in Box 1, maps specific actions on six key Regional Action Plan indicators across four domains
that include Social Determinants, Behavioural Risk Factors, Intermediate Conditions and End-stage
Disease. Specific strategies from this list should be adopted based on each country’s available
resources and priorities. They should be included in National Action Plans for Tobacco Control and, as
appropriate, in other national strategic plans such as those for non-communicable disease prevention
and control, oral health care and health surveillance.

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 9

 Box 1. Platform for Action for the Control of Betel Nut and Tobacco Use

Strategies Social Determinants Risk Factors Intermediate Conditions End Disease

(Environmental, economic (Chewing betel nut (Oral leukoplakia and (Oral cancer,
and sociocultural) alone; chewing betel nut submucous fibrosis) other tobacco-related
with tobacco or other cancers)
substances
Legislation and • Regulate the sale of • Implement • Mandate funding • Pass legislation
policies betel nut (e.g. laws relevant supply for oral screening to support cancer
restricting sales to and demand and cessation registries, including
minors) reduction services mandatory
• Establish import and provisions of the • Establish reporting of oral
export trade policies WHO FCTC guidelines for and other cancers
• Establish laws and screening for
policies restricting precancerous
betel nut use on conditions by
school property, at oral health care
health care facilities, providers
etc.
Governance • Enforce laws • Include betel • Implement oral • Ensure accurate
and local restricting sales nut and tobacco screening at reporting from
enforcement of betel nut and control strategies all levels of the health care
tobacco products to within national health care providers
minors and local system
• Enforce action plans for
anti-smuggling tobacco control
policies and establish
targets to reduce
prevalence
Public • Strengthen • Formulate and • Educate the • Inform
awareness, communication implement public about policy-makers that
education, and advocacy effective mass the early betel nut chewing
communication activities in relation communication signs of these causes oral cancer
and advocacy to changing social education conditions and
norms regarding the the importance
• Use role models dangers of betel of oral health
• Support education nut and tobacco exams for early
and information use, particularly detection
campaigns that the link to cancer
target youth and • Inform the public
children about where to
• Encourage citizens get cessation
to monitor and services
report violations of
bans on sales to
minors
Alliance and • Support • Actively share • Mobilize dental • Mobilize cancer
partnerships multisectoral information with associations to control advocates
strategies to control stakeholders advocate for and to support cancer
betel nut production about the health expand training registries and
and the marketing of risks of betel nut of providers disseminate
betel nut, especially use, with and to increase findings, lobby
in combination with without tobacco screening legislators and
tobacco products testify at hearings

10 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

 Strategies Social Determinants Risk Factors Intermediate Conditions End Disease
(Environmental, economic (Chewing betel nut (Oral leukoplakia and (Oral cancer,
and sociocultural) alone; chewing betel nut submucous fibrosis) other tobacco-related
with tobacco or other cancers)
substances
Tobacco • Work to ensure • Ask about betel • Create effective • Use testimonials
dependence that appropriate nut and tobacco referral systems from individuals
treatment cessation services use at every for cessation whose betel nut
are created and are encounter with services and use led to oral
promoted towards health workers treatment cancer
those who may wish
to quit using betel
nut and tobacco

Surveillance • Map social • Integrate • Support research • Monitor and report

and knowledge and economic questions about to work out morbidity and
management determinants of betel nut use into cost-effective mortality from oral
betel nut use with Global Tobacco techniques for cancers
tobacco Surveillance screening and • Use the data
System and other early detection for national
national health health plans and
risk behaviour noncommunicable
surveys disease prevention
and control

Legislation and policies

The Regional Action Plan encourages countries to formulate legislation and related policies,
regulations, ordinances, administrative issuances and other measures to ensure timely compliance
with all provisions of the WHO FCTC. As a broad strategy, the WHO FCTC addresses both supply
and demand reduction measures for tobacco products, and some of these measures also may be
considered for the prevention and control of betel nut use.

Betel nut is commonly used in the Pacific island countries. Its regulation there has been almost
exclusively limited to legislation or policies that ban spitting in public places, most notably in health
care facilities and schools. The legislature in the Marshall Islands passed a law in 2010 banning the
importation of betel nut and making it a crime to import, distribute or sell betel nut, backed by a fine of
up to US$ 100 and 30 days in jail.4 But the main reason cited by legislators for passing the law was
that spitting from betel chewers was unsightly and might lead to the spread of disease.

Using the Key Messages contained in this report, tobacco control and other public health advocates
actively should disseminate information to policy-makers about the serious threat that betel nut and
tobacco use poses to public health. In terms of supply issues, policy-makers in the agricultural
and economic development sectors of some western Pacific island countries have promoted
the expansion of betel nut production as a viable commodity for both local and export markets.5
Tobacco control and public health advocates need to be proactive in communicating to planners and
policy-makers that increased production of betel nut negatively impacts on the health and well-being
of island populations and measures must be taken to identify economically viable alternative crops to
betel nut.

4
Pacific Islands Report, Honolulu, March, 2010

5
Federated States of Micronesia, Business Opportunities Report, Island Business Opportunties S. Lee, A. Ghandi, F. Eliptico;
July, 2007; http://www.islandbusinessopportunities.com/links_resources/islands/FSM.pdf

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 11

 There are some unique challenges in attempting to apply many of the WHO FCTC demand reduction
measures to the control of betel nut use. Despite its classification as a Group 1 carcinogen by the
IARC, betel nut in most countries is sold as an unregulated agricultural product. There is no packaging
with labels to warn consumers about potential hazards to health and no taxation or pricing structure as
commonly applied to substances known to be harmful to health. It is often sold in proximity to tobacco
products, and in several countries tobacco products are sold in such a way as to accommodate their
use in combination with betel nut (e.g. sales of single cigarettes). The lack of regulation of betel nut
reinforces its acceptability and creates an environment that enables individuals to use it habitually.

In many areas, the high degree of social acceptability of betel nut use is likely to be the greatest
challenge to implementing policies intended to reduce demand. Efforts to formulate demand reduction
policies may need to be preceded by public education and awareness activities intended to convince
people of the harmful effects of betel nut and tobacco use and then to mobilize support for demand
reduction legislation and policies.

Governance and local enforcement

The Regional Action Plan calls for the implementation and enforcement of laws and policies through
national coordinating mechanisms or their equivalent. Currently, such mechanisms may not be
well-developed in many of the countries where betel nut and tobacco use are a major concern.
Therefore, the formulation and implementation of national action plans should reflect specific measures
to prevent and reduce the use of smokeless tobacco such as with betel nut.

In many Pacific island countries, governance for tobacco prevention and control activities may be
folded into larger strategic plans for noncommunicable disease (NCD) prevention and control. Based
on the large body of evidence linking betel nut use to the increased risk for many NCDs (Appendix B),
enforcement measures for legislation and policies for prevention and control of betel nut use should
be identified clearly in national action plans for tobacco and/or NCD control in all countries where
betel nut use is common.

Countries should also formulate and enforce measures that will protect public health policies from
commercial and vested interests of the tobacco industry. This is in accordance with WHO FCTC Article
5.3., which calls for full public disclosure by political leaders and policy-makers on any interaction with
the tobacco industry. It is recommended that this be extended to include reporting of personal income
gained from the sales and profit from betel nut in order to achieve transparency and accountability.

Two additional areas of governance include the formulation of clinical practice guidelines for screening
for precancerous conditions by oral health care providers and establishing policies that will ensure
accurate and timely reporting of oral cancer cases by health care providers.

There is some evidence that early detection of precancerous conditions (oral leukoplakia and
submucosous fibrosis) can lead to early treatment and prevention of oral cancer in many cases.6
The establishment of clinical practice guidelines for oral screening and support to apply them to
appropriate settings will help to speed the broad implementation of such programmes in areas where
they can be of benefit.

6
Sankaranarayanan, R. 1997 ‘Health care auxiliaries in the detection and prevention of oral cancer’, Oral Oncology, Vol.33,
No.3 pp.149-154

12 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

In most of the countries where betel nut and tobacco use is prevalent, accurate data on cancer is
limited and there is a need for improved data to monitor the incidence of oral and other cancers.
Very few countries in the Pacific have well-established cancer registries, although there has been
significant collaborative work done in recent years to establish support for regional cancer registries
which can serve smaller Pacific island nations.7 Establishing reporting requirements in statute is the
best way to ensure consistent reporting by physicians to local or regional cancer registries.

Public awareness, education, communication and advocacy

Well-designed communication programmes can inform a variety of different audiences about the
hazards of betel nut and tobacco use and interventions. The Regional Action Plan calls for the
implementation of communication and advocacy activities in relation to changing social norms. This
may be accomplished by using role models, supporting education and information campaigns that
target youth and children and encouraging citizens to monitor and report violations of bans on sales
to minors.

Successful health communication programmes involve more than the production of messages and
materials. Ideally, they should use formative research to shape the development of key messages
and determine the best channels that will deliver those messages to the right audiences.

On its own, a well-designed health communication strategy can increase the intended audience
knowledge and awareness of a health issue and problem and increase the likelihood that the target
audience will take action. It may also help to strengthen organizational relationships.

When combined with the other strategies contained in this document, health communication can lead
to a sustained change in which an individual adopts and maintains a new health behaviour or an
organization adopts and maintains a new policy direction.

Target audiences may include individuals, groups, organizations or whole communities, and
communication strategies may use a wide range of strategies to design programmes to fit specific
circumstances. The Platform for Action in Figure 1 shows a range of topics for public awareness,
education, communication and advocacy as they relate to social determinants (e.g. changing social
norms), understanding the health risks of betel nut and tobacco use, knowledge about the importance
of early screening and detection and clearly communicating health data to policy-makers.

Regardless of the topic, certain attributes can make health communication campaigns more effective.
The guidelines shown in Box 2 can be helpful in planning effective health communication campaigns
and strategies.

7
http://pacificcancer.org/Cancer/CaResources/PRCCR/

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 13

 Box 2. Characteristics of Effective Health Communications Campaigns

Define the communication campaign goal effectively:

• Identify the larger goal
• Determine which part of the larger goal could be met by a communication
campaign
• Describe the specific objectives of the campaign; integrate these into a
campaign plan

Define the intended audience effectively:

• Identify the audience to whom you want to communicate your message
• Consider identifying subgroups to which you could tailor your message
• Learn as much as possible about the intended audience; add information
about beliefs, current actions and the social and physical environment to
demographic information

Create messages effectively:

• Brainstorm messages that fit with the communication campaign goal and
the intended audience(s)
• Identify channels and sources that are considered credible and influential
by the intended audience(s)
• Consider the best times to reach the audience(s) and prepare messages
accordingly
• Select a few messages and plan to pretest them

Pretest and revise messages and materials effectively:

• Select pretesting methods that fit the campaign’s budget and timeline
• Pretest messages and materials with people who share the attributes of the
intended audience(s)
• Take the time to revise messages and materials based upon pretesting
findings

Implement the campaign effectively:

• Follow the plans formulated at the beginning of the campaign
• Communicate with partners and the media as necessary to ensure the
campaign runs smoothly
• Begin evaluating the campaign plan and processes as soon as the campaign
is implemented

*Adapted from “Making Health Communications Programs Work”, U.S. Department of Health & Human Services,
Public Health Service, National Institutes of Health, National Cancer Institute

14 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

Alliance and partnerships
Working with relevant stakeholders is recognized as one of the keys to achieving comprehensive
and sustainable tobacco prevention and control. In the countries where betel nut and tobacco are
commonly used, alone or in combination, tobacco control advocates should forge strong alliances
that can advocate for a range of prevention and control strategies.

Partnerships should be forged among policy-makers, enforcement agencies, nongovernmental groups

and professional organizations to address the need for stronger controls on the marketing and sale
of betel nut in combination with tobacco products, especially to minors. In particular, tobacco control
advocates should remind all partners that the WHO FCTC requires parties to adopt and implement a
range of effective measures to prohibit the sale of tobacco products to minors and that this extends to
the prohibition of the sale of cigarettes individually or in small packets, which increase the affordability
of tobacco products to minors. These should include multisectoral partnerships with governmental
agencies and community groups to explore viable alternative crops to betel nut.

Tobacco control advocates also should form and strengthen alliances and partnerships with professional
organizations, particularly regional and national medical and dental associations that can serve as
advocates for policies, programmes and practises to prevent and control betel nut and tobacco use.
For example, the Papua New Guinea Medical Society began advocating in 2009 for the regulation of
chewing and selling betel nut.8 These groups can also help in advocating for training of oral health
care providers to increase screening and for improved data collection and reporting on the impact of
betel nut and tobacco use.

Tobacco dependence treatment

Individuals who use tobacco products should be offered assistance to quit, and this assistance
should be extended to those who chew betel nut with or without tobacco. The Regional Action Plan
recommends that treatment of tobacco dependence be integrated into the health care system, with
particular emphasis on primary health care. This includes asking every patient about tobacco use,
providing brief advice about the dangers of betel nut and tobacco use and offering help to quit at
every patient encounter. This should include dental care and, where appropriate, may be conducted
in other community settings.

This may require training for primary health care workers and other stakeholders to provide brief
cessation advice and working to secure appropriate health care financing for tobacco dependence
treatment services. The Guidelines for the Implementation of Article 14 of the WHO FCTC (Demand
Reduction Measures Concerning Tobacco Dependence and Cessation) will be a helpful reference for
formulating cessation treatment services.9

Whenever possible, patients who are interested in quitting should be referred to more intensive
counseling services that can increase their likelihood of quitting successfully. Appropriate mass
media and educational materials should be designed to target both betel nut and tobacco users so
as to ensure they know about available cessation services. An effective way to do this is to include
testimonials from role models in the community who have successfully quit using betel nut or betel
nut with tobacco.

8
PNG Post-Courier, Feb. 11, 2009, http://www.indigenousportal.com/Health/BETEL-NUT-CHEWING-DEADLY-IN-PAPUA-
NEW-GUINEA.html

9
Parties are directed to the WHO FCTC web site (http://www.int/fctc/) where further sources of information on topics covered
by these guidelines are maintained.

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 15

 Surveillance and knowledge management
The accumulation of reliable adult and youth tobacco use data by 2014 is one of the overall indicators
contained in the Regional Action Plan. Given the close association between betel nut and tobacco
use in some countries of the Western Pacific Region, it is strongly recommended that these countries
continue to gather reliable data on the use of betel nut among adults and youth and by gender.
While many countries collect information on betel nut use through national surveys, there is no
standardization of data collected on betel nut use, making comparisons among countries difficult.
Through its technical support to countries to implement the Global Tobacco Surveillance System, the
TFI can work with countries to formulate appropriate standardized questions about betel nut use with
and without tobacco.

Countries also should use a variety of mechanisms to collect data that will help in mapping social and
economic determinants of betel nut use with and without tobacco and ensure that data is linked to
programmes, policies and health outcomes.

16 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 17
18 Review of Areca (Betel) Nut and Tobacco Use in the Pacific
ANNEX 1

Betel Nut and Tobacco Use: Origin, History and Current Trends
Betel (areca) nut

The use of psychoactive substances is an integral part of life in many societies (McDonald 1998).
Psychoactive substances can be defined as those that change the way we think or feel (McDonald
1998). Pacific island communities traditionally have used substances such as tobacco, betel nut,
coffee and kava as part of the social fabric of their societies. It has been estimated that 10%-20% of the
world’s population, or about 600 million people, use betel nut in some form (Gupta & Warnakulasuriya
2002). The habit of chewing betel nut is thought to have originated in South East Asia, most probably
in Malaysia (Norton1998).

While there are several varieties of Areca palm, the betel nut collected for chewing comes from the
family known botanically as Areca catechu (Artero & Santos 2000). The cultivated Areca species is
thought to have originated in the Philippines (Gowda 1951). It is probable that the Areca palm and
the habit of using betel nut subsequently was spread to the southwestern Pacific by the makers and
traders of Lapita pottery, about 3600 years ago (Lebot et al. 1992).

The Areca palm is a tall, slender tree which grows from 12-30 metres high. It can grow in a variety
of soils, but grows and fruits poorly at altitudes above 1200 metres (Jamrozik 1985). The type of
betel nut grown varies among regions. The nuts differ not only in appearance but also in flavour and
strength. For example, the betel nuts from Guam and Saipan have a pink interior and are nonfibrous
whereas nuts from Palau and Yap have a very fibrous coat and have a red interior. New palms start
producing nuts after four to seven years, and the nuts can take between six and eight months to ripen
(Artero & Santos 2000).

The raw cultivated nuts are used as a mild stimulant at all stages of ripening -- from young, green
nut to old, dry and germinating nut (Thomas & MacLennan 1992). There is significant geographical
variation in preferred usage, both within and among countries. Commonly, betel nut is chewed in
combination with the leaf or fruit of a pepper plant (Piper betle) and lime powder. The common name
“betel nut” originated from the association of chewing betel nut with the P. betle leaf. The term “betel
quid” refers to the mixture of the betel nut, part of the betel pepper vine and lime. Other ingredients
-- spices such as cardamom and cloves or tobacco -- may be added to the betel-quid to enhance
the flavor or physiological effects. The quid, consisting of the betel nut, lime and other ingredients,
may be wrapped in P. betle leaf or left unwrapped with the ingredients being added separately to the
mouth.

While the Areca palm and P. betle vine grow in more southern regions, the Solomon Islands and the
northern islands of Vanuatu is the southernmost extension of the betel nut chewing habit.

Prevalence of betel nut chewing

The use of betel nut has been well-documented throughout history within many societies in the
Western Pacific Region. There is evidence that betel nut has been chewed in Guam and the
Commonwealth of the Northern Mariana Islands for at least 2000 years (Pietrusewsky 2005) and
in Solomon Islands for at least 1000 years (Alependava 1992). Evidence exists of a centuries-old
tradition of chewing tobacco with betel nut in Cambodia (Reichart 1996).

Historically significant variations in the prevalence of betel nut chewing have been demonstrated
within the Western Pacific Region. Betel nut traditionally has not been grown in the Marshall Islands
and Kiribati and betel growth in Vanuatu is restricted to the Northern Province. The use of betel nut
in these countries has not been traditional.

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 19

 The tobacco industry has targeted the Pacific region to increase sales as smoking prevalence
decreases in higher income countries. Consumption of tobacco in the Pacific region increased by
15% between 1988 and 1992 (Leung 1995). This occurred despite the adverse health effects of
tobacco consumption being well-known throughout the Pacific (Marshall 1991). The tobacco grown
in the Pacific is not sufficient to meet this increased demand and a significant amount of the tobacco
used in the Region is imported either as manufactured cigarettes or twist tobacco (Brott 1981).

Current trends in usage of betel nut with tobacco

Within the Western Pacific Region, the frequency and method of betel nut use shows distinct
geographical variation, both within and among countries. However, the major ingredients -- the betel
nut, P. betle leaf and lime -- are relatively constant. The ingredients may be wrapped together and
placed in the mouth as a whole or may be added individually (unwrapped quid). In Solomon Islands
and Papua New Guinea, unwrapped quid is universal whereas wrapped quids are more common in
the Federated States of Micronesia and Cambodia.

The betel nut provides the mild stimulant effect of the quid. The nuts are ovoid in shape with a
pointed apex usually 3-5 cm in length and 2-4 cm long (IARC Monograph 2004). The outer fibrous
shell is removed and the kernel is either chewed whole or split into smaller pieces before chewing
(IARC Monograph Vol.85 2004). The shell of the nut may be chewed or used for cleaning teeth.
It is reported to have a sweet taste and a mild stimulant effect and is used more commonly by women
and children (Wilson et al. 1983).

The betel nut contains nine known alkaloids which are released on mastication (Farnworth 1976).
Arecoline is the most abundant alkaloid with arecaidine, guvacine and guvacoline occurring to a
lesser degree. Other constituents include protein, carbohydrates and copper. A comprehensive list
of constituents can be found in the IARC Monograph (IARC Monograph Vol. 85, pp. 48).

The fine, white lime powder used in betel nut chewing is usually obtained from locally available
sources. Commonly, it is produced by burning coral rock, sea coral or shells (Wilson et al. 1983).
The product that remains after the burning and cooling process is used for the lime powder (calcium
oxide or quicklime). Water then may be added to produce slaked lime (calcium hydroxide). The lime
is hygroscopic and must be kept in sealed containers. The type of lime and the specific techniques
used to reduce the source material show regional variation. Commercially produced builders lime
also may be used in the betel quid (MacLennan et al. 1985).

In Papua New Guinea, the betel nut is placed in the mouth first. After it has been chewed for a few
seconds, the lime is added to the mouth using a spatula or the betel pepper inflorescence. In other
areas, the betel nut is cracked, covered with a thick layer of lime powder or paste and wrapped in
betel leaf before chewing (Gupta & Ray 2004).

The lime powder is used to enhance the stimulant effect of the betel nut. This occurs as it hydrolyses
the arecoline from the nut to produce the central nervous stimulant, arecaidine (Norton 1998).

Parts of the P. betle vine are added to the quid to enhance its flavour. The betel vine has edible leaves,
stems and inflorescence that contain phenols which produce a spicy flavor (IARC Monograph Vol. 85
2004). Most commonly, the fresh green leaves of the vine are used in the betel quid. However, the
dried leaves or part of the vine stem are used when the green leaves are unavailable. Conversely,
in Papua New Guinea, the inflorescence of the female plant is the most frequently used part of the P.
betle vine (Wilson et al. 1983).

When betel nut, lime and P. betle leaves are chewed together in the quid, the resultant chew turns
bright red. During mastication, reddened fragments and saliva are either swallowed or spat out.
The residual chew is usually spat out.

20 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

While betel nut use has been demonstrated for a long time in Guam among the Chamorro people,
the usage patterns have changed. Before the 1800s, betel nut commonly was chewed as part of a
“quid,” including the P. betle leaf. However, change occurred in the 1900s when chewing hard, ripe
nut became the norm (Paulino 2009).

In Papua New Guinea, the use of unwrapped betel quid has been common in the coastal areas since
that is where the Areca palm grows (McDonald 1998). Unwrapped quids without tobacco also are
universal in Solomon Islands. Wilson et al. (1983) reported that betel nut and tobacco use in Solomon
Islands was common at all levels of society, with most islanders having chewed betel nut at some time
in their life. They estimated that more than 50% of adults chewed at least once a week. Both women
and men were as likely to chew betel. But men had a lower age of initiation and were heavier users.
Young children commonly chew the betel nut husk then progress to chewing betel nut. The regular
chewing of betel quid was not commonly observed before puberty. The use of lime is common but not
universal (Wilson et al. 1983).

The betel nut chewing habit was introduced to the Northern Province of Vanuatu in the 1950s during
the evangelization of the region by elders of the Anglican Church, who previously were based in
Solomon Islands (Jean-Jacques Rory, pers.comm.).

Commenting on the role of betel nut in traditional societies in the Pacific, Marshall (1987) states that
“betel is used in informal interpersonal exchanges, in formal presentations, in ceremonials and rituals,
in decorations and ornamentation, in trade and commerce, in magic and sorcery, and in medicinal
preparations” (Marshall 1987, pg. 21). Yap elder statesman John Mangafel, commenting on the role
of betel nut in consensus politics, said, “Stopping and chewing betel nut, means to consider and think
how to reach consensus so there’s no ill-feeling”. This is his interpretation of the old Yapese phrase,
“Wisdom comes out of the betel nut basket”. (Cited, Johnson Feb. 2005).

Currently, the use of betel nut is widespread in parts of Melanesia, principally Papua New Guinea,
Solomon Islands, the Northern Province of Vanuatu and in the Federated States of Micronesia,
particularly in Guam, Palau, the Commonwealth of the Northern Mariana Islands and the Marshall
Islands. Melanesia is a region that includes most of the islands north and northeast of Australia. In
Cambodia, the betel nut is predominantly used in rural regions.

Introduction of tobacco

Tobacco (Nicotiana tabacum) was not known in Pacific island communities before European contact
(Marshall 1991). Evidence suggests that tobacco first was cultivated in the Philippines in 1600 by
the Spanish (Gilmour 1931) and both the Dutch and Portuguese introduced tobacco to Java in 1601
(Gilmour 1931; Haddon 1947). Tobacco was introduced to Papua New Guinea by Malay traders
(Brady 2001; Hays 2003; Marshall 1987). Once introduced there, it was swiftly distributed via trade
channels and became a major medium of exchange (Marshall 1987).

Tobacco subsequently spread throughout the Pacific along with European contact. It was transported
from Manila to Guam by the Spanish colonizers of what is now the Commonwealth of the Northern
Mariana Islands in the late 17th century (Marshall 2005). From Guam, tobacco plants and the methods
used for smoking it were distributed widely to other parts of what today is the Federated States of
Micronesia (Marshall 2005).

The tobacco plant thrived in many regions of the Pacific with its warm climate and fertile soils, for
example, on Chuuk’s high volcanic islands and in Papua New Guinea and Solomon Islands. By
the end of the 19th century, techniques for growing and smoking tobacco were well established
and it was traded whenever the opportunity arose (Marshall 1987, p. 32). Tobacco is frequently
shared or exchanged as a way to demonstrate generosity and cement friendship and kinship ties
(Kooijman1962; Weiner 1976; Marshall 1987). As tobacco became integrated into Pacific island
cultures, its manufacture and consumption increased.

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 21

 Betel nut used in combination with tobacco

Tobacco is used with betel nut in one of two ways. It is either added to the betel quid or a smoking
habit coexists with the betel nut chewing habit. In Melanesia, tobacco is not added to the betel quid.
However, betel nut chewers may smoke tobacco, often at the same time as chewing the nut. In parts
of the Federated States of Micronesia and Cambodia, tobacco is commonly added to the betel quid.

The tobacco added to the betel nut chew may be either loose tobacco or a section of cigarette inserted
into the cracked nut before it is coated in lime and wrapped in the leaf. The use of lime lowers the
intraoral pH, thereby enhancing the stimulant effect of the nicotine in the tobacco (Cawte 1985).

Social importance of betel nut

The long-established habit of betel nut use is integral to community life in many Western Pacific
Region countries. It is a socially approved habit that is incorporated into both ceremonial situations
and routine aspects of daily life. In addition, the reciprocal gifs of the ingredients contribute to the
reinforcement of community links (MacLennan 1991). “In practical terms it is an affordable activity
that meets the needs of its users at various levels, and has therefore maintained its status in the
village despite negative external reactions to it” (Anne Ring, cited in MacLennan 1991, p.10).

Initially, the use of betel nut and tobacco was controlled by social norms. These norms governed the
people who could use betel, the situations in which it was used and the ingredients that were added to
the quid. Use was frequently restricted to elders and high-ranking members of society. In Papua New
Guinea, there were various restrictions on the use of betel. For example, premenopausal women and
young men of Gnau (Southern Madang Province) were not permitted to use lime with betel nut while
Garia women were not permitted to chew betel nut until the 1960s. (Brunton 1989) Recent studies
and observations suggest these social restrictions are no longer strictly observed.

The Secretariat for the Pacific Community (SPC) conducted Key Informant interviews in 2005 in
several Pacific island countries where betel nut and tobacco are commonly used, including the
Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, Palau,
Papua New Guinea, the Marshall Islands and Solomon Islands. Those surveyed predominantly
worked in the health sector, although employees of other sectors such as youth affairs and cultural
affairs also were included in the interviews.

The social importance of betel nut use was examined through questions about the importance of betel
nut use to the country and the changes observed in betel nut use within the last 10 years.

Of the respondents, 68% (15 of 22 people) replied that betel nut was culturally significant in their
country. Several respondents replied that they considered that betel nut was not culturally significant
because it no longer was used in traditional ways. One respondent considered that it was just a
recreational habit that had been adopted from other cultures.

The changes observed by respondents over the last 10 years included an increase in the number of
people using betel nut (81% agreed or strongly agreed) and an increase in the use of betel nut by
young people (76% agreed or strongly agreed). Other indicators suggested an increase in the overall
use of betel nut. For example, responses such as “it is more common to see red saliva patches on
the street” (95% agreed or strongly agreed) and “betel nut is more readily available in the market” (all
respondents agreed or strongly agreed).

In response to the question about whether people are now more likely to chew betel nut with tobacco,
48% agreed or strongly agreed. This result may not accurately reflect the current use of tobacco with
betel nut in Melanesia since it is more common to smoke while chewing betel nut. Two respondents
did agree with this statement, adding that they have observed an increase in smoking rather than
chewing tobacco with the betel quid.

22 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

Studies and Observations

Cambodia

Significant sex and regional variation in tobacco use was reported in a recent study aimed at
identifying the demographic characteristics of current tobacco users in Cambodia (Singh et al. 2009).
Generally, cigarette smoking was more commonly reported in men (48.0%) as opposed to women
(3.6%). However, women were much more likely to use chewing tobacco. It was estimated that 560
482 women (95% confidence interval, CI) currently chewed tobacco, typically as a component of betel
quid. The prevalence of chewing tobacco more than doubles with each decade of adulthood up to the
point that about half of all older women chew tobacco.

Both men and women cited the influence of older relatives as their main reason for starting to use
tobacco. About one out of five rural women who used chewing tobacco started their habit for relief
from morning sickness. The highest prevalence of chewing tobacco among women was seen among
traditional birth attendants (67.9%) and traditional healers (47.2%). High rates (66.8%) of cigarette
and pipe tobacco use occurred among ethnic minorities who represent hill tribes found throughout
South East Asia.

The Commonwealth of the Northern Mariana Islands

The variety of Areca grown in the Commonwealth of the Northern Mariana Islands has a soft nonfibrous
coat, so it is easier to chew alone than other varieties of Areca. However, Lee (1990) reported it was
becoming common to add tobacco to betel quid containing P. betle leaf and lime. Other ingredients
added to the chew to make it more palatable, including condensed milk (Joanne Ogo pers. comm.).

A recent unpublished study revealed that 90% of survey participants chewed betel nut in association
with tobacco (Cabrera, in prep). Nearly all survey participants were initiated into betel nut use at
about 12 years old. Initial use of betel nut was without tobacco, although tobacco was usually added
to the chew about two years later. The onset of dependence on betel nut with tobacco was reported
by many respondents (mean age of 15.6 years).

The 2000 Commonwealth Youth Tobacco Survey (CYTS) reported nearly 55% of middle school
students and 85% of high school students had tried cigarettes, with nearly 10% of middle school
students and 30% of high school students being regular smokers. In the previous 30 days, one third
of the students reported to have chewed betel nut with tobacco (33.9% of high school and 34.7% of
middle school students), with 30.0% of high school and 11.4% of middle school students chewing
betel nut with tobacco during at least 20 of the past 30 days (CYTS 2000).

The Federated States of Micronesia

The Federated States of Micronesia (Pohnpei) Noncommunicable Diseases (NCD) Risk Factors
STEPS (2008) reported on betel nut chewing among adults. About 29.9% of the total population
reported chewing betel nut, with significantly more men (43.5% ±5.9)1 than women (16.0% ±3.0)
currently chewing betel nut. For both genders, the highest proportions of betel nut chewers were in the
youngest age group, 25-34 years (men: 67.0%; women: 28.0%), declining thereafter with increasing
age (the Federated States of Micronesia NCD 2008).

Overall, 26.9% of the population used betel nut daily. The highest proportion of daily betel nut chewers
were in the 25-34-year age group (44.0%). Men reported a significantly higher proportion of daily
betel nut chewing than women, 39.2 % (±5.9) and 14.4% (±3.1), respectively.

1
95% Confidence Interval

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 23

 Among the current betel nut chewers, the mean number of nuts chewed at any one time was 1.3, with
no significant difference between men and women. On average, adults chewed betel nut 14 times per
day, with no significant gender difference between men and women (men 15.2 ±2.1 times and women
10.7 ±2.5 times, respectively).

The Federated States of Micronesia 2007 Global Youth Tobacco Survey (GYTS) of 2670 school
students in grades 7-11 reported nearly half of the students currently use some form of tobacco 47.3%
product (male 54.6%, female38.7%) with one third of students currently smoking cigarettes (29.6%
male, 37.1%, female 21.0%). Most students (86%) who currently smoked reported they wanted to
stop (the Federated States of Micronesia GYTS 2007)

A study conducted on Ulithi Atoll in Yap into the health issues facing the isolated outer islands of
the Federated States of Micronesia reported that 81% of people over 15 years old chewed betel nut
there (Hancock et al. 2007). Only 24% of those using betel nut used the traditional mixture of betel
nut, lime and pepper leaf, while 76% percent added tobacco to their betel nut. Most of those that
added tobacco (71%) soak it in alcohol first, and this was more common on Mogmog (Hancock et al.
2007).

Guam

Recent data from the 2007 Guam Behavioral Risk Factor Surveillance System (BRFSS) identified two
types of betel nut chewing behaviours: Chamorros who chewed the ripe, red nut and subsequently
swallowed the nut and other Micronesians who chewed the unripe nut with lime and tobacco and did
not swallow the betel nut (Paulino 2009).

The way betel nut is used appears to be changing among Guamians. A summary of the Youth Risk
Behavioral Surveys (YRBS) between 1999 and 2003 showed that a significant percentage of school
students chewed tobacco with betel nut. Chewing tobacco is highest among Micronesians (21.7% of
high school and 31.7% of middle school students in 2003), and usage is increasing among Chamorro
high school students (from 3.7% in 1999 to 6.8% in 2003). Recent qualitative studies on Guam
revealed that while migrants from Chuuk had no tradition of betel use, this habit was adopted from
other Micronesian students when they left home for schooling (Paulino 2009).

The YRBS in 2003 reported on smoking prevalence among high school students: 75.6% had tried
smoking and 31.6% had smoked in the last 30 days. This mirrors the high rate of smoking among
Guamanian adults, which is reported to be the highest among all U.S. states and territories (Guam’s
Epidemiological Workgroup, 2006).

Kiribati

In the 2009 Kiribati GYTS, 1461 school students aged 13-15 years were interviewed. Significant
numbers of students reported currently using tobacco in some form, i.e. 19.8% of students were
current cigarette smokers and 31.2% of students currently use other forms of tobacco (Kiribati GYTS
2009). A significant percentage of school students (68.3%) were exposed to tobacco smoke at home.
Most students (92.3%) stated that cigarette smoking was probably or definitely harmful to health
(Kiribati GYTS 2009).

A recent change in the use of chewing tobacco has been identified among the youth of Kiribati:
that of chewing tobacco with immature green coconuts (Kireata Ruteru, pers. comm.).

Papua New Guinea

Some dramatic changes have occurred in Papua New Guinea in the use of betel nut and tobacco.
Areca palms only grow and fruit well below 1200 metres and therefore betel nut chewing was not a
traditional feature of highland societies. Before road links, planes were chartered to transport betel
nut from the Sepik River plantations to the highlands. Trade in betel nut significantly increased with
the improvement of the road system linking highland and coastal areas (Freeman 2001).

24 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

In a recent study into the impact of drug use in three provinces in Papua New Guinea, (National
Capital District, Western Highlands Province and East Sepik Province), Baldwin et al. (2007) reported
89.6% of respondents had tried betel nut, with 11.7 years old being the average age of their first try.
No difference was reported between men and women in betel nut usage. Common reasons for using
betel nut were “people reported wanting to have a red-coloured mouth” and that “everyone else was
doing it” (Baldwin et al. 2007).

The WHO STEPS survey conducted by HOPE worldwide (Papua New Guinea) during the period
March 2007 to March 2008 in five regions in Papua New Guinea (National Capital District, Manus,
Gulf, Madang and Simbu) surveyed adults about various risk factors for chronic disease and reported
79% (95% CI 77.8%-80.3%) of respondents were current betel nut users, with the mean number of
times betel nut was chewed during a day being 5.5 (95% CI 4.9%-6.2%). The results were similar for
both males and females. Betel nut was most commonly used with lime and mustard (78.3% of all betel
nut users). While 44% of all respondents reported being current tobacco users, significantly more
men (60.3%) than women (27.0%) reported using tobacco. The mean age of initiation of smoking
was also younger in men, i.e. 17.9 years as opposed to 19 years for women (HOPE worldwide (Papua
New Guinea, 2010).

Palau

Ysaol et al. (1996) surveyed 1110 Palauans and reported 55% of those aged 5-14 years and 86% of
those aged 35-44 years chewed betel nut. Cigarettes were added to the betel nut by 80% of users
and 24% added other tobacco.

Chewing was more prevalent with increasing age and educational status. Women were more
likely to add tobacco to the quid (84% as opposed to 81% of men); the use of lime was universal.
No significant difference was demonstrated in tobacco usage in the chew among age groups, with
the youngest age group interviewed (5-14 years) reporting 87% usage of tobacco. They concluded
that each year more than 1.21 million packs of cigarettes were consumed in association with betel nut
chewing (Ysaol et al. 1996).

The use of piper leaf was less common among young people, probably to avoid red discoloration of
the saliva and thereby disguise their betel nut use or because it was more cosmetically acceptable
(Ysaol et al. 1996).

More recent Palau Youth Tobacco Surveys (PYTS) from 2001, 2005 and 2009 measured betel nut
and tobacco use in school students. Although less than previous years, very high usage of betel nut
was demonstrated in 2009, with 62.9% of middle school students (82% in PYTS 2005) and 74.8% of
high school students (78.1% in PYTS 2005) having ever tried betel nut. Use was significantly higher
among students of Palauan origin than other students (PYTS, 2009).

The 2009 survey reported 52.2% of high school students usually added tobacco to the chew (down
from 61.1% in 2005), with the vast majority of students using cigarettes as the source of tobacco
(PYTS 2009). Over one third of students using tobacco with betel nut had experienced cravings
within three hours of their last chew.

These studies support the findings of the report questionnaire in which respondents from Palau
considered that betel nut was no longer used in the traditional cultural context.

The Marshall Islands

In the Marshall Islands, the habit of betel nut use has grown recently after initially being introduced by
betel nut users migrating from other Micronesian islands. The Areca nut palm is not widely grown in
the Marshall Islands (although some palms exist) and betel nut is principally imported. With the rapid
adoption of the betel nut habit, the social controls evident in traditional use do not seem to have been

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 25

 adopted (Emi Chutaro pers. comm.). Commonly, the betel nut is chewed as part of the betel quid,
with the habit being increasingly accessorized, i.e. users have special implements and bags for using
and transporting the quid.

According to the 2007 Marshall Islands NCD Risk Factors STEPS Report, 4.5% of the total population
use betel nut daily, with the highest proportion of users in the 25-34 age group (9.3 % ± 3.8). Overall,
8.1% (±3.6) of male respondents were daily chewers, but the majority (90.2% ±3.5) were non-betel
users. The highest proportion of daily betel chewers (17.0% ±6.6) was reported in the 25-34 age
group. Females were less likely to chew betel nut, with 97.9 being non-betel users (the Marshall
Islands NCD 2007).

Solomon Islands

The Solomon Islands NCD Risk Factor STEPS 2010 reported 62.6% (± 8.0) of respondents had
chewed betel nut in the past 12 months, with the largest proportion of chewers (69.2% ±7.9) in the 25-
34 age group. Rates of betel use remained relatively constant in the age groups 35-44 and 45-54, but
declined in the 55-64 age groups. Significantly, more men (67.8%) than women (57.3%) had chewed
betel nut in the past 12 months.

Overall, 30.0 % (± 5.1).of the population were daily chewers, with the highest proportion of daily betel
chewers (32.5% ± 5.3) being in the 25-34 age group. Among current daily betel chewers, the mean
age of starting betel use was younger in men (20.4 (±1.1) years) than women (21.5 (±0.7) years).
This was reflected in the mean number of years of betel nut use being slightly longer in men (17.5 ±1.3
years) than women (16.4 ±1.2 years). However, women in the 55-64 age group reported starting at
a younger age than men.

A higher percentage of youth aged 15-24 years reported betel nut use, with 77.5% (±8.3) of men
being current betel nut chewers compared with 66.3% (±5.9) of women. Both genders reported
starting betel use at a younger age than all other age groups (15.2 ±0.7 years) and having used betel
nut for a mean of 5.3 (±0.6 years). A significant percentage of youth were daily betel nut chewers,
(34% ±8.9 of men and 20.9% ±5.9 of women), (Solomon Islands NCDRF 2010).

Vanuatu

Habitual use of betel nut is mainly restricted to the Northern Province of Vanuatu with people from
Malaita, Makira, Guadalcanal and Temotu being cited as the heaviest users. The Vanuatu GYTS
(2007) school-based survey of 1900 students in grades 7-9 reported over one fourth of students
currently use tobacco in some form, with 18.5% of the students smoking cigarettes and 14.3% using
some other form of tobacco (male = 14.8%, female = 12.0%). Three fourths (74.4%) of the current
smokers reported wanting to quit smoking. A high percentage of students (65.1%) reported being
offered a free cigarette by a tobacco company representative.

Various studies have been conducted in the Western Pacific Region to measure the prevalence of
betel nut use and tobacco use. The results of these studies are summarized in Table 1.

26 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

 Table 1. Summary of results of studies on the use of betel nut and tobacco in the Western Pacific Region

Country Study & Year Sample size Surveyed Group Betel nut Tobacco Additional information
(% using) (% using)
Cambodia Singh et al. 2009 13 988 Adults 18 years Currently using tobacco, Marked sex and regional
and older women 49% (cigarette 3.6% variation of chewing
chewing 17%) tobacco, 43.4% ,women
men 49% (cigarette 48%, over 48years old and
chewing 1%) 48% of rural women.
Highest users were
rural Traditional birth
attendants, 67.9%
GYTS, 2003 2011 Youth aged 8.8% currently use any
13-15 years tobacco product
(male 11.4%, female 3.2%)
5.5% currently smoke
cigarettes (male 7.9%,
female 1.0%)
4.2% currently use other
tobacco products

Review of Areca (Betel) Nut and Tobacco Use in the Pacific

(male 4.8%, female 2.5%)
National Institute of 3600 30% of men over 15 years old Higher smoking
Statistics. Cambodian households smoke daily prevalence in rural areas
Socioeconomic 20% of rural population
Survey, 2007 smokes
5% of Phnom Penh
population smokes
National Institute of 15 000 over 14 years 40% Cambodian men
Statistics. Cambodian households over 14 years smoke
Socioeconomic 4% women smoke
Survey, 2004
National Institute of 6000 4.5% were regular smokers,
Statistics. Cambodian households male 8.1%, female 1.1%
Socioeconomic
Survey, Phnom
Penh1999

27
28
Country Study & Year Sample size Surveyed Group Betel nut Tobacco Additional information
(% using) (% using)
Commonwealth YRBS 2007 2292 High school 31.1% currently smoked 5.9% smoked more than
of the Northern students cigarettes 10 cigarettes a day,
Mariana Islands 78.1% have ever smoked 74% of whom had tried to
cigarettes quit smoking.
Many risk factors
surveyed, including use of
alcohol and drugs
Oakley, Demaine 309 Cross-sectional 63.4% regular users of 24.9% smoked tobacco Oral lesions present
et al. 2005 study of school betel nut 17.5% chewed tobacco
children
Factors Associated 41 nut Adults recruited Participants selected as 90% chew tobacco with nut, Mean age of initiation
with Nut Use – chewers from public they- used betel nut 16% of whom also smoke - betel nut 12.2 years, and
study conducted health clinic with tobacco 14.5 years
2005, Cabrera,
unpublished
Youth Tobacco Survey 2809 Middle (MS) 77.2% HS and 64% MS 39.2% currently smoke Environmental smoke
2000 and high school have tried betel nut 52.7% currently using other exposure.
(HS) students 33.1% HS and 34.7% MS tobacco products Means of obtaining
had chewed betel nut with cigarettes and age at first
tobacco in last 30days trying smoking, chewing
tobacco and chewing
betel nut
YRBS 1993 School students 52% of grade 12 students Ethnic variation also cited
from grades smoked – 27% of Carolinian youth
7–12 and 42% of Chamorro
youth smoked.
The Commonwealth 150 81% Carolinians and 62% Carolinian adults smoke Ethnic variation in
of the Northern households 29% of Chamorros cigarettes chewing patterns
Mariana Islands chewed betel nut
household survey
1981

Review of Areca (Betel) Nut and Tobacco Use in the Pacific

 Country Study & Year Sample size Surveyed Group Betel nut Tobacco Additional information
(% using) (% using)

The Federated GYTS, 2007 2670 School children Ever smoked 46.4%
States of grades 7-11 (male 55.7%, female 36.0%)
Micronesia 47.3% current users, any
tobacco male, 54.6%,
female 38.7%
29.6% currently smoke
cigarettes, male 37.1%,
female 21.0%
Currently use other tobacco
products, 37.5%; male 44.2%,
female 30.4%
The Federated 1638 Adults aged 29.9% currently chew 31.6% Current Smoker
States of Micronesia selected 25-64 years betel nut (men: 42.0%
(Pohnpei) NCD using (men: 43.5% women: 21.0%)
STEPS Survey, 2002 random women: 16.0%
cluster both sexes: 29.9%) 25.5% daily smokers

Review of Areca (Betel) Nut and Tobacco Use in the Pacific

sampling (men: 34.8%
26.9% daily betel nut women: 16.1%)
chewer
(men: 39.2%
women: 14.4%)
Pohnpei Youth 507 Students aged 19.6% boys and 17.3% girls Use of kava, methylated
Health Behaviour and 13-15 years smoked cigarettes spirits and marijuana
Lifestyle Survey at least weekly
Phongsavan et al.
2005
Pohnpei Nutritional 293 adult Food patterns in 36.8% used betel nut 34.7% used tobacco during
survey, Corsi 2004 women adult women during the previous week previous week

Ulithi Atoll, Yap 301 81% use betel nut; of 55% of respondents over 71% of betel nut chewers
Health Assessment, chewers, 76% added 18years smoked, 2% of those who used tobacco, dipped
Handcock, et al. 2007 tobacco under 18 years smoked chew in alcohol before
chewing

29
30
Country Study & Year Sample size Surveyed Group Betel nut Tobacco Additional information
(% using) (% using)
SPC/Chuuk Dept of 444 Nutritional 31% used betel nut or 18.7% smoked tobacco
Health Survey snuff
2002

UNICEF Health 1516 youth Health 47.9% students used One third chewed tobacco Betel nut most common
Behaviour and Behaviour and betel nut daily substance used
Lifestyle of Pacific Lifestyle of
Youth (HBLPY) Pacific Youth
Report, Ponhpei 2001

Guam Paulino, 2009 Current betel nut chewers Current smokers 31% 79% of smokers and
12% (Chamorro 24%, (Chamorro, 44% 36% of betel nut chewers
non-Chamorro 24%, non- Chamorro, 16%, consumed alcohol
Micronesian 24%, Micronesian 41%,
non-Micronesian 0.3%) non-Micronesian 21%)
Ever chewed betel nut
37%
QMark report on Youth 6% had chewed betel nut Of betel nut chewers, Age of initiation of tobacco
substance use 2008 10-17years in last 30 days. 28% chewed with tobacco and betel nut 25%
Of betel nut chewers, 13 or 14 years,
52% chewed betel only, 50% at 15-16 years and
25% at 17 years+
QMark report on Adults aged 17% had chewed betel Of betel nut chewers,
substance use 2008 18 years and nut chewers in 29% chewed it with tobacco
older last 30 days, of whom
69% chewed betel nut by
itself.
YRBS 2007 1716 High school 20.4% girls and 25.4% boys Many risk factors
students are current cigarette smokers. surveyed, including use of
6.3% use of non smoking alcohol and drugs
tobacco
(5.6% girls and 6.9% boys)
YRBS 2003 1722 Middle and high 31.6% of high school students
school students smoked in last 30 days
YRBS 2001 3059 Middle and high 62% said their friends Risk prevalence by
school smoked ethnicity

Review of Areca (Betel) Nut and Tobacco Use in the Pacific

students
 Country Study & Year Sample size Surveyed Group Betel nut Tobacco Additional information
(% using) (% using)
Behavioral Risk 506 Adults 80% Pacific islanders Risk factor by ethnicity
Factor Surveillance smoking or had smoked Pacific islanders, Asian,
System (BRFSS) non-Asian Pacific
1999 islanders
YRBS 1999 1211 Middle and High 38% all high school students Risk prevalence by
school students (44% Pacific islanders) ethnicity
BRFSS 1995 896 Adults 75% Pacific islanders had Risk factor by ethnicity
smoked or are current Pacific islanders, Asian,
smokers non-Asian Pacific
islanders
Jarvis et al., Health 402 Adult betel nut 48% Chamorros,
Risk Factor Study, use by ethnicity 37.5% Micronesians,
1993 18.6% whites chew betel
nut
BRFSS Pinhey et al. 175 women Chamorro Yes Yes
1992 and Philippine
women

Review of Areca (Betel) Nut and Tobacco Use in the Pacific

Haddock et al. 1981 714 screening 24.65% used betel nut. 18.49% smoked cigarettes Risk factors for oral
project in senior 8.4% chewed betel nut lesions
citizens and smoked

Kiribati GYTS 2009 1461 Students aged Current cigarette smoker Exposed to cigarette
13-15 years 19.8% smoke at home, 68.3%.
Current user of other tobacco
31.2%

Papua New HOPE worldwide and 2944 Adults 79% currently use betel 44% currently smoke tobacco Alcohol consumption
Guinea WHO STEPS 2010 15-64 years nut, of whom 78.3% use it (men 60.3%, women 27.0%), – 7.1% current drinkers.
from five regions with mustard and lime of whom 72.0% smoke Other NCD risk factors
(NCD, Manus, Mean number of times manufactured cigarettes. reported on included
Gulf, Madang betel nut is chewed daily, 43.7% were daily tobacco consumption of fruit and
and Simbu) 5.5 smokers vegetables, body mass
index (BMI), fasting blood
glucose levels and levels
of physical activity.

31
32
Country Study & Year Sample size Surveyed Group Betel nut Tobacco Additional information
(% using) (% using)
Baldwin et al. 2007 615 Age range 89.6% had tried betel nut. Within the last two weeks
10-50 years 85% had used betel nut in 56.9% had used alcohol,
from three last two weeks 26.7% had used home
provinces, Port brew and 35.7% had used
Moresby, Mount cannabis.
Hagen, East
Sepik
GYTS 2007 1867 School children 61.6% of students had ever Attitudes to smoking and
grades 6-9 smoked (males69%, females tobacco use
52.8%)
53.7% were current users 84.1% of smokers had
of tobacco (males 59.7%, tried to quit during the
females 46.1%) past year
49% were current smokers
(males 55.8%, females
40.7%)
Smoking prevalence 3000 Students from In NCD 12% males and In NCD 10% males
in young people in National Capital 8% females smoked and 37% females did
Papua New Guinea District (NCD) cigarettes not smoke cigarettes,
Hiawalyer, G. 2002 and Manus marijuana or mutrus
Gibson 1998 1400 Urban demand Used by 75% of urban Used by 70.6% of urban
for food, households households
beverages,
betel nut and
tobacco
Tobacco use survey 1285 Coastal and Coastal men 58% and Regional variation in
1991, Collins and Highlands 17% women. Highlands prevalence
Dawse 1996 provinces adults women 38% used tobacco
Thomas 1992, 1678 adults in New 94% chewed betel nut 75% of men and Prevalence of oral
prevalence of Ireland Province 27% of women smoked leukoplakia
leukoplakia in adult

Review of Areca (Betel) Nut and Tobacco Use in the Pacific

 Country Study & Year Sample size Surveyed Group Betel nut Tobacco Additional information
(% using) (% using)
Vallace et al. 413 (1970) Smoking habits Reduction in smoking Increase in use of
1987Vallace et al. of adults in a prevalence from 55% to 41%, commercial cigarettes
1987 257 (1984) rural Highlands especially in young adults among smokers from
community, 28% to 93%
1970 and 1984

Palau PYTS 2009 1125 h 58.6% HS students and 52.9% HS students and Minors’ access to tobacco,
47.6% MS students used 41.6% MS students used any knowledge and attitudes
betel nut, 53.3% HS form of tobacco, of young people about
students and 36.3% MS 41.4% HS students and tobacco and betel nut use,
students used betel nut 36.3% MS students currently exposure to second-hand
with tobacco smoke smoke
YRBS 2007 732 High school 30.6% girls and 44.4% boys
students currently
PYTS 2005 943 High school and 43.1% MS students and 55.3% MS students and Patterns of nut and
middle school 61.1% of HS students 69.3% HS students currently tobacco use.
students currently chew betel nut use tobacco Attitudes and knowledge
with tobacco of nut and tobacco

Review of Areca (Betel) Nut and Tobacco Use in the Pacific

PYTS 2001 973 High school and Daily betel nut use with Patterns of nut and
middle school tobacco in 68% of HS tobacco use.
students students and 54% MS Attitudes and knowledge
students of nut and tobacco
Ministry of Health, 227 Ministry 74% Ministry of Health 50% smoked
2001 of Health staff and 79% Oral Health
employees Division staff chew betel
nut with tobacco
1997 substance 802 70% of adults chewed Most chewers added tobacco
abuse needs betel nut
assessment
Ysaol et al.1996 1110 From age 55% those aged 80% of chewers added
5 years 5-14 chewed betel nut cigarette,
86% those aged 24% added chewing tobacco
35-44 years chewed betel
nut

33
34
Country Study & Year Sample size Surveyed Group Betel nut Tobacco Additional information
(% using) (% using)
The Marshall 2007 YRBS 1522 High school 24.4% girls and 40.9% boys Many risk factors
Islands students currently smoke cigarettes. surveyed, including use of
53.1% girls and 71.2% boys alcohol and drugs.
had ever smoked cigarettes
The Marshall Islands 1865 Random cluster Currently chew betel nut Current smoker
NCD STEPS Survey, sample of adults (men: 9.8% men: 38.8
2002 aged 25-64 women: 2.1% Women: 7.0%
years both sexes: 6.1%) Both sexes: 23.4%

Daily betel nut chewer Daily smoker

Men: 8.1 (men: 35.3%
Women: 0.8 women: 5.4%
Both sexes: 4.5 both sexes: 20.8%)
Chen T-H, et al. 2004 3294 Students aged Betel nut chewing rate 10.6% smoking rate overall, Risk factors for smoking
9–20 years currently not available 33.5% those aged 18 years
or more

Solomon NCD STEPS Survey, 1925 Random cluster 62.6% currently chew 39.8% current smoker Mean age started
Islands 2005 sampling of betel nut (men: 54.1% smoking
adults aged (men: 67.8% women: 25.0%) (men: 20.3
25-64 years women: 57.3%) women: 23.1
30.6% daily smoker both sexes: 21.0)
30.0% daily betel nut (men: 43.9%
chewer women: 16.9%) Mean age started chewing
(men: 35.8% (men: 20.4
women: 24.0%) women: 21.5
both sexes: 20.8)
Mean duration of betel nut
habit Mean duration of smoking
(men: 17.5% (men: 17.2
women: 16.4% women: 15.0
both sexes: 17.1%) both sexes: 16.6)

Review of Areca (Betel) Nut and Tobacco Use in the Pacific

 Country Study & Year Sample size Surveyed Group Betel nut Tobacco Additional information
(% using) (% using)
Smoking and Chewing 48 cases Retrospective 90% of oral cancer Site of cancer.
Habits of Oral Cancer study between patients chewed betel nut Statistical risk of smoking
Patients – Lumukana 1994 and 1997 and smoked and chewing nut on oral
& King, 2003 and 1999 of oral cancer
cancer patients
at National
Referral
Hospital
1995 YRBS High school 23.8% current users
students

Vanuatu 2007 1900 School children 28.0% of students had ever

grades 7-9 smoked cigarettes (male
27.0%, female 29.9%)
26.3% currently use any
tobacco product (male 26.4%,
female 25.3%)

Review of Areca (Betel) Nut and Tobacco Use in the Pacific

18.5% currently smoke
cigarettes (male 18.1%,
female 19.8%)
14.3% currently use other
tobacco products (male
14.8%, female 12.0%)
Smoking in Port Vila; 1000 Youth 58.20% males Reported in Western
1988 Vanuatu Youth 17.7% females Pacific Regional Office
People’s Project , Country Profiles, Tobacco
1998 or Health, 2000. URL:
http://www.wpro.who.int
National Non- Adults 49.0% males
communicable 5% females
Diseases Survey.
1998

35
 Migration

Several studies have linked the use of betel nut to migrant status (Pinhey et al. 1992). Migration has a
dual impact on the use of betel nut. Firstly, the continued use of betel nut helps migrants reinforce their
cultural identity in the new country. Pinhey et al. (1992) reported the use of betel nut was significantly
related to migrant status for younger Philippine women on Guam. In addition, the broader effects of
migrants introducing a new habit to a community, or a new way of using a substance, are important.
For example, Micronesian immigrants have introduced betel nut chewing to the Marshall Islands and
immigrants from the Federated States of Micronesia to Hawaii and the mainland of the United States
of America have created a demand and, subsequently, a trade market for betel nut there.

Multiple drug use

Concern has been expressed as to whether the habitual use of betel nut provides a gateway to
other, potentially more harmful drugs. Pacific prevalence studies seem to suggest the combination
of tobacco and betel nut is alarmingly common, particularly among young people (Ysaol et al. 1996,
PYTS 2001, 2005, 2009). In communities where tobacco is commonly added to the betel quid,
initiation occurs with betel nut alone, especially in the youngest groups. There is a subsequent
graduation to the use of lime and tobacco.

While there are studies that link tobacco and betel nut use, few studies exist which explore the
link to abuse of other substances, particularly alcohol and marijuana, which are widely available in
the Western Pacific Region. Betel nut is a readily available and cheap alternative to other mood-
enhancing drugs. Sales to minors are not restricted, as may be the case for alcohol and tobacco.

Pinhey et al. (1992) reported several variables were related to the use of betel nut, tobacco and
alcohol among Chamorro and Philippine women in Guam. There was a limited relationship between
socioeconomic factors and betel nut use. Education levels were negatively associated with tobacco
use for both Philippine and Chamorro women (Pinhey et al. 1992).

The McDonald survey of substance use in Papua New Guinea reported a significant percentage of
drug users used or had used a combination of different drugs. Of particular interest, 91% reported
use of betel nut, 87% of tobacco and 82% of alcohol (McDonald 1998).

A more recent study in Papua New Guinea reporting on the use of alcohol, home brew, cannabis and
betel nut showed the age of first trying betel nut was significantly lower (11.7 years) than for other
drugs (alcohol 16.53 years, home brew 18.5 years and cannabis 18.02 years). A significant finding to
emerge from the study was a strong culture of intoxication in Papua New Guinea (Baldwin 2007).

Socioeconomic aspects of betel nut

Apart from the traditional use of betel nut in intergroup exchange, the use of the betel nut as a
commercial product is a relatively recent phenomenon in the Pacific (Watson 1987). The market for
betel nut has grown along with the growth of urban centres and has increased along with the number
of waged employees. Demand also has increased with improved communication routes. This has
been especially significant with better road access to the highland provinces of Papua New Guinea.

The growth of interisland trade and export of betel nut has been enhanced by different regional
growing seasons and regional migrants wanting to access products from their homelands. There is
evidence of demand for particular varieties of betel nut. For example, betel nut from Yap is reported
to be stronger than other varieties (Ben Yoromad, cited Radway 2004).

Betel nut products are now increasingly available in Pacific countries that have no previous history of
usage – the mainland of the United States of America, Australia and New Zealand. An extensive array
of betel nut products is available through the Internet.

The socioeconomic effects of betel nut include income expenditure and generation as well as
environmental impacts.

36 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

Income generation

For growers and distributors, betel nut provides an essential source of income for the family. School
fees, food, medicine and other household items are bought with the income generated from betel
nut (Vele 1982). This is also true for suppliers of other quid ingredients -- tobacco, lime and P. betle
leaves.

In the Chris Owen documentary “Betelnut Bisnis”, filmed in Goroka, Eastern Highlands Province,
Papua New Guinea, comments made by interviewees reflect the social and economic importance of
betel nut to the community. Betel nut is referred to as “green gold” and called “the life blood of Papua
New Guinea” (Betelnut Bisnis 2004).

Baldwin also reported the sale of betel nut is a very important source of income for many people
in certain provinces of Papua New Guinea, especially those who are outside the formal economy.
Betel nut sales ranged from small-scale opportunistic exchanges to well-planned business ventures
(Baldwin 2007).

The 1996 Mapping Agricultural System estimated 1,227,234 people received income from betel nut
in Papua New Guinea and the total income from betel nut was USD 7,094,993, or 9.5% of the total
income from agricultural products (Caven & McKillop 2000).

Figures from the Solomon Islands 2010 STEPS survey reported a betel nut seller could earn up to
USD 63.49 per day (Solomon Islands NCD 2010).

Yap is the leading supplier of betel nut to the region. Betel nut from Yap is primarily sent to Guam
and the Commonwealth of the Northern Mariana Islands, with smaller amounts to Chuuk, Palau
and the Marshall Islands (Radway, 2006). The Yap Department of Agriculture reported during the
financial year March 2003-February 2004 that 211 tonnes of betel nut and 16.3 tonnes of pepper leaf
were exported. These figures were obtained from the export records of air freighted betel nut (Cited
Radway 2006). Betel nut is now the most important cash crop for Yap, with an estimated value of
USD 3,000,000 between 2003 and 2004 (Gov. Robert Robuecho, cited Radway 2004). The true
value of the crop is likely to be even higher because the statistics do not include betel nut transported
in personal luggage.

The United States Food and Drug Administration lifted the ban on betel nut importation for personal
use in 2000. The main reason was that people were ignoring the ban anyway, which was regarded
as posing a greater agricultural risk (Department of Agriculture, Animal and Plant Health Inspection
Service). Some states in the United States of America require the husk to be removed from the betel
nut because it is the husk that poses the greatest risk of introducing agricultural pests and diseases.

Income expenditure

Gibson reported that betel nut and tobacco accounted for 2.32% and 3.09%, respectively, of total
household expenditure in urban households in Papua New Guinea. When urban household incomes
increased, the most significant increase in demand occurred for betel nut, fresh vegetables and sweet
potato (Gibson 1998).

Frequent users of betel nut and betel quid may buy it in preference to other essential items. Several
questionnaire respondents remarked that habitual users will sacrifice food and medicine in favor of
betel quid ingredients, especially tobacco. These appetite suppressant products may be bought
instead of food to satiate hunger. Economic impact figures from Palau have predicted a regular betel
nut chewer spends USD 32.55 a week on betel nut, which equates to USD 1,692.60 per year. A 1995
survey on the prevalence of betel nut use estimated the cost to Palauans of betel nut use and its
associated additives (slaked lime, pepper leaf and tobacco) was USD 9.2 million annually (Country
Profiles 2000).

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 37

 In the Western Pacific Region, increasing areas of arable land are being converted to the production
of betel nut (Vele 1982; Gibson 1998). Statistics from Guam show 4100 pounds of betel nut were
harvested from 16 farms in Guam alone (Guam Statistical Yearbook 2008). In the Region, larger
scale plantations are more visible and home gardens are being planted with Areca palms rather than
food crops.

Families may compromise their food security in changing from food production to cash crops. Food
insecurity could result if the price obtained for the betel nut crop drops due to market saturation or if
the price of food staples (e.g. sweet potato) increases due to scarcity. Experience in Guam with the
Areca palm blight demonstrates that heavy reliance on one crop can be disastrous if the crop fails.
In addition, Areca palms take at least four years to become productive, creating a significant lead time
before income is generated from the land.

Experience in Taiwan has shown there may be other unforeseen problems in changing from traditional
crops. The rapid expansion of betel nut cultivation has placed farmers at risk of the progressive loss
of fertile soil and land erosion because the Areca palms do not retain soil during the rainy season
(Ko et al. 1992).

Reef destruction

In Solomon Islands, harvesting of Acropora coral to obtain lime for betel quid has destroyed important
reef habitats and caused changes in coral reef communities as reefs become devoid of stag horn
Acropora corals. To reverse these negative impacts of coral harvesting, local women have been
trained as coral farmers. The coral grown has been used to regenerate the reefs and supply coral for
the United States of America aquarium market, generating essential export revenue (Solomon Islands
Development Trust (SIDT). Marked destruction of reef coral for use in betel quid also has been noted
in parts of Papua New Guinea (McEldowney 1993).

Betel nut was viewed as an important part of the economy by 55% of respondents. It was noted that
it was more important to the micro-economy at a family group level.

38 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

ANNEX 2

Health Concerns: Why is Betel Nut Use a Problem?

While betel nut has been used for its stimulant properties, concern has long been expressed over its
association with negative health consequences. A significant percentage of respondents (73%, i.e.
16 of 22 people) to the questionnaires believe that betel nut use affects the health of their community.
The physiological effects of betel nut use may be caused by the betel nut alone or by the combination
of the additional ingredients -- the lime, P. betle leaf and tobacco. These ingredients may act in their
own right, or synergistically with the betel nut, to cause the health effects commonly associated with
habitual betel nut use.

Pharmacology

The use of betel nut is associated with both immediate and long-term physiological effects.
The immediate effects can occur within minutes of chewing the betel nut because the ingredients are
absorbed directly into the blood stream via the oral mucosa. These effects are caused by activation
of the sympathetic pathway by the betel nut alkaloids and have been described as a combination of
the following symptoms (Rooban et al. 2005):

• Dizziness and heart palpitations

• Heightened awareness
• Hot sensation and sweating
• Epigastric discomfort and diarrhoea
• Increased respiration and heart rate
• Diminished thirst and hunger
• Relaxed, happy feeling

The effects of betel nut are more pronounced in first-time users and if the chewer is suffering from
malnutrition or a physical illness such as malaria (Cawte 1985). Regular users of betel nut may
develop tolerance and therefore experience less dramatic initial symptoms (Burton-Bradley1979;
Winstock 2002).

Habitual use of betel nut has been associated with a number of long-term adverse health effects:
specific oral effects, including oral precancer and cancer and other types of cancer, heart and
respiratory effects, diabetes mellitus, poor pregnancy outcomes and mental illness, addiction and
toxic effects.

Effects on Oral Hard Tissues

Tooth discoloration and dental caries

Chewing a combination of betel nut, lime and P. betle produces the copious red saliva associated with
betel quid use. With regular betel quid chewing, this stain becomes embedded in the teeth, gingiva
and oral mucosa. The colour deepens from red to black with increasing duration and frequency of
use.

Traditionally, this tooth colouration was regarded as aesthetically pleasing by some societies, but with
Western influence it seems to be becoming less so (Norton 1998). Vigorous brushing of the teeth,
particularly with the fibrous husk of the betel nut, is used to reduce the amount of staining.

Several studies have discussed the role of tooth stain in a reduced rate of dental caries in regular betel
nut users (Moller et al. 1977; Howden 1984; Nigam & Srivastava 1990). Howden (1984) reported that
the stain acted as a physical barrier to tooth demineralization.

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 39

 It also has been suggested that the use of lime with betel nut contributes to the reduced rate of dental
caries in some betel nut users because it increases the intra-oral pH and provides a source of calcium
for remineralization of the tooth enamel. (Alependava 1992).

Excessive tooth abrasion and fractured teeth

The hard fibrous nature of the betel nut causes fractured teeth and extensive abrasion of the occlusal
tooth surface of regular users. The molars, premolars and canine teeth frequently completely lose
their cuspal form and the incisors become shortened. The abrasive nature of the lime further increases
this effect. A survey of oral health of the Huli people from Southern Highlands Province, Papua New
Guinea, reported nearly half of those aged 45–64 years had back teeth that were completely smooth
and flattened (Newell 2001). Tooth attrition is more pronounced in coastal areas that have higher
rates of betel nut use (Davies 1990).

Temporomandibular joint pathology

It has been speculated that the chewing forces generated during habitual betel nut use could give rise
to deterioration of the temporomandibular joint (TMJ) (Trivedy et al. 2002). This is difficult to prove
because many of the symptoms associated with TMJ pathology, e.g. trismus, also occurs in fibrotic
conditions linked to betel nut use.

Effects on Oral Soft Tissues

Periodontal Disease

Periodontitis is a significant cause of tooth loss for adult Pacific islanders (Cutress & Tapealava 1996;
Cutress 2003). It is a progressive gum disease that results in the loss of the supporting structures of the
teeth and is linked directly to inadequate oral hygiene. Poor oral hygiene is frequently associated with
betel nut chewing (Nigam & Srivastava 1990; Pickwell et al. 1994). Studies of betel extracts containing
arecoline have suggested betel may be cytotoxic to periodontal fibroblasts, thus exacerbating pre-
existing periodontal disease (Trivedy et al. 2002).

Tobacco use is associated with increased severity of periodontitis and tooth loss (Bergstrom 1989).
Therefore, it is likely that the concurrent use of tobacco with betel nut predisposes users to periodontitis.
The Ministry of Health in Palau states that as a consequence of the majority of the population in
Palau using tobacco products, “the entire population in Palau is considered to be at very high risk for
development of periodontal disease” (MOH Palau 2005, p. 9).

Periodontitis is further exacerbated by diabetes mellitus, a disease also associated with betel nut use
(see section on Diabetes Mellitus below).

Treatment of periodontal disease and stain removal from teeth and repairing fractured teeth due to
betel nut chewing, may require continuing dental treatment at significant cost to the betel nut user.

Betel chewer’s mucosa

Betel chewer’s mucosa (BCM) first was described by Mehta et al. (1972). It is characterized by a
brownish-red discolouration of the oral mucosa localized to the site of betel quid placement and is
associated with epithelial hyperplasia (Trivedy et al. 2002). Although BCM is not considered to be a
premalignant lesion, it frequently coexists with premalignant lesions, e.g. leukoplakia.

The use of lime in betel quid damages the oral mucosal membrane, leading to direct abrasion of the
mucosal surface and ulceration.

40 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

Betel -induced lichenoid lesions

Daftary et al. (1980) identified lesions in regular betel quid users at the site of betel quid retention,
principally the buccal mucosa and tongue, which histologically showed a lichenoid reaction.
These lesions disappeared with the cessation of betel nut use.

Leukoplakia, erythroplakia and oral submucous fibrosis

Oral leukoplakia can be defined as a predominantly white patch on the oral mucosa that cannot
be characterized clinically as another lesion (Axell et al. 1984). Various types of leukoplakia exist,
including speckled, nodular and verrucous leukoplakia (Trivedy et al. 2002). Erythroplakia is a bright
red velvety patch on the oral mucosa that cannot be characterized as another condition (Hashibe et
al. 2000).

There is extensive evidence of oral leukoplakia among betel nut chewers who chew with or without
tobacco. Ikeda et al. (1996) reported the prevalence of leukoplakia in selected Cambodian populations
was 2.2% among men and 0.6% among women. Several studies report that the prevalence of oral
leukoplakia appears particularly high in Papua New Guinea (4.6%-17%), with the prevalence in the
Papua New Guinea lowlands being among the highest in the world (Pindborg et al. 1968; Forlen et al.
1965; Atkinson et al. 1964; Bailit et al. 1968; Thomas 1993; Newell 2002).

A significant dose-related relationship of the frequency and duration of betel nut chewing has been
demonstrated for both erythroplakia and leukoplakia (Gupta 1984; Hashibe et al. 2000; Lee et al.
2003).

A malignant transformation rate for oral leukoplakia of 0.1%–17.5% is reported in the literature
(Van der Wall et al. 2002). Downer and Petti (2005) calculated the global incidence of oral cancer
incidence due to leukoplakia was 6.2–29.1 cases for every 100 000 people. Lee et al. (2003) reported a
statistically significant interaction between betel nut and tobacco in the causation of oral leukoplakia.

Oral submucous fibrosis (OSF) is characterized by persistent and recurrent stomatitis leading to
progressive sclerosis of the dermal and muscular tissue of the oropharynx (Norton 1998). Early
stages may present with fibrotic bands across the palate which progress to other areas of the oral
mucosa and the oropharynx. Advanced stages are characterized by restricted oral opening and
protrusion of the tongue, making eating, swallowing and speech difficult (Rajendran 1994). Betel nut
chewing is now widely accepted as the most important etiological factor in the development of OSF
(Warnakulasuriya et al. 1997).

OSF also has shown a malignant transformation rate of between 3% and 7.6% (Pindborg et al. 1984;
Murti et al. 1985; Sinor et al. 1990). Murti et al. (1985) followed a group of patients with OSF for 17
years, after which the malignant transformation rate of OSF was 7.6%. Given that oral cancer can
take many decades to develop, it is possible that these studies may underestimate the long-term
malignant transformation rate.

Oakley et al. (2005) reported a significant number of high school students in the Commonwealth of
the Northern Mariana Islands presented with oral lesions associated with betel nut and tobacco use.
Oral leukoplakia was present in 12.9% of students while 8.8% had OSF (one third of whom already
showed a restriction in mouth opening). Cessation of betel nut and tobacco use has been shown to
decrease the severity of lesions, sometimes leading to their complete resolution (Gupta et al. 1995).

Oral cancer

Cancer of the oral cavity is the sixth most prevalent cancer worldwide (Hamner et al. 1986; Parkin
et al. 2005), with squamous cell carcinoma accounting for between 90% and 99% of all oral cancers
(Pindborg 1980; Jamrozik 1985; Forastiere et al.2001). In 2002, oral cancer cases were estimated at
274 000 worldwide, almost two thirds of which were men. Melanesia is reported to be the Region with
the highest incidence -- 31.5 per 100 000 in men and 20.2 per 100 000 in women. This compares with
an incidence in Australasia of 10.2 per 100 000. Australasia is defined as Australia, New Zealand, New

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 41

 Guinea and neighbouring islands. The average mortality is commonly less than half the incidence
(Parkin et al. 2005); however, the mortality rate from oral cancer in the Federated States of Micronesia
and Melanesia is significantly higher. Barton et al. (2001) reported that 80% of the people with cancer
in Papua New Guinea will die of the disease. The Micronesian oral cancer cases that received
treatment at the Tripler Army Medical Center in Hawaii, reviewed by Carpenter et al. (2005), had a
67% mortality rate.

The use of tobacco and alcohol are the major etiological factors in the development and recurrence of
treated oral cancer in Western populations. Detailed evaluations are available elsewhere for the role
of tobacco and alcohol in the etiology of oral cancer (IARC 1985 b; IARC 1988; NIH 1992). Individually,
regular use of tobacco and alcohol increase the risk of developing cancer and the recurrence of
treated oral cancer by about sixfold (Silverman 1972). When tobacco and alcohol habits coexist, they
act synergistically to increase the risk of oral cancer dramatically to a multiple of each individual risk
factor (Rothman & Keller 1972).

The association between the use of betel nut and oral cancer has been known for many years (Orr
1933; Eisen 1946). The International Agency for Research on Cancer conducted an extensive review
of the available literature on betel nut chewing in the production of the 2004 monograph “Betel-quid
and Areca-nut chewing and some Areca-nut-derived nitrosamines”. The evaluation, based on expert
opinion and the available literature, resulted in the following conclusions (IARC Monograph 2004,
p.239):

• Betel quid with tobacco is carcinogenic to humans (Group 1)

• Betel quid without tobacco is carcinogenic to humans (Group 1)
• Areca nut is carcinogenic to humans (Group1)

This evaluation was based on strong evidence of betel nut causing the precancerous condition, OSF,
and sufficient evidence of carcinogenicity in experimental animals. There was also strong supporting
evidence. The IARC linked oral cancer to the use of betel quid without tobacco and oropharyngeal
cancers to betel quid use with tobacco.

Commonly, 70% of oral squamous cell carcinomas present in just 20% of the oral mucosa. However,
the dominant site differs greatly among countries. In Western countries, the floor of the mouth and
tongue are the most common sites, but betel-associated lesions usually present in the buccal mucosa
from the corner of the mouth posteriorally and the lateral border of the tongue (Thomas & MacLennan
1992). This finding was supported by Endican et al. (2010) in their review of the oral cancer cases
treated at Goroka General Hospital, Papua New Guinea, between April 2008 and August 2009, where
over 97% of cases were located in these sites within the oral cavity.

Pacific studies

The Federated States of Micronesia

Palafox et al. (2004) reported that the age-adjusted cancer prevalence for the Federated States of
Micronesia during the period 1985-1998 showed marked geographical variation. Yap showed the
highest oral cancer prevalence of 22.1 per 100 000. The other states had much lower prevalence
rates with Kosrae 7.9, Pohnpei 6.2 and Chuuk 3.8 per 100 000.

The Yap Memorial Hospital medical records reported oral cancer represented the second most
common cancer at 14.1% of all cancer cases between 2000 and 2002 and 7.7% of cancer deaths
between 1998 and 2002.

42 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

Guam

Early studies in Guam suggested betel nut chewing posed no increased risk of oral cancer
(Wells 1925; Gerry et al. 1952) or that the risk of oral cancer from betel nut chewing was equivalent
to the risk posed by tobacco use (Haddock 1981). Commonly, the study’s subjects were Chamorro,
who had used betel nut alone, not in combination with other ingredients. However, since the Compact
of Free Association (United States Public Law 99–239, 1986), there has been significant immigration
from the Federated States of Micronesia, which may have changed the risk profile of oral cancer.

The Guam Cancer Registry 2003-2007 ranks oral cancer as tenth in cancer incidence for Guam
(Guam Comprehensive Cancer Control Coalition 2009). Oral cancer incidence is higher for males
(sixth in incidence). Deaths due to oral cancer were ranked ninth in cancer-related mortality for both
men and women.

The Guam Cancer Registry also reports a large variation in the age-adjusted incidence of oral cancer
among ethnic groups; Micronesian (29.4) and Caucasians (26.7) had a very high incidence, Chamorro
(18.0) had a high incidence and other ethnic groups had significantly lower oral cancer incidences:
Filipino 2.7, Asian 6.2 and USA 10.3.

It has been suggested these statistics may be skewed slightly because Micronesians may travel to
Guam for medical treatment. However, even taking this into consideration, the etiology behind the
differences in oral cancer incidence rates should be explored further. The frequency of betel nut use
and the mode of use, i.e. with or without tobacco, definitely should be considered in determining the
factors that contribute to the difference in incidence rates (Haddock 2005).

Papua New Guinea

Oral cancer in Papua New Guinea has been known and reviewed for many years (Eisen 1946;
Backhouse 1955). The Tumor Registry of Papua New Guinea was established in 1958, and within six
years Atkinson et al. (1964) reported a disproportionately high incidence of oral cancer in the country
(17.4%) and a distinct geographical variation in oral cancer prevalence. A higher incidence of oral
cancer was shown to closely match areas of betel nut use.

Thomas (1993) provides a thorough discussion and extensive literature review of the etiology,
geographical distribution and incidence of oral carcinoma in Papua New Guinea. Notable features
are the high incidence of oral cancer there, particularly in men, where it is the most frequently reported
cancer and a distinct geographical variation in prevalence. The annual average reported oral cancer
rate per 100 000 for the highlands was 3.5 for men and 1.9 for women compared with 50.7 for men
and 21.8 for women in island provinces. Typically, oral cancer was most prevalent in the 45-year age
group, which is 20 years earlier than Western populations (Coates & Armstrong 2000). Further, it was
site-specific with the site of tumor presentation corresponding to the site of lime application in 77%
of reviewed cases. Typically, cases of oral cancer presented very late when the disease was well
advanced and difficult, if not impossible, to treat (Thomas 1993).

In a further case-controlled study of cancer cases in Papua New Guinea, Thomas et al. (2007) showed
that betel quid is an independent risk factor for the development of oral cancer (Thomas et al. 2007).

Barton et al. (2001) reported the high mortality rate from oral cancer in Papua New Guinea because
of the late presentation of cases and lack of knowledge of the availability of treatment. The authors
reported 80% mortality from all types of cancer in Papua New Guinea. Endican et al. (2010) reported
80% of the oral cancer cases presenting at Goroka General Hospital between 2006 and 2008 had
been in the third or fourth stage.

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 43

 Oral cancer incidence in the highlands has been increasing dramatically along with the increase
in betel nut use, and Barton et al. (2001) reported an impending epidemic in oral cancer in the
highlands of Papua New Guinea. One specialist interviewed for the report stated there was already
an oropharyngeal cancer epidemic at the Kudjip Health Centre (Dr Bill McCoy, cited Barton et al.
2001, p. 14).

Palau

The Palau Cancer Registry reported an oral and pharyngeal cancer incidence rate of 11.5 per
100 000 between 1991 and 1995. A dramatic increase was reported between 1997 and 2002 when
the incidence rose to 18.0. The Oral Health Division reports that these figures may be underestimates
because cases only are registered if there is a formal diagnosis in Palau. Suspected cases that are
referred for treatment and formally diagnosed elsewhere may not be registered (Palau Ministry of
Health 2005).

The Marshal Islands

Palafox (2004) reported that the oral cancer prevalence for the Marshall Islands was 12.6 per
100 000 between 1985 and 1998. While this is lower than other regions in the Pacific, it is still a
significant figure and could reflect a trend towards higher incidence associated with increasing betel
nut use.

Solomon Islands

Reed (1977), in his review of the age-adjusted cancer incidence in Solomon Islands in the mid-1970s,
reported cancer of the lip, mouth and pharynx represented 15% of all cancers. This percentage
was significantly higher than the histologically-proven oral cancers diagnosed in the Honiara Central
Hospital, which accounted for 9% of malignancies in men and 8% of malignancies in women.

Wilson et al. (1983) estimated the annual reported incidence of oral cancer in Solomon Islands as
10 per 100 000 between June 1980 and July 1983, while the annual incidence of histologically-proven
oral cancer was five per 100 000.

A small case-control study of oral cancer showed that the group identified as the highest consumers
of betel nut had a significantly greater risk of oral cancer than those who did not chew betel nut or only
chewed occasionally (Wilson et al. 1983). It also was shown that chewers who added lime had five
times the risk of those who did not add lime.

In a review of 48 newly diagnosed cases of oral cancer between 1994 and 1997 and in 1999, Lumukana
and King (2003) reported the annual incidence ranged from seven to 13 cases per 100 000.

Treatment for oral cancer

The treatment for oral cancer usually involves surgical removal of the lesion with or without radiotherapy
(Bhandary 2003). Chemotherapy as an adjunctive therapy recently has been used to reduce the
invasiveness of oral cancer and improve the survival rate. A recurrence rate of 80%-90% for oral
cancers treated with aggressive surgery alone has been reported at Goroka General Hospital, Papua
New Guinea (Endican et al. 2010).

Traditionally, oral cancer that is diagnosed and treated early has a good prognosis and outcome.
However, oral cancer can spread rapidly along tissue planes, invade bone and muscles and show a
high rate of lymphatic spread (Bhandary 2003). Bhandary reported a five-year survival rate of 86% for
patients treated within a month of becoming symptomatic as opposed to 47% for those treated within
seven months. None of the patients who waited for 12 months for treatment survived.

44 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

Even among those successfully treated for oral cancer, many have a significantly reduced quality
of life as a result of their cancer treatment (BDA 2000). Subsequent alterations in appearance and
difficulties in eating, drinking, swallowing and speaking can have devastating consequences for those
affected.

Carpenter et al., in their review of the Tumor Registry (1977–2003) of the Tripler Army Medical
Center in Hawaii, which provides tertiary care for remote Pacific island nations, concluded that
“betel nut induced oral carcinomas are aggressive malignancies requiring aggressive treatment
and long-term follow-up” (Carpenter et al. 2005, p.158). In particular, first and second stage
betel nut-induced oral carcinomas, particularly those in the buccal mucosa, behaved more invasively
than normally would be expected and therefore required adjunct therapy to surgery alone as well as
intensive and long-term follow-up (Carpenter et al. 2005).

Barton et al. (2001) reported that a significant barrier to obtaining treatment for oral cancer in Papua
New Guinea was the general lack of knowledge about cancer in the country. “Few people in the
community knew what cancer was, how it was caused, and that treatment was available”, (Barton et
al., 2001, p. 14). This lack of awareness was demonstrated at all levels of society, from community
health workers through to government. Therefore, increasing general awareness of oral cancer in
Papua New Guinea is regarded as an integral part of treatment for oral cancer.

Other Cancers

Betel nut chewing has been associated with a higher risk of other cancers. Rajkumar et al. (2003)
demonstrated a significant association between chewing more than five betel quids a day (with or
without tobacco) and cervical cancer.

Chewing betel quid without tobacco has been demonstrated to be associated with an increased risk
of liver cancer in a dose-dependent manner (Tsai et al. 2001). This increased risk was demonstrated
after controlling for sex, age, alcohol, smoking, drinking, anti-hepatitis C virus (anti-HCV) and hepatitis
B surface antigen (HBsAg). The association of betel nut chewing and liver cancer may be important
in Yap, where liver cancer was the most prevalent cancer (15.6% of total cancer cases) between 1998
and 2002 and the leading cause of death by cancer (23.1% of cancer deaths) between 2000 and 2002
(Taoka et al. 2004).

The highlands of Papua New Guinea already have a high incidence of liver cancer because of a
high rate of hepatitis B infection (WHO 1998). The increased prevalence of betel nut use may further
increase the burden of liver cancer in this region.

A recent study of women in northeastern India identified betel nut use as an important risk factor
in the development of breast cancer (Kaushal et al. 2010). The risk factors of tobacco smoking,
tobacco chewing, betel quid chewing and alcohol were analysed in 117 breast cancer cases and
174 cancer-free controls, and betel quid chewing was reported as the main risk factor for the
development of breast cancer. Also, women with a betel quid chewing history had five times the risk
of contracting breast cancer than those who did not chew betel nut (Kaushal et al. 2010).

Other Effects

Cardiovascular and respiratory effects

Studies in humans suggest betel nut chewing is associated with activation of the sympathetic pathway,
with elevation of adrenaline and noradrenalin (Chu 1995) and, in higher doses, the parasympathetic
pathway (Chu 1994). The resulting symptoms can range from tachycardia, palpitations, tachypnea
or dyspnea, hypotension to acute myocardial infarction. Usually the effects of betel nut use are
mild and transient. However, acute betel nut toxicity and subsequent death has been reported
(Deng et al. 2001).

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 45

 Bronchoconstriction and aggravation of asthma have been demonstrated in betel nut chewers
(Kiyingi 1991; Kiyingi & Saweri 1994). The authors of the paper recommend that asthma sufferers
avoid using betel nut.

The long-term use of betel nut on respiratory and cardiovascular health remains unclear. Singh (1994)
warns against betel nut chewing before the administration of a general anesthetic.

The detrimental effect of tobacco on cardiovascular and respiratory health is well documented
(IARC Monograph Vol. 37 1985, NIH, 1992). A recent meta-analysis of cardiovascular disease
(CVD) in Taiwan concluded there is an association between betel nut chewing with or without
tobacco and the risk of CVD and betel nut use may even impose a greater risk of CVD than smoking
(Zhang et al. 2010).

The development of a betel nut habit also may increase the use of tobacco and thereby increase its
adverse effects on cardiovascular and respiratory health.

Adverse pregnancy outcomes

Acute and chronic fetal exposure to betel nut has been associated with placental abnormalities,
spontaneous abortion, lower birth weight of infants and preterm birth (Yang et al. 2001).
These occurrences are further exacerbated by the use of tobacco with betel nut during pregnancy
(WHO 1999). Animal studies have shown prenatal betel nut exposure can produce tetragenic effects
(Sinha et al. 2001).

In a study on the effect of maternal betel quid exposure during pregnancy on birth outcomes among
aborigines in Taiwan, Yang et al. (2008) reported that betel quid chewing during pregnancy has a
substantial effect on a number of birth outcomes, including sex ratio at birth (fewer males born), lower
birth weight and reduced birth length (Yang et al. 2008).

Senn et al. (2009) in a study of betel nut chewing among pregnant women of Madang Province,
Papua New Guinea, reported betel nut chewing had a statistically significant impact on birth weight
reduction. The main reasons for pregnant women chewing betel nut were reported as a means of
preventing morning sickness and preventing a foul-smelling mouth. Fully 80% of the women thought
that chewing betel nut would not have any effect on the fetus (Senn et al. 2009).

Dependency, addiction and withdrawal

Chronic daily use of betel nut has been demonstrated across many cultures (Gupta et al. 2002).
Frequent heavy users often experience withdrawal symptoms, which may include anxiety,
mood swings, irritability, paranoia, lack of concentration, sleep disturbance and increased appetite
(ADF 2006). Evidence of the development of tolerance to betel nut and betel quid has been shown
(Winstock et al. 2000), with the effects of betel nut use being stronger for first-time or occasional users
than for habitual users.

Burton-Bradley (1966) identified three syndromes associated with frequent betel nut use -- habituation,
addiction and toxic psychosis. Using tobacco with betel nut significantly increases its addictiveness.
In one Indian study, dependence on betel nut was demonstrated in 38.8% of those who used betel nut
alone as opposed to 79.6% who used it with tobacco (Velayudhan et al. 1999). Ysaol et al. (1996) also
reported heavier usage of betel nut among tobacco users in Palau. Winstock et al. (2000) reported
that typical dependency symptoms in users of betel quid with tobacco included difficulty abstaining,
lethargy, headache and sweating on withdrawal. Symptoms were relieved by partaking of betel quid
and continual sequential use, analogous to chain-smoking.

Some studies have reported cases of neonatal withdrawal syndrome in infants born to chronic betel
nut users and arecoline, the principal neuroactive alkaloid in betel nuts, has been found in the placental
tissue (Garcia-Agar et al. 2005; López-Vilchez et al. 2006).

46 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

Mental illness

Burton-Bradley (1966) reported that the use of betel nut may be associated with acute, reversible
toxic psychosis with subsequent auditory hallucinations and delusions. This was a rare occurrence
found in susceptible people. Errington (1970) reported that people of the Duke of York Islands in
Papua New Guinea used particular nuts to promote visions and spiritual access.

Sullivan et al. (2000) reviewed schizophrenia patients in Palau and reported a beneficial effect on the
primary symptoms of schizophrenia in people who chewed betel nut. They suggested the benefits
were caused both by the muscarinic agonist actions of the arecoline along with some social functions
of betel nut chewing.

Diabetes and glucose intolerance

The use of betel nut has been linked to the development of hyperglycemia and diabetes mellitus, both
experimentally in the laboratory (Boucher et al. 1994) and in human case studies (Tung et al. 2004):
“This association is dose-dependent with respect to the duration of betel nut use and the quantity of
betel nut chewed per day”. Mannon et al. (2000) demonstrated an association between chewing betel
nut and increased waist size and weight, factors known to be related to the development of glucose
intolerance and diabetes. Paulino (2009) found betel nut chewers in Guam were 5.7 times more likely
to be obese than nonchewers (Paulino 2009).

Using betel nut may further exacerbate complications due to diabetes. Tseng (2008) reported betel
nut chewing was significantly associated with hypertension in Taiwanese patients with type 2 diabetes
mellitus, and the association was stronger in women (Tseng 2008).

Hsin-Fen et al. (2010) demonstrated the first in vitro evidence of a betel-quid-induced change in
fat cell metabolism that could help explain the mechanism by which betel nut chewing could cause
metabolic syndrome disorders.

A further study suggested that exposure to paternal betel quid chewing also increased the risk of
early-onset metabolic syndrome in human offspring in a dose-dependent manner (Chen et al. 2006).

The association between betel nut use and diabetes mellitus is particularly relevant to many Pacific
island communities already struggling to cope with the growing burden of diabetes. There is a
misconception by some users of herbal medicine that betel nut use is a treatment for diabetes (Benjamin
2001; and Dennie Iniakwala, pers. comm.), rather than a causal agent or associative factor.

Benjamin (2001) concluded, after reviewing the literature and conducting a community screening in
Papua New Guinea that betel nut chewers have high fasting capillary blood glucose and diabetics
should therefore be advised not to chew betel nut. Tobacco, whether chewed or smoked, also has
been implicated in the development of, and increased severity of, complications in diabetes mellitus
(Kawakami et al. 1997; Persson et al. 2000). Concurrent use of both betel nut and tobacco could
significantly increase an individual’s risk of developing diabetes mellitus.

Communicable diseases

Concern has been expressed that the frequent expectoration of excess saliva caused by chewing betel
quid poses an environmental health hazard (Emi Chutaro, pers. comm.; Divi Ogaoga, pers. comm.).
Saliva may contain bacterial and viral matter, thereby providing a vehicle for disease transmission.

Tuberculosis, a bacterial infection transmitted by inhalation of infected particles, is prevalent in many

Pacific island communities (WHO 2006). The control of spitting and coughing in infected people is
advised to minimize the possibility of disease transmission. The spitting of excess saliva as a result
of betel nut chewing may provide a significant vehicle for infection in countries with a high prevalence
of betel nut use and tuberculosis infection.

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 47

 Sputum receptacles, which frequent chewers of betel nut may carry with them or leave lying around,
may contain viable viral particles of hepatitis B or C.

Oral lesions associated with betel nut can provide an infection pathway for blood borne diseases.

Dietary effects

The use of betel nut affects the diet in three main ways. Firstly, the ingredients contained within the
betel nut chew supply some dietary nutrients. Weegels et al. (1994) reported betel nut contains a
negligible amount of protein and energy, which could play a role in the diet of consumers of very high
quantities of betel nut. P. betle leaf contains large amounts of carotenes (80.5mg/g) and some vitamin
C (1.9mg/g), (Wang & Wu 1996) Inclusion of the leaves in the betel quid may be an important source
of carotenes if the leaves are swallowed.

Secondly, the physiological effects of betel nut use may affect the consumption and absorption
of nutrients consumed as part of the regular diet. Finally, betel nut and the associated betel quid
ingredients may be bought in preference to nutritious food.

How significant these factors are in affecting an individual’s overall diet will depend on many variables,
including the general basic diet, level of addiction to betel nut, relative price of betel nut and associated
products and frequency of use.

48 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

References
Aghi, M.B., Gupta, P.C., Mehta, F.S., Pindborg, J.J. 1992 ‘An intervention study of tobacco habits
among rural Indian villagers’, In: Smokeless Tobacco or Health – An International Perspective.
USA Smoking and Tobacco Control Monograph 2. NIH Publication No. 92-3461, pp.307-312

Alependava, C. 1991 ‘Betel nut’, Proceedings from the First Pacific Workshop on Tobacco and
Cancer,’ ed. Stanton, pp. 80-84

Allen, M., Price, L., Fieldsend, A., Liberman, J., Driskell, S., 2005 ‘Tobacco and alcohol in the
Pacific Island Countries Trade Agreement: impacts on population health’, Secretariat on the
Pacific Community, Noumea

Australian Drug Foundation 2006 ‘Betelnut: The effects of chewing areca nut and betel quids’,
DRugInfo Clearinghouse, http://druginfo.adf.org.au/article_print.asp?ContentID=betelnut
(accessed 20 September 2006).

American Clinical Health Practice Research (ACHPR) 1998 ‘Best practice guidelines for smoking
cessation’ US Department of Health and Welfare, Washington DC.

Anonymous (1994). 1993-1994 CMNI teen behavioral risk survey. Saipan, CNMI: CMNI Public
School System and Dept. of Health Services.

Anon. 2003 ‘Betelnut: Mama’on’, <http://ns.gov.gu/pugua.html>, (accessed 20 June 2006)

Artero, V.T., Santos, V.M. Date ‘Betel-Nut Palm Care’ Guam Cooperative Extension, University
of Guam. http://www.hawaii.edu/hivandaids/Betel-Nut%20Palm%20Care.pdf (accessed 12
June 2006)

Atkinson, L., Chester I.C., Smyth, F.G., Ten Seldam R.E. 1964, ‘Oral cancer in New Guinea: a
study in demography and etiology’. Cancer, Vol. 17, pp.1289 1298.

Axell, T., Kramer, I.H.R., Pindborg, J.J., Shear, M. 1984 ‘International seminar on oral leukoplakia
and associated lesions related to tobacco habits’, Community Dentistry and Oral Epidemiology,
Vol.12, pp.145-154

Backhouse, R.C. 1955 ‘Malignant tumours of Melanesia’, Medical Journal of Australia, Vol.2, pp.
139-141

Bailit HL, Ogan E, Leigh R. 1968, ‘Oral Health of the Nasioi of Bougainville’, Australian Dental
Journal; Vol.13, pp.353 359.

Barton, M., Kricker, W., Kron, T., Smylie, J., Tattersall, M. 2001 ‘The Hidden Burden. Cancer in
Papua New Guinea’. Report for the Australian Agency for International Development (Papua
New Guinea Health Services Support Program), Liverpool, NSW: IDP Education Australia,
GRM International PTY Ltd, Jane Thomason and Associates

Benjamin A.L. 2001 ‘Community screening for diabetes in the National Capital District, PNG:
is betelnut chewing a risk factor for diabetes?’, Papua New Guinea Medical Journal, Vol. 44,
No.3-4, pp. 101-107

Bergstrom, J.1989 ‘Cigarette smoking as a risk factor in chronic periodontal disease’, Community
dentistry and Oral Epidemiology, Vol. 17, pp. 245-247

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 49

 Betelnut Bisnis 2004, Ronin Films, Australian Capital Territories, producer Chirs Owen
(documentary film)

Bhandary, S., Bhandary, P. 2003 ‘Cancer of the oral cavity – a growing concern in the Micronesia:
a case report from the Marshall Islands’, Pacific Health Dialogue, Vol.10, No.1, pp. 76-78

Boucher BJ, Ewen SW, Stowers JM. 1994 ‘Betel nut (Areca catechu) consumption and the
induction of glucose intolerance in adult CD1 mice and in their F1 and F2 offspring’ [see
comments]. Diabetologia, Vol.37, pp.49-55.

Brady, M.2001 ‘Historical and Cultural Roots of Tobacco Use among Aboriginal and Torres Strait
Islander People’, Australian and New Zealand Journal of Public Health, Vol.26, No.2, pp.120–
124

British Dental Association 2000 ‘Opportunistic oral cancer screening’ British Dental Association,
occasional paper No.6, April

Brott, K. 1981 ‘Tobacco smoking in Papua New Guinea’. Papua New Guinea Medical Journal,
Vol. 24, pp. 229-236.

Brunton, R. 1989 ‘The Abandoned Narcotic’, Cambridge University Press. The Bath Press,
Avon

Burton Bradley, B.G.1966, ‘Papua and New Guinea transcultural psychiatry: Some implications
of betel chewing’, Medical Journal of Australia; Vol.2, pp.744 746.

Burton-Bradley, B.G. 1978 ‘Betel chewing in retrospect’ Papua New Guinea Medical Journal,
Vol.21, pp. 236-41

Burton-Bradley, B.G. 1979 ‘Arecaidism: betel chewing in trans-cultural perspective’ Canadian

Journal of Psychiatry, Vol. 24, pp. 481-488

Burton-Bradley, B.G., 1980, ‘Psychosomatics of arecaidism’ Papua New Guinea Medical Journal,
Vol. 23, pp.3-7

Cabrera, F.T. 2005 ‘Factors associated with the use of tobacco in betel nut chewing on Saipan,
Commonwealth of the Northern Mariana Islands’, (unpublished)

Carpenter, J.M., Syms, M.J., Sniezek, J.C. 2005 ‘Oral carcinoma associated with betel nut
chewing in the Pacific: an impending crisis’, Pacific Health Dialogue, Vol. 12, No.1, pp. 158-
162

Caven, R.D., McKillop, R.F. 2000 ‘Improving Agricultural Services in Papua New Guinea’, in
Food Security for Papua New Guinea Eds: R.M. Bourke, M.G. Allen and J.G. Salisbury,
Proceedings of the Papua New Guinea Food and Nutrition 2000 Conference, PNG University
of Technology, Lae, 26–30 June

Cawte J. 1985 ‘Psychoactive substances of the South Seas: betel, kava and pituri’, Australian
New Zealand Journal of Psychiatry,Vol.19, pp.83-87.

Chapman, S. 1998, ‘Smokefree workplace policies and declines in tobacco consumption in

Australia and the United States’, Australian Journal of Public Health, Vol.29, pp.345–348.

50 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

 Chen, T.H., Chiu, Y.H., Boucher, B.J. 2006 ‘Transgenerational effects of betel-quid chewing on
the development of the metabolic syndrome in the Keelung Community-based Integrated
Screening Program’, American Journal of Clinical Nutrition, Vol.83, No.3, pp.688-692

Chen, T-H, Ou, A.C., Haberle, H., Miller, V.P., Langidrik, J.R., Palafox, N.A. 2004 ‘Smoking rates
and risk factors among youth in the Republic of the Marshall Islands: results of a school
survey’, Pacific Health Dialogue, Vol.11, No.2, pp.107-113

Choudhury, S.N.S. 1980 ‘Betel nut syndrome – a rare cause of bronchospasm following general
anaesthesia’, Bangladesh Medical Journal, Vol. 9, pp.84-88

Chu NS. 1993 ‘Cardiovascular responses to betel chewing’, Journal of the Formosan Medical
Association, Vol.92, pp.835-837.

Chu NS. 1994 ‘Sympathetic skin responses to betel chewing’, Journal of the Formosan Medical
Association, Vol.93, pp.260-262.

Chu NS. 1994 ‘Effects of betel chewing on electroencephalographic activity: spectral analysis
and topographic mapping’, Journal of the Formosan Medical Association; Vol.93, pp.167-
169.

Chu NS. 1994 ‘Effect of betel chewing on performance reaction time’, Journal of the Formosan
Medical Association, Vol.93, pp.343-345.

Chu NS. 1995 ‘Effect of betel chewing on RR interval variation’ Journal of the Formosan Medical
Association,Vol.94, pp.106-110.

Chu N.S.1995.’Sympathetic response to betel chewing’ Journal of Psychoactive Drugs,Vol.27,

pp.183-186.

Chu, N-S. 2001 ‘Effects of betel chewing on the central and autonomic nervous systems’, Journal
of Biomedical Science, Vol.8, pp. 229-236

Coates, M., Armstrong, B., 2000 Cancer incidence in New South Wales incidence and mortality
in 1997 New South Wales, Cancer Council Sydney

Collins,V.R.,Dowse, G.K. 1996 ‘Smoking prevalence in the Pacific’, Pacific Health Dialogue,
Vol.3 No.1, pp.87-95

Corsi, A. 2004 ‘An Exploratory Study of Food and Nutritional Beliefs and Practices in Pohnpei,
Federated States of Micronesia’, A thesis submitted to the Department of International Health
Rollins, School of Public Health Emory University B.A., University of Colorado http://www.
islandfood.org/publications/al_thesis.pdf, (accessed 2 December 2006)

Country Profiles 2000 ‘Tobacco or Health’ Tobacco-Free InitiativeWestern Pacific Region, www.
wpro.who.int/interne./country+profiles+2000.pdf

Croucher, R. & Islam, S. 2002 ‘Socio-economic aspects of areca nut use’ Addiction Biology, Vol.
7, No1, pp.139 – 146.

Cutress, T.W., Tapealava, N.M. 1996 ‘Oral conditions among Tongan children and adults, 1966
and 1986’, Pacific Health Dialogue, Vol.3, pp. 8-13

Cutress, T.W. 2003 ‘Periodontal health in South Pacific populations: A review’, Pacific Health
Dialogue, Vol.10, No.1, pp.68-75

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 51

 Daftary, D.K., Bhonsle, R.B., Murti, R.B., Pindborg, J.J., Mehta, F.S., 1980 ‘An oral lichen planus-
like lesion in Indian betel-toabcco chewers’, Scandinavian Journal of Dental Research, Vol.88,
pp. 244-9

Davies G. N. 1990 ‘The future of the dental services in Papua New Guinea: A Draft Report: Port
Moresby: Department of Health

de Costa C, Griew AR. 1982 ‘Effects of betel chewing on pregnancy outcome’, Australian New
Zealand Journal of Obstetrics and Gynaecology, Vol.22, pp.22-24.

Deahl M. 1989 ‘Betel nut-induced extrapyramidal syndrome: an unusual drug interaction’,

Movement Disorders, Vol.4, pps.330-332.

Deng, F-J, Ger, J., Tsai, W-J., Kao, W-F., Yang, C-C. 2001 ‘Acute toxicities of betel nut: Rare but
probably overlooked events’, Clinical Toxicology, Vol.30, No.4, pp.355-360

Dobbin, J. 1996 ‘Drugs in Micronesia’, Micronesian Counseler, Series 2, No. 1 Micronesian

Seminar, FSM

Downer, M.C., Petti, S. (2005) ‘Leukoplakia prevalence estimate lower than expected.What is
the global prevalence of leukoplakia?’ Evidence-Based Dentistry. Vol.6, pp.12–14.

Dowse GK. 1994 ‘Betel-nut chewing and diabetes in Papua New Guinea and elsewhere’ [letter;
comment]. Diabetologia, Vol.37, pp.1062-1064.

Eisen MJ. 1946 ‘Betel chewing among natives of the southwest Pacific islands. Lack of
carcinogenic action’, Cancer Research, Vol.6, pp. 39 141.

Errington, F.C. 1970 ‘The eyes of the Tubuam: a study in the Symbols of social relations’, Ph.D.
dissertation, Cornell University, New York

Farnworth ER. 1976. ‘Betel nut: it’s composition, chemistry and uses’, Science in New Guinea,
Vol.4, No.2, pp.85 90.

Farnworth ER. 1975 ‘Areca catechu and Pi per betel in Papua New Guinea: an elemental
analysis’, Science in New Guinea; Vol. 3, pp. 211 214.

Farago C. 1963 ‘Review of 110 cases of cancer of the oral cavity in Papua New Guinea’, British
Medical Journal, Vol.1, pp.1264 1266.

Federated States of Micronesia (Pohnpei) 2008 NCD Risk Factors STEPS Report, Suva, Fiji,

Federated States of Micronesia GYTS 2007

Forastiere, A., Koch, W., Trotti, A., Sidransky, D. 2001 ‘Head and k cancer’, New England Journal
of Medicine, Vol.345, pp.1890-1900
Forlen H.P., Hornatein, O., Stuttgen, G. 1965 ‘Betel quid and leukoplakia’, Archiv für klinische
und experimentelle Dermatologie, Vol.220, pp.463-480 (in German)

Freeman, P. 2001 ‘The current tobacco situation in Papua New Guinea’, Development Bulletin,
Vol.54; April: pp. 72-75

Frewer, L.V. 1990 ‘The effect of betel nut on human performance.’ Papua New Guinea Medical
Journal, Vol. 33, pp. 143-145.

52 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

 Futterman, A., Lyman, A. 1998 ‘Palau Substance Abuse Needs Assessment (SANA). Koror:
Palau Ministry of Health

Garcia-Algar, O., Vall, O., Alameda, F., Puig, C., Pellegrini, M., Pacifici, R., Pichini, S. 2005
‘Prenatal exposure to arecoline (areca nut alkaloid) and birth outcomes’, Archives Disease
Child Fetal Neonatal Education, Vol.90, pp.276-277

Gerry RG, Smith ST, Calton, ML. 1952 ‘The oral characteristics of Guamanians including the
effects of betel chewing on the oral tissues’, Oral Surgery, Oral Medicine, Oral Pathology;
Vol.5, pp.762 781, 884 894,1004 1011

Gilmour, J.S.L. 1931 ‘The Species of Tobacco Grown in New Guinea’ Anthropological Report,
No. 11.Port Moresby: Government Printer, Territory of Papua.

Gibson, J. 1998 ‘Urban demand for food, beverages, betelnut and tobacco in Papua New Guinea’,
Papua New Guinea Journal of Agriculture, Forestry and Fisheries, Vol.41, No.2, pp.37-42

Gowda, M.1951 ‘The Story of Pan Chewing in India’, Botanical Museum Leaflets, 14,8, Harvard
University, pp. 181-214.

Guam State Epidemiological Working Group 2006 ‘Strategic prevention framework: State
Incentive Grant(SPF-SIG) Guam Substance Abuse Epidemiological

Gupta PC. 1984 ‘A study of dose-response relationship between tobacco habits and oral
leukoplakia’ British Journal of Cancer, Vol.50, pp.527-531.

Gupta PC. 1991 ‘Betel quid and oral cancer: prospects for prevention’, IARC.Sci.Publ. pp.466-
470.

Gupta, P.C., Murti, P.R., Bhonsole, R.B., Mehta, F.S., Pindborg, J.J. 1995 ‘Effect of cessation of
tobacco use on the incidence of oral mucosal lesions in a 10 year follow-up study of 12, 212
individuals users’, Oral Disease, Vol. 1 pp. 54-58

Gupta PC, Mehta FS, Daftary DK, Pindborg JJ, Bhonsle RB, Jalnawalla PN, Sinor PN, Pitkar
VK, Murti PR, Irani RR, Shah HT, Kadam PN, Iyer KSS, Iyer HM, Hegde AK, Chandrashekar
GK, Shroff BC, Sahiar BE, Mehta MN. 1980 ‘Incidence rates of oral cancer and natural history
of oral precancerous lesions in a 10 year follow up study of Indian villagers’, Community
Dentistry and Oral Epidemiology; Vol.8, pp.287 333.

Gupta PC, Pindborg J.J., Bhonsole R.B., Murti, P.R., Mehta, F.S., Aghi, M.B.1990 ‘ A primary
prevention study of oral cancer among Indian villagers. Eight year follow-up results. In Hakama,
Beral, V., Cullen, J.W., Parkin, D.M. eds. Evaluation effectiveness of primary prevention of
cancer. Lyon: International Agency for Research on Cancer IARC Monograph No 103: pp.
149-156

Gupta PC, Pindborg JJ, Mehta FS. 1982 ‘Comparison of carcinogenicity of betel quid with and
without tobacco: an epidemiological review’, Ecology of Disease, Vol.1, pp.213-219.

Gupta, P.C., Ray, C.S. 2004 ‘Epidemiology of betel quid usuage’, Annals Academy of Medicine
Singapore, Vol.33(suppl), No.4, pp. S31- S36

Gupta, P.C. & Warnakulasuriya, S. 2002. ‘Global epidemiology of areca nut usage’, Addiction
Biology, Vol. 7, No.1. pp.77 - 84

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 53

 Haddock, R.L., Hoffman, J.H., and Williams, W.R. 1981 ‘Betel Nut Chewing on Guam’, Fiji
Medical Journal, August/September, pp. 139-149

Haddock, R. 2005 ‘Oral cancer incidence disparity among ethnic groups on Guam’, Pacific
Health Dialogue, Vol.12, No. 1, pp. 153-154

Haddon, A.C. 1931 ‘Tobacco in New Guinea. American Anthropologist, 33: 657-659’ Cited by
Marshall M.1987 ‘An overview of drugs in Oceania’. In Drugs in Western Pacific Societies:
Relations of substance, (Association for Social Anthropology in Oceania Monograph no. 11),
ed. L. Lindstrom, Lanham, MD: University Press of America

Hammond, D., Fong, G.T., McDonald, P.W., Brown, K.S., Cameron, R. 2004 ‘Graphic Canadian
Cigarette Warning Labels and Adverse Outcomes: Evidence from Canadian Smokers’,
American Journal of Public Health Vol. 94, No. 8, pp.1442-1445

Hamner, J.E. 1986 ‘Aetiology and epidemiology of oral cancer’, in: Cancer and the Oral Cavity,
ed. L.W. Carr and K.Sako, Chicago, Quintessence, pp.17-30

Hashibe, M., Mathew, B., Kuruvilla, B., Thomas, G., Sankaranarayanan, R., Parkin, D.M., Zhang
Z-F. 2000 ‘Chewing tobacco, alcohol, and the risk of erythroplakia’, Cancer Epidemiology
Biomarking and Prevention, Vol. 9, pp. 639-645

Hays, T. E.1991 ‘No Tobacco, No Hallelujah’: Missions and the Early History of Tobacco in
Eastern Papua. Pacific Studies 14(4):91–112.

Hay,T.E. 2003 ‘They Are Beginning to Learn the Use of Tobacco. Cultural Context and the Creation
of a Passion in Colonial Papua New Guinea’ In Drugs, Labor, and Colonial Expansion, eds. W.
Jankowiak and D. Bradburd, pp. 59–71, University of Arizona Press, Tucson.

Henderson BE, Aitken GH. Cancer in Papua New Guinea.1979 National Cancer Institute
Monograph, Vol. 53, 67 72 .

Hiawalyer, G. 2002, ‘Smoking prevalence among young people in Papua New Guinea’, Pacific
Health Dialogue, Vol.9, No.2 pp.209-213

Hirsch, E.1990 ‘From Bones to Betelnuts: Processes of Ritual Transformation and the Development
of ‘National Culture in Papua New Guinea’, Man, New Series, Vol. 25, No. 1, pp. 18-34

Ho, C-S., Gee, M-J, 2002 ‘The Parental Influence of Betel-Chewing Behavior Among Junior High
School Students in Taiwan’ Substance Abuse, Vol. 23, No.3, pp.183-189

Howden, G.F. 1984 ‘The cariostatic effect of betel nut chewing’, Papua New Guinea Medical
Journal, Vol.27, pp.123-131.

Hsin-Fen Hsu, Tsui-Chun Tso, How-Ran Chao, Cherng-Gueih Shy, Ya-Ting Kuo, Feng-Yuan Tsai,
Szu-Ching Yeh and Ying-Chin Ko., 2010,’ Effects of arecoline on adipogenesis, lipolysis, and
glucose uptake of adipocytes—A possible role of betel-quid chewing in metabolic syndrome’,
Toxicology and Applied Pharmacology, Volume 245, Issue 3, pp. 370-377

IARC 1985a Monographs on the evaluation of the Carcinogenic Risk to Humans, Vol. 37,
Tobacco Habits Other Than Smoking; Betel-Quid and Areca-nut chewing; and some Related
Nitrosaminess, Lyon, IARC Press

IARC (2004) Monographs on the Evaluation of Carcinogenic Risks to Humans, Vol. 85, Betel-
quid and Areca-nut chewing and Some Areca-nut-derived Nitrosamines, Lyon, IARC Press

54 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

 Ichiho, H.M., Wong, V., Hedson, J., David, W.J.2004 ‘Cancer in Pohnpei State, Federated States
of Micronesia’ Pacific Health Dialogue, Vol.11, No.2, pp.44-49

Jamrozik, K. 1985 ‘Regional variation of oral cancer in Papua New Guinea’. Papua New Guinea
Medical Journal, Vol. 28, pp. 9-13

Jarvis, G.K., Wood, D.W., Bachtold, J. 1993 ‘Betel nut users in Guam’, International Centre for
Health Promotion and Disease Prevention Research, School of Public Health, University of
Hawaii, June

Jayant K, Deo MG. 1986 Oral cancer and cultural practices in relation to betel quid and tobacco
chewing and smoking. Cancer Detection and Prevention, Vol.9, pp.207-213.

Jensen GD, Polloi AH. 1988 ‘The very old of Palau: health and mental state’, Age and Ageing;
Vol.17, pp.220-226.

Johnson, F. Y. 1994 ‘Clinical Observations on Substance Abuse Related Health Problems at the
Port Moresby General Hospital, National Capital District, Papua New Guinea’, Medical Law
Vol.13, No.3-4: 251-62.

Johnson, F. Y. A. 1990 ‘An Epidemiological Survey of Alcohol and Drug Abuse in the National
Capital District of Papua New Guinea’, Medical Law Vol. 9, No2, pp. 797-830.

Johnson, F. Y. A. (1998). ‘A Study of Substance Abuse on Two Campuses of University of Papua

New Guinea’, Med Law Vol.17, pp. 229-241.

Kanandru, K. 1991 ‘Papua New Guinea: The accomplishment to date report’ Proceedings from
the First Pacific Workshop on Tobacco and Cancer,’ ed. H. Stanton, pp. 80-84

Kaushal, M, Mishra,AK, Raju,B.S., Ihsan,R., Chakraborty,A., Sharma,J., Zomawia,E., Verma,Y.,

Kataki,A., Kapur,S., Saxena,S., 2010 ‘Betel quid chewing as an environmental risk factor
for breast cancer’, Mutation Research/Genetic Toxicology and Environmental Mutagenesis,
doi:10.1016/j.mrgentox.2010.08.011

Kawakami, N., Takatsuka, N., Shimizu, H., Ishibashi, H. 1997 ‘Effects of smoking on incidence
of non-insulin-dependent diabetes mellitus: replication and extension in a Japanese cohort of
male employees’, American Journal of Epidemiology, Vol.145, pp.103–109

Zhang, L, Yang, Y-M, Xu, Z-R, Gui, Q-F., HU,Q-q 2010 ‘Chewing substances with or without
tobacco and risk of cardiovascular disease in Asia: a meta-analysis’, Biomedicine &
Biotechnology, Vol. 11(9,), pp.681-689

Khawaja, MI et al. 2005 ‘ Preventing the oral cavity cancer epidemic’ Asian Pacific Journal of
Cancer Prevention, Vol. 6, No.3, pp. 420

Kiyingi, K.S., Saweri, 1990 , ‘Betel nut and asthma’, in Abtracts and Proceedings of the
Twenty-sixth Annual Symposium of the Medical Society of Papua New Guinea, Goroka, 6-8
September.

Kiyingi KS.,1991. ‘Betel-nut chewing may aggravate asthma’, Papua New Guinea Medical
Journal; Vol. 34, pp.117-121.

Kiyingi, K.S., Saweri A.1994 ‘Betelnut chewing causes bronchoconstriction in some asthma
patients’, Papua New Guinea Medical Journal, Vol.37, No.2, pp. 90-99

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 55

 Knauft, B.1987 ‘Managing Sex and Anger: Tobacco and Kava Use among the Gebusi of Papua
New Guinea’. In Drugs in Western Pacific Societies: Relations of Substance, ed L. Lindstrom,.
pp. 73–98. ASAO Monograph No. 11. Lanham, MD: University Press of America.

Ko YC, Chiang TA, Chang SJ, Hsieh SF. 1992 ‘Prevalence of betel quid chewing habit in Taiwan
and related sociodemographic factors’, Journal of Oral Pathology and Medicine; Vol.21,
pp.261-264.

Lebot, V., Merlin, M., Lindstrom, L.1992. Kava: The Pacific drug. New Haven, Yale University
Press, pp.25-26, 54-55, 141.

Lee CH, Lin RH, Liu SH, Lin-Shiau SY1996. Mutual interactions among ingredients of betel quid
in inducing genotoxicity on Chinese hamster ovary cells. Mutation Research;367:99-104.

Lee, C.H., Ko, Y.C., Huang, H.L., Chao, Y.Y., Tsai,C.C., Sheih, T.Y., Lin, L.M.2003 ‘The precancer
risk of betel quid chewing, tobacco use and alcohol consumption in oral leukoplakia and oral
submucous fibrosis in southern Taiwan’, British Journal of Cancer, Vol.88, pp.366-372.

Lee, H. 1990 The health effects of kava/sakau and betel nut. Western Regional Centre for Drug-
Free Schools and Communities, Portland, Northwest Regional Educational Laboratory.

Lee, P.H., Chang, M.C., et al. 2006 ‘Prolonged exposure to arecoline arrested human KB
epithelial cell growth: Regulatory mechanisms of cell cycle and apoptosis’, Toxicology, March
15: Vol. 220 (2-3), pp. 81-9

Lee Jie-Min, 2007 ‘The synergistic effect of cigarette taxes on the consumption of cigarettes,
alcohol and betel nuts’, BMC Public Health, Vol.7, Iss. 1, pp.121

Lepowsky M. 1982 ‘A comparison of alcohol and betel nut use on Vanatinai (Sudest Island)’In
Marshall M (Ed) Through a Glass Darkly: Beer and Modernization in Papua New Guinea.
Monograph 18, Institute of Applied Social and Econe Research, Boroko, Papua New Guinea.

Leung, C. 1995 ‘The Problem of tobacco in the Pacific’, prepared for Western Pacific Regional
Office of the World Health Organization, for the Pacific Regional Tobacco Conference, Saipan,
CNMI, July 5-7

Lopez-Vilchez MA, Seidel V, Farre M, Garcia-Algar O, Pichini S, Mur A.2006 ‘Areca-nut abuse
and neonatal withdrawal syndrome’ Pediatrics,Vol.117, pp. 129-131.

Lumukana, R. & King, T. 2003, ‘Smoking and Chewing Habits of Oral Cancer Patients in the
Solomon Islands’, Pacific Health Dialogue, Vol. 10, No.1, pp. 41-44

Lyman, A. 2001 ‘Tobacco use prevention and control activities in the Republic of Palau’
Development Bulletin, Vol. pps.54-55

MacLennan R, Paissat D, Ring A, Thomas S.,1985 ‘Possible aetiology of oral cancer in Papua
New Guinea,’ Papua New Guinea Medical Journal, Vol. 28, pp.3-8.

MacLennan, R. Thomas, S.J., Battistutta, D., Paissat, D. 1991 ‘Oral Cancer in Papua New
Guinea. Project Report’ unpublished

McDonald, D. 1999 ‘Rapid Situation Assessment of drug abuse in Papua New Guinea, 1998’,
Papua New Guinea National Narcotics Bureau, Papua New Guinea

56 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

 Mahoney D, Quinn N, Afenya P, Hugman S, Sappu M. 1985.The technology and economics of
slaked lime manufacture for betel nut mastication in Papua New Guinea. Proceedings of the
Papua New Guinea Institute of Chemistry Congress 1985. University of Papua New Guinea,
Port Morsby

Mannon, N., Boucher, B.J., Evans, S.J. 2000 ‘Increased waist size and consumption of Areca
catechu (betel-nut); a risk factor for increased glycaemia in Asians in east London’, British
Journal of Nutrition, Vol. 83, pp. 267 -275

Marshall LB. 1985 ‘Substance use in pregnancy among two groups of urban women in Papua
New Guinea’, Papua New Guinea Medical Journal; Vol.28, pp.195-204.

Marshall, M. 1987 ‘An overview of drugs in Oceania’, in: Drugs in Western Pacific societies:
Relations of substance, ed. L. Lindstrom (Association for Social Anthropology in Oceania
Monograph no. 11), Lanham, MD: University Press of America

Marshall, M. 1990 ‘Combining insights from epidemiological and ethnographic data to investigate
substance use in Truk, Federated States of Micronesia’, British Journal of Addiction, 85, 1457-
1468.

Marshall, M. 1991 ‘Beverage alcohol and other psychoactive substance use by young people
in Chuuk, Federated States of Micronesia (Eastern Caroline Islands)’ Contemporary Drug
Problems, 18, 331-371.

Marshall, M. (1993b). ‘A Pacific haze’, In: Contemporary Pacific societies: studies in development
and change, eds. V. S. Lockwood, T. G. Harding, & B. J. Wallace., (pp. 260-272). Englewood
Cliffs, NJ: Prentice Hall.

Marshall M. 1997 ‘Tobacco prevention in FSM’, Drug Alcohol Review, Dec. 16(4), pps. 411-9

Marshall, M. 2005 ‘Carolina in the Carolines: a survey of patterns and meanings of smoking on
a Micronesian Island’, Medical Anthropology Quarterly, Vol. 19, No. 4, pp. 365-382

Martin C. 1990. ‘Cancer on the increase in Papua New Guinea: The failure of Preventive
measures’. Papua New Guinea Medical Journal; Vol.33, pps.85-87.

Martin, W.M.C., Sengupta, S.K. et al 1992 ‘The Spectrum of Cancer in Papua New Guinea – An
analysis Based on the cancer registry 1979 – 1988’, Cancer, Vol.70(12) pp.2942-2950

Martin, W.M.C. 1990 ‘Cancer on the increase in Papua New Guinea: the failure of preventive
measures, Papua New Guinea Medical Journal, Vol. 33, pps. 85-87

Mathew, B., Sankaranarayanan,R., Wesley, R., Nair, M.K. ‘Evaluation of mouth self-examination
in the control of oral cancer’, British Journal of Cancer, Vol.71, No.2, pp.397-399

Mehta, F.S., Gupta, P.C., Daftary, D.K., Pindborg, J.J., Choksi, S.K., 1972 ‘An epidemiologic
study of oral cancer and precancerous conditions among 101, 761 villagers in Maharashtra,
India’, International Journal of Cancer, Vol.10, pps. 134-141

Mokuau, N. (Ed.). 1998 Responding to Pacific Islanders: Culturally Competent Perspectives for
Substance Abuse and Prevention. Washington, DC: US Department of Health and Human
Services (DHHS Publication No. SMA 98-3195).

Moller, I.J., Pindborg, J.J., Effendi I. 1977 ‘The relation between betel chewing and dental caries’,
Scandinavian Journal of Dental Research; Vol.85, pps. 64-70.

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 57

 Murti, P.R., Bhonsole R.B, Pindborg J.J, Daftary, D.K., Gupta PC, Mehta, F.S., 1985 ‘Malignant
transformation rate in oral submucous fibrosis over a 17-year period’, Community Dentistry
and Oral Epidemiology, Vol. 13, pp. 340-341

Nair J, Ohshima H, Friesen M, Croisy A, Bhide SV, Bartsch H. Tobacco-specific and betel nut-
specific N-nitroso compounds: occurrence in saliva and urine of betel quid chewers and
formation in vitro by nitrosation of betel quid. Carcinogenesis 1985;6:295-303.

Norton, S.A. 1998 ‘Betel: Consumption and consequences’ Journal of the American Academy of
Dermatology, Vol. 38, No.1 pp 81- 87

Newell, P. 2002, ‘Huli oral health’, Papua New Guinea Medical Journal, Vol. 45 (1-2), pps. 63-
79

Nigam, P. Srivastava, A.B. 1990 ‘Betel chewing and dental decay’, Federation of Operative
Dentistry, Vol.1, pp.36-38.

Oakley, E., Demaine, L. Warnakulassuriya, S. 2005 ‘ Areca (betel nut) chewing habit among
high-school children in the Commonwealth of the Northern Mariana Islands (Micronesia)’,
Bulletin of the WHO, Vol. 83 (9), pp.656-659

Orr, I.M. 1933 ‘Oral cancer in betel nut chewers in Travancore; its aetiology, pathology and
treatment’, Lancet; 2:575 580.

Pacific Regional Central Cancer Registry (PRCCR), 2008, http://pacificcancer.org/Cancer/

CaResources/PRCCR/

Palafox, N.A., Yamada, S. Ou, A.C., Minami, J.S., Johnson, D.B. Katz, A.R., 2004 ‘Cancer in
Micronesia’ Pacific Health Dialogue, Vol. 11, No.2, pp. 78-83

Palau Ministry of Health 2005 ‘Oral health in Palau – Disease Burden and Plan’, Ministry of
Health, Bureau of Public Health, Oral Division http://palaugov.net/minhealth/publichealth/
divoralhlth/oralhlthdoc/ohbrdndocplan.pdf, (accessed 21 August 2006)

Parkin, M.D., Bray, F., Ferlay, J., Pisani, P., 2005 ‘Global Cancer Statistics, 2002’, CA A Cancer
Journal for Clinicains, Vol. 55, pp.74-108

Persson, P.G., Carlsson, S. Svanström, L., Östenson, C.G., Efendic, S.V., 2000 ‘Cigarette
smoking, oral moist snuff use and glucose intolerance’, Journal of Internal Medicine, Vol. 248,
No.2, pp.103

Petrucelli, L. 1991 ‘Betel mania’, Islands Vol.11, pp. 25-26

Petersen, P.E. 2003 ‘Global Framework Convention on Tobacco Control: The Implications for
Oral Health’ Community Dental Health, Vol. 20, pp.137-138

Phongsavan, P., Olatunbosun-Alakija, A., Havea, D., Bauman, A., Smith, B.J., Galea, G., Chen, J.
2005 ‘Health behaviour and lifestyle of Pacific youth surveys: a resource for capacity building’,
Health Promotion International, Vol.20, No.3, pp.238-248.

Pickwell, S.M., Williams, S.A., Curzon, M.E., 1994 ‘Betelmania. Betel quid chewing by Cambodian
women in the United States and its potential health effects’, Western Journal of Medicine,
Vol.160, pp. 326-30

58 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

 Pietrusewsky M, Douglas MT, Ikehara-Quebral RM. 1997 ‘An assessment of health and disease in
the prehistoric inhabitants of the Mariana Islands’, American Journal of Physical Anthropology,
Vol.104:315-342.

Pindborg JJ, Barmes D, Roed Peterson B. 1968 ‘Epidemiology and histology of oral leukoplakia
and leukoedema among Papuans and New Guineans’ Cancer, Vol.22, pps.379 384.

Pindborg JJ, Kiaer J, Gupta PC, Chawla TN. ‘Studies in oral leukoplakias. Prevalence of
leukoplakia among 10 000 persons in Lucknow, India with special reference to use of tobacco
and betel nut’ Bull Wld Hlth Org 1967; 37:109 116.

Pindborg JJ, Mehta FS, Daftary DK. 1970. ‘Occurrence of epithelial atypia in 51 Indian villagers
with oral submucous fibrosis’, British Journal of Cancer; Vol.24, pps.253 257.

Pindborg JJ, Zheng KH, Kong CR, Lin FX. 1984 ‘Pilot survey of oral mucosa in areca (betel) nut
chewers on Hainan Island of the People’s Republic of China’, Community Denistry and Oral
Epidemiology,Vol.12,pps.195-196.

Pinhey, T.K., Workman, R.L., Borja, J.P. 1992 ‘Women’s use of betel nut, alcohol and tobacco on
Guam’. Journal of Micronesian Studies, Vol.1, pps. 413-423.

Radway, S. 2004 ‘The Cuban cigar of Micronesia? Yap’s betel nut fuels entrepreneurial spirit’ in:
Pacific Magazin,e http://www.pacificmagazine.net/pm52004/pmdefault.php?urlarticleid=0004,
(accessed 24 July 2006)

Rajendran, R., 1994 ‘Oral submucous fibrosis: etiology, pathogenesis, and future research’
Bulletin of the World Health Organization, Vol. 72 no.6 pp. 831-1016

Rajkumar, T., Franceschi, S., Vaccarella, S., Gajalakshmi,V., Sharmila, A., Snijders,P.J.F., Munoz,
N., Meijer, C>J.L.M., Herrero, R.,2003 ‘Role of paan chewing and dietary habits in cervical
cancinoma in Chennai, India’, British Journal of Cancer, Vol.88 pp. 1388-1393

Reed, D. 1977 ‘Current status of cancer studies in the South Pacific’, National Cancer Institute
Monograph, 47: pp.61-66

Riesenfeld A. 1956 ‘Tobacco in New Guinea and the other areas of Melanesia’. Royal
Anthropological Journal; 81:69

Rooban T, Joshua,E., Rooban, A., Govind,G.K. 2005 ‘Health hazards of chewing arecanut
and products containing arecanut’, Calicut Medical Journal, Vol.3, No.2 <http://www.
calicutmedicaljournal.org/2005/3/2/e3/index.htm> (Accessed 8 August 2006).

Rothman K, Keller A. 1972 ‘The effect of joint exposure to alcohol and tobacco on risk of cancer
of the mouth and pharynx’. Journal of Chronic Disease, Vol. 25, pp. 711 716.

Republic of Marshall Islands 2007 NCD Risk Factors STEPS Report, Suva, Fiji,

Sankaranarayanan, R. 1997 ‘Health care auxiliaries in the detection and prevention of oral
cancer’, Oral Oncology, Vol.33, No.3 pp.149-154

Scrimgeour EM, Jolley D.1983 ‘Trends in tobacco consumption and incidences of associated
neoplasms in Papua New Guinea’, British Medical Journal, Vol.286, pps.1414 1416.

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 59

 Senn,M., Baiwog,F., Winmai,J, Mueller,I., Rogerson, S., Senn,N., 2009, ‘Betel nut chewing
during pregnancy, Madang province, Papua New Guinea’, Drug and Alcohol Dependence,
Volume 105, Issues 1-2, pp. 126-131

Shah, N., Sharma, P.R. 1998 ‘Role of chewing and smoking habits in the etiology of oral
submucous fibrosis (OSF): a case-controlled study’, Journal of Oral Pathology and Medicine,
Vol27, pps.475-479

Silverman, j., Griffiths, M., 1972 ‘Smoking characteristics of patients with oral carcinoma and the
risk for a second oral primary carcinoma’ Journal of the American Dental Association, Vol.85,
pp.637-640

Silverman S, Bhargava K, Mani NJ, Smith LW, Malaowalla AM. 1976 ‘Malignant transformation
and natural history of oral leukoplakia in 57 518 industrial workers of Gujarat, India’, Cancer;
Vol.38, pp.1790 1795

Sinha, A., Rao, A.R. 2001 ‘Embryotoxicity of betel nuts in mice’, Toxicology, Vol.37, pp.315-326

Sinor, P.N., Gupta, P.c., Murti, P.R., Bhonsle, R.B., Daftary, D.K., Mehta, F.S., Pindborg, J.J.,
1990 ‘A case controlled study of oral submucous fibrosis with special reference to the etiologic
role of areca nut’, Journal of Oral Pathology and Medicine, Vol.19, No.2, pp.94-98

Singh, B., Dua, R., Chabra, B., Dua, M. 1994 ‘A ‘peep’ before sleep’, Middle East Journal of
Anaesthesiology, Vol. 12, pp. 493-495

Solomon Islands 2010 NCD Risk Factors STEPS Report, Suva, Fiji,

SPC Pin http://www.spc.int/Lifestyle/Resources/PIN%2057%20web.doc

Stanton, H. 2001 ‘The social and economic impacts of tobacco in Asia and the Pacific’,
Development Bulletin, Vol.54, pp.55-58

Stich HF, Brunnemann KD, Mathew B, Sankaranaryanan R, Nair MK. 1989 ‘Chemopreventive
trials with vitamin A and beta-carotene: some unresolved issues’, Preventative Medicine;
Vol.18, pp.732-739.

Strickland, S.S. 2002 ‘Anthropological perspectives on use of the areca nut’ Addiction Biology,
Vol. 7, No. 1, pp. 85-98

Sullivan, R.J., Allen, J.S., Otto, C., Tiobech, J., Nero, K. 2000 ‘Effects of chewing betel nut
(Areca catechu) on the symptoms of people with schizophrenia in Palau, Micronesia’, British
Journal of Psychiatry, Vol. 177, pp. 174-178

Talonu, N.T. 1989 ‘Observations on Betel-Nut Use, Habituation, Addiction and Carcinogenesis in
Papua New Guinea’, Papua New Guinea Medical Journal, Vol. 32, pp.195 –197

Talonu, T. 1982 ‘“Buai” addiction’, Paper presented at the Medical Society of Papua New Guinea,
Eighteenth Symposium

Taoka, S., Hancock, T., Ngaden, V., Yow, A.R., Durand, A.M. 2004 ‘Cancer in Yap State, Federated
States of Micronesia’, Pacific Health Dialogue, Vol.11, No.2, pp. 50-56

Taufa T. 1988 Betel-nut chewing and pregnancy. Papua New Guinea Medical Journal; Vol. 31,
pp.229-233.

60 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

 Taylor, R, Parker, M. et al. 1983 ‘Cancer in Solomon Islands 1970-1982’ Papua New Guinea
Medical Journal, Vol.26, No.2, pp. 102-110

Taylor RF, al-Jarad N, John LM, Conroy DM, Barnes NC. 1992 ‘Betel-nut chewing and asthma’,
Lancet, May 9 Vol.339 (8802), pp. 1134-1136

Thomas, S.J. 1993 ‘Studies of the aetiology of oral neoplasia in Papua New Guinea’, University
of Queensland, Faculty of Medicine.

Thomas, S., Brennan, J., Martel, G., Frazer, I., Montesano, R., Sidransky, D., Hollstein, M. (1994)
Mutations in the conserved regions of p53 are infrequent in betel-associated oral cancers from
Papua New Guinea’, Cancer Research, Vol. 54, No.13, pp. 3588-3593,

Thomas, S.J., MacLennan, R. 1992 ‘Slaked lime and betel nut cancer in Papua New Guinea’,
Lancet, Vol.340, pp 577

Thomas, S.J., Bain, C., Battistutta, D., Ness, A.R., Paissat, D., MacLennan, R.L.(2007) ‘Betel
quid not containing tobacco and oral cancer: a report on a case-control study in Papua New
Guinea and a metaanalysis of current evidence’, International Journal of Cancer 120:1318-
1323. PMID:17163423

Thomas SJ, MacLennan R, Olszowy H, Hegarty J. Variation in oral cancer and in the composition
of lime in Papua New Guinea (unpublished)

Trivedy, C.R., Craig, G., Warnakulasuriya, S. ‘The oral health consequences of chewing areca
nut’, Addiction Biology, Vol. 7, (1), pp. 115-126

Tsai, J.F., Chuang, L.Y., Jeng, J.E., Ho, M.S., Hsieh, M.Y., Lin, Z.Y. 2001 ‘Betel quid chewing
as a risk factor for hepatocellular carcinoma: A case-control study’, British Journal of Cancer,
Vol.84, pp. 709-713

Tseng Chin-Hsiao, 2008 ‘Betel Nut Chewing Is Associated with Hypertension in Taiwanese Type
2 Diabetic Patients’, Hypertension Research Vol.31, pp.417–42

Tung, T.H., Chiu, Y.H., Chen, L.S., Wu, H.M., Boucher, B.J., Chen, T.H.; 2004 ‘A population-
based study of the association between areca nut chewing and type 2 diabetes mellitus in
men (Keelung Community-based Integrated Screening programme No. 2)’, Diabetologia,
Vol.47, No.10, pp.1776-1781

UNICEF 2001 ‘The State of Health Behaviour and Lifestyle of Pacific Youth, Pohnpei State,
Federated States of Micronesia’, Report’ UNICEF Pacific. Suva, Fiji.

US Department of Health and Human Services 1992 Monograph 2‘Smokeless Tobacco or

Health: An International Perspective’, National Institute of Health September 1992

US Department of Agriculture, Animal and Plant Health Inspection Service

U.S. Public Law 99-239, The Compact Act of Free Association http://www.fm/jcn/compact/introfr.
html, (accessed 20 November 2006).

Vallace, P.J.T., Anderson, H.R. Alpers, M.P. 1987 ‘ Smoking habits in a rural community of Paua
New Guinea in 1970 and 1984’, Papua New Guinea Medical Journal, Vol:30, pp. 277-280

Van der Waal I, Axell T. 2002 ‘Oral leukoplakia: a proposal for uniform reporting’, Oral Oncology,
Vol.38, pp.521–526

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 61

 Van McCrary, S., 1998 ‘The Betel Nut: An emerging public health threat? Health Law and
Policy Institute, www.law.uh.edu/heaalthlawperspectives/HealthPolicy/980908Betel.html,
09/08/1998

Velayudhan, A., Kumar, S., Benegal, V. 1999 ‘Betel Nut: A socially sanctioned drug of abuse’,
National Institute of Mental Health and Neurosciences, Bangalore, http://www.nimhans.kar.
nic.in/deaddiction/lit/Betel%20Nut-Socially%20Sanctioned%20Drug.pdf (accessed 20 July
2006)

Vele, A. 1982 ‘Cash economy from betel nut’ Medical Society of Papua New Guinea, Eighteenth
Symposium.

Wang, C-K., Wu, M-J. 1996 ‘The separation of phenolics from Piper betle leaf and the effect on
the mutagenicity of arecoline’, Journal of Chinese Agriculture and Chemistry Society, Vol.34,
pp.623-632 (in Chinese)

Wang S.C., Tsai C.C., Huang S.T. Hong Y.J.2004 ‘Betel nut chewing: the prevalence and the
intergenerational effect of parental behavior on adolescent students’, Journal of Adolescent
Health. Mar;34(3):244-9.

Warnakulasuriya, S. 2002 ‘Areca nut use following migration and its consequences’ Addiction
Biology, Vol. 7, No. 1, pp. 127-132

Waterhouse J, Muir C, Shanmugaratnam K, Powell J, (Ed). Cancer Incidence in Five Continents,

Volume IV. IARC Scientific Publications No 42, International Agency for Research on Cancer,
Lyon, 1982.

Watson, P. 1991 ‘Does abundant supply of drugs lead to heavy consumption? A Papua New
Guinea case study’, Drugtext

Watson, P.1987 ‘An overview of drugs in Oceania’, in: Drugs in Western Pacific societies:
Relations of substance, ed. L. Lindstrom (Association for Social Anthropology in Oceania
Monograph no. 11), Lanham, MD: University Press of America, Chp 5

Weegels P, Heywood P, Jenkins C. 1984 ‘Consumption of betel nut and its possible contribution
to protein and energy intakes’, Papua.New Guinea Medical Journal, Vol.27, pp.37-39.

Warnakulasuriya, S. 2002 ‘Areca nut use following migration and its consequences’ Addiction
Biology, Vol. 7, No. 1, pp. 127-132

Wells, C.R., 1925 ‘Betel nut chewing and its effects’, US Navy Medical Bulletin, Vol.22 pp. 437

Winstock, A. 2002 ‘Areca nut-abuse liability, dependence and public health’ Addiction Biology,
Vol. 7, (1), pp. 133-138

Workman, R.L. 2001 ‘Tobacco use among Pacific Islanders: risk-behavior surveys and data sets
for the study of smoking behavior in Guam’, Asian American Pacific Islander Health, Vol.9(1),
pps. 15-24

World Health Organization 1978 Declaration of Alma-Ata, in: Primary health care –
Geneva,WHO,p79

World Health Organization 1980 Guide to epidemiology and diagnosis of oral mucosal diseases
and conditions. Community Dentistry and Oral Epidemiology, Vol. 8, pps1 26.

62 Review of Areca (Betel) Nut and Tobacco Use in the Pacific

 World Health Organization 1995 ‘Healthy Islands’, The Yanuca Island Declaration on Health,
Conference of Ministers of Health for the Pacific Islands (Suva and Yanuca Island1995),
Manila,WHOWPRO,pp.51-65

World Health Organization 1998 Manual on the prevention and control of common cancers (20),
WHO Regional Publication, Western Pacific Series

World Health Organization 1999 ‘International Consultation on Environmental Tobacco Smoke

(ETS) and child health’ Tobacco Free Initiative, 11-14 January, Geneva, <http://www.who.int/
tobacco/research/en/ets_report.pdf> (accessed 16 November 2006)

World Health Organization 2003 The Crete Declaration on Oral Cancer Prevention
<http://www.who.int/oral_health/events/crete_declaration_05/en/> (accessed 20 June 2006)

World Health Organization 2003 Tonga Commitment to Promote Healthy Lifestyles and
Supportive Environment, <http://www.wpro.who.int/NR/rdonlyres/21E2A8CB-3321-426E-
B2DA-4C568F4C65CB/0/TongaEnglish2.pdf>, (accessed 20 November 2006)

World Health Organization Global Oral Health Programme, <http://www.who.int/oral_health/

objectives/en/index.html> (accessed 20 June 2006)

World Health Organization 2006 ‘Tuberculosis control in the Western Pacific Region: 2006
Report’, WHO Regional Office for the Western Pacific, Manila, <http://www.wpro.who.int/
publications/pub_9290612193.htm> (accessed 20 November 2006)

World Health Organization Stepwise approach to chronic disease risk factor surveillance (STEPS)
<http://www.who.int/chp/steps/riskfactor/en/index.html> (Accessed 9 September 2006)

World Health Organization 2005 ‘Best Practices in Tobacco Control. Cambodia’s experience with
smoke-free Buddhist Monks and WATS. http://www.wpro.who.int/NR/rdonlyres/B07E573D-
8249-4833-9E4F-567585B07E21/0/BestPracticesforSFMonksproject.pdf

World Health Organization 2003 WHO Framework Convention on Tobacco Control. http://www.
who.int/fctc/en/

Yang, M.S., Chung, T.C., Yang, M.U., Hsu, T-Y, Ko, Y.C.2001 ‘Betel quid chewing and risk of
adverse birth outcomes among aborigines in eastern Taiwan’, Journal of Toxicology and
Environmental Health, Vol.64, pp.465-72

Youth Risk Behavioural Survey, www.cdc.gov/nmwr/PDF/ss/ss5712.pdf#

Ysaol, Y., Chilton, J.I., Callahan, P. 1996 ‘A survey of betel nut chewing in Palau’, Journal of
Micronesian Studies, Vol.4, pps. 244-255.

Zain, R.B. 2000, ‘Cultural and dietary risk factors of oral cancer and precancer – a brief overview’,
Oral Oncology, Vol 37 pp. 205-210

Zhang, L., Yang,Y-m, XU,Z-r., Qi-feng GUI,Q-f., Hu, Q-q. 2010 ‘Chewing substances with or
without tobacco and risk of cardiovascular disease in Asia: a meta-analysis’, University Science
B (Biomedicine & Biotechnology), Vol.11(9) pp. 681-689

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 63

64 Review of Areca (Betel) Nut and Tobacco Use in the Pacific
Acknowledgements
This report was prepared by Dr Donna Kennedy Langly in collaboration with the Tobacco Free Initiative unit of the
WHO Regional Office for the Western Pacific. The review of this report and the development of recommendations
were done through key informant interviews conducted in 2006 and during the Meeting on Control of Betel Nut
and Tobacco Chewing held in Manila, Philippines in August 2010. In this regard, we recognize the outstanding
contributions of the following:

RESPONDENTS TO KEY INFORMANT INTERVIEWS

Republic of Marshall Islands
Dr Ohnmar Tut
Preventive Services Dentist, Ministry of Health
Ms Emi Chutaro, Communication Officer, HIV/AIDS and STI Section, Secretariat of the Pacific Community

Federated States of Micronesia

Dr Marcus Samo, Assistant Secretary of Health
Dr Kino S. Ruben, Epinet Focal Point; Cancer Program Coordinator; Chief of Primary Health Care (Chuuk)
Dr Mark Durand, Director Health Services (Yap)

Commonwealth of Northern Mariana Islands

Ms Louise Oakley, Public Health Registered Dietician
Dr Alberto B. Ventura, Clinical Superviso for the Community Health Centre Dental Services

Nauru
Ms Maree Bacigalupo, Secretary for Health and Medical Services

Niue
Ms Karen Fukofuka, Nutrition Adviser, HPL Section, Secretariat of the Pacific Community

Republic of Palau
Mr Tino Faatuala, Nutritionist
Ms Valerie N. Remengesau Whipps, Palau Tobacco Control Program Manager
Mrs Joanne Sengebau-Kingzio, Environmental Health
Mrs Henrietta Merei, TB Control Program Manager

Papua New Guinea

Paul Aia, TB Control Program
Mr Charles Semwakesa, Technical Services Manager, National Youth Commission

Solomon Islands
Dr Lorraine Oti Maekera, Director of Dental Services
Ms Jillian Tutuo-Wate, Nutritionist
Dr Divi Ogaogo, Undersecretary for Health Improvement
Dr Dennie Iniakwala, HIV and STI Section Head, Secretariat of the Pacific Community

Tonga
Dr Viliami Puloka, Physical Activity Adviser, HPL Section, Secretariat of the Pacific Community

United States of America

Mr Michael S. O’Mallan, Environmental Health Specialist, Guam
Ms Marie B. Luarca, Secretary, Department of Public Health and Social Services, Guam
Mr Ken Agustin, Administrative Assistant, Department of Public Health and Social Services, Guam
Ms Joann Diego, Administrative Officer, Department of Public Health and Social Services, Guam
Dr Mark Greer, Hawaii

Review of Areca (Betel) Nut and Tobacco Use in the Pacific 65

 PARTICIPANTS OF THE MEETING ON CONTROL OF BETEL NUT AND TOBACCO CHEWING
NATIONAL FOCAL PERSONS

Cambodia
Dr Khun Sokrin, National Center for Health Promotion

Guam
Dr Annette M. David

Kiribati
Mr Kireata Ruteru, Ministry of Health and Medical Services

Republic of Marshall Islands

Mr Russell Edwards, Ministry of Health

Federated States of Micronesia

Mrs Shra Alik, Department of Health and Social Affairs

Commonwealth of Northern Mariana Islands

Ms Joanne C. Ogo, Department of Public Health

Republic of Palau
Mr Roman B. Oseked, Sr., Tobacco Use Prevention and Control Program, Ministry of Health

Solomon Islands
Mr Albino Lovi, Ministry of Health

Vanuatu
Mr Jean-Jacques Alberick Rory, Ministry of Health

TEMPORARY ADVISERS
Dr Prakash Gupta, Healis - Sekhsaria Institute for Public Health, India
Ms Annabel Lyman, Framework Convention Alliance (FCA), Republic of Palau
Dr Yvette C. Paulino, University of Guam

PARTICIPANTS OF THE
SECRETARIAT MEETING ON CONTROL OF
BETEL NUT AND TOBACCO
Dr Susan Mercado, WHO Regional Office for the Western Pacific
CHEWING
Mr James Rarick, WHO Regional Office for the Western Pacific
Dr Ali Akbar, WHO Regional Office for the Western Pacific
Dr Yel Daravuth, WHO Cambodia
Mr Kia Henry Nema, WHO Papua New Guinea
Dr Li Dan, WHO South Pacific
Mr Raj Shalvindra, WHO South Pacific

66 Review of Areca (Betel) Nut and Tobacco Use in the Pacific