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Defining a global research and policy agenda for betel quid and areca nut
Abstract
Betel quid and areca nut are known risk factors for many oral and oesophageal cancers, and their use is highly prevalent in the Asia-Pacific region. Additionally, betel quid and areca nut are associated with health effects on the cardiovascular, nervous, gastrointestinal, metabolic, respiratory, and reproductive systems. Unlike tobacco, for which the WHO Framework Convention on Tobacco Control provides evidence-based policies for reducing tobacco use, no global policy exists for the control of betel quid and areca nut use. Multidisciplinary research is needed to address this neglected global public health emergency and to mobilise efforts to control betel quid and areca nut use. In addition, future research is needed to advance our understanding of the basic biology, mechanisms, and epidemiology of betel quid and areca nut use, to advance possible prevention and cessation programmes for betel quid and areca nut users, and to design evidence-based screening and early diagnosis programmes to address the growing burden of cancers that are associated with use.
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“The major risk factors for oral cancers are tobacco, alcohol and areca nut (betel quid).[25][26][27]”
From Oral diseases: a global public health challenge (2019) · cites this paper as [27]
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“Tobacco smoking, alcohol consumption, and betel quid use are risk factors causing an increase in mortality rates due to OSCC [2].”
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“Betel quid is widely consumed in Asia and the Pacific and is probably the fourth most widely used psychoactive substance after caffeine, alcohol, and tobacco (Arora & Squier, 2019; Gupta & Warnakulasuriya, 2002; Mehrtash et al., 2017).”
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“The practice of AN chewing is especially prevalent in the Asia-Pacific regions of the world, including (but not limited to) India, Pakistan, Myanmar, Sri Lanka, Taiwan, Cambodia, and Malaysia (Auluck et al. 2009; Mehrtash et al. 2017).”
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“In particular, the National Cancer Institute has portrayed that health consequences of AN use remain an under-recognized public health issue in their policy review (Mehrtash et al., 2017).”
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“…implications for policy as unlike tobacco, for which the WHO Framework Convention on Tobacco Control (FCTC) provides evidencebased measures for reducing use, no global or national policy exists for the control of betel quid and areca nut use at the national or global level (Mehrtash et al., 2017).”
BackgroundA Review of Intervention Strategies for Areca Nut Use Cessation
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Aging and head and neck cancer insights from single cell and spatial transcriptomic analyses
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Guerrero, R. T. L., Palafox, N. A., Hattori-Uchima, M., Robinett, H. R., & Vogel, C. (2020) · JCO Global Oncology · doi:10.1200/go.19.00213 · Cited by 12
Wang, W. (2025) · Ecotoxicology and Environmental Safety · doi:10.1016/j.ecoenv.2025.118108 · Cited by 11
Caffeic Acid Phenethyl Ester and Caffeamide Derivatives Suppress Oral Squamous Cell Carcinoma Cells
Shih, Y.-H., Chen, C.-C., Kuo, Y., Fuh, L., Lan, W.-C., Wang, T., Chiu, K., Nguyen, T.-H. V., Hsia, S., & Shieh, T. (2023) · International Journal of Molecular Sciences · doi:10.3390/ijms24129819 · Cited by 11
Asghar, W., Akhtar, A., Rahman, H. U. U., Sami, A., & Khalid, N. (2022) · World Food Policy · doi:10.1002/wfp2.12056 · Cited by 10
Spatiotemporal Evolution and Impact Mechanisms of Areca Palm Plantations in China (1987–2022)
Wang, C., Yin, Z., Luo, R., Qian, J., Fu, C., Wang, Y., Xie, Y. J., Liu, Z., Qiu, Z., & Pei, H. (2024) · Forests · doi:10.3390/f15101679 · Cited by 10
Tissue-specific and maturity-dependent distribution of pyridine alkaloids in Areca triandra
Wu, J., Zhang, H., Wang, S., Yuan, L., Grünhofer, P., Schreiber, L., & Wan, Y. (2019) · Journal of Plant Research · doi:10.1007/s10265-019-01115-9 · Cited by 11
A Discourse Analysis on Betel Nut Chewing in Hunan Province, China
Tang, Q., & He, L. (2020) · Journal of Psychoactive Drugs · doi:10.1080/02791072.2020.1740362 · Cited by 10
“Mehrtash et al. (2017) pointed out the side effects of betel quid and areca nut on oral and esophageal cancers.”
BackgroundPrevalence and Correlates of Betel Quid Chewing among Bhutanese Adults
Wangdi, K., & Jamtsho, T. (2020) · Substance Use & Misuse · doi:10.1080/10826084.2019.1673416 · Cited by 10
“Regular chewing of betel quid is very prevalent in the Asia-Pacific region (Gupta and Warnakulasuriya, 2002; Mehrtash et al., 2017; Pratt, 2015; Tovosia et al., 2007).”
BackgroundReview of the toxic effects and health functions of arecoline on multiple organ systems
Liu, H., Zheng, H., Zhang, J., Chen, F., Hu, X., & Wang, X. (2024) · Food Innovation and Advances · doi:10.48130/fia-0024-0005 · Cited by 9
Overlap in oncogenic and pro-inflammatory pathways associated with areca nut and nicotine exposure
Garg, K., Kumar, A., Kizhakkethil, V., Kumar, P., & Singh, S. (2023) · Cancer Pathogenesis and Therapy · doi:10.1016/j.cpt.2023.09.003 · Cited by 9
Lu, Y., Yu, J., Liu, W., Jing, G., Li, W., & Liu, W. (2022) · Journal of Separation Science · doi:10.1002/jssc.202200361 · Cited by 9
Su, S. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph192114329 · Cited by 9
“For all subjects (containing unexposed and exposed subjects together) at a particular age and period, the oral cancer mortality rate r can be directly calculated by the total number of oral cancer deaths and total number of people, and it is also a mixture of r00, r01, r10, and r01, that is, r = r00 × P00 + r01 × P01…”
MethodInfluentialLuo, Z., Zhu, X., Hu, Y., Yan, S., & Chen, L. (2022) · Frontiers in Oncology · doi:10.3389/fonc.2022.920452 · Cited by 8
“Studies were included if they (1) were prospective cohort, case–control, or cross-sectional studies; (2) investigated the association between DII and risk of oral cancer; (3) reported estimates of the hazard ratio (HR), relative risk (RR), or odds ratio (OR) with their 95% confidence intervals (Cis) or sufficient info…”
Addressing oral cancer inequalities: a multifaceted approach to equitable healthcare
Jerjes, W. (2024) · BDJ · doi:10.1038/s41415-024-8118-9 · Cited by 8
Betel quid use is associated with anemia among both men and women in Matlab, Bangladesh
Sznajder, K. K., Shenk, M. K., Alam, N., Raqib, R., Kumar, A., Haque, F., Blumenfield, T., Mattison, S. M., & Wander, K. (2023) · PLOS Global Public Health · doi:10.1371/journal.pgph.0001677 · Cited by 9
Wei, G., Xu, J. M. S., Zhang, Z., Zhang, G., Chen, S., & Dong, L. (2023) · Frontiers in Microbiology · doi:10.3389/fmicb.2023.1188986 · Cited by 8
“Betel-quid and areca-nut chewing is widely prevalent in Chinese Taipei and Southeast Asia, and it has been the fourth most common habit after tobacco, alcohol, and caffeine-containing beverages (Lin et al., 2020).”
BackgroundInfluentialSaraswat, N., Pillay, R., Prabhu, N. T., Everett, B., & George, A. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph182111111 · Cited by 8
“It is usual for medical curricula to reflect current health trends and challenges in the country, but in light of increasing immigration from India [32] and reports of areca (betel) nut use becoming popular in Australia [28,29,60], it is important that medical students in Australia should be made aware of these new ca…”
BackgroundBetel Nut Chewing Is Associated with the Risk of Kidney Stone Disease
Chang, C.-K., Lee, J., Chang, C., Lee, Y., Jhan, J., Wang, H.-S., Shen, J.-T., Tsao, Y.-H., Huang, S., & Geng, J. (2022) · Journal of Personalized Medicine · doi:10.3390/jpm12020126 · Cited by 8
“Unfortunately, despite the adverse effects of betel nut, there is a lack of global policy to control the use of betel nuts [44].”
BackgroundChen, S., Yang, X., Huang, L., Xie, Y., Li, Y., & Lin, Y. (2025) · World Journal of Surgical Oncology · doi:10.1186/s12957-025-03933-9 · Cited by 8
“Consequently, betel nuts and tobacco were classified as Group 1 carcinogens by the International Agency for Research on Cancer (IARC) in 2004 and 2007, respectively [43, 44].”
Exposure assessment to areca alkaloids in the Chinese populations through areca nut chewing
Ji, M., Zhang, L., Bao, H.-H., Chen, H., Yu, W., Hu, X.-S., Chen, F., & Zhu, Y. (2024) · Journal of Food Science and Technology · doi:10.1007/s13197-024-05966-6 · Cited by 7
“Slaked lime could increase the enjoyment and excitement of chewing areca nuts by enhancing the conversion of alkaloid esters to areca alkaloids and promoting the absorption of areca alkaloids by the oral mucosa (Mehrtash et al. 2017).”
Noggle, B., Cheng, H. G., & Sarkar, M. A. (2024) · JMIR Cancer · doi:10.2196/51936 · Cited by 7
“Tobacco, alcohol, and areca nut (betel quid) use are among the leading causes of oral cancer [6].”
Areca catechu L. (Chikni Supari): A Review Based Upon its Ayurvedic and Pharmacological Properties
Grover, M. (2021) · The Journal of Phytopharmacology · doi:10.31254/phyto.2021.10510 · Cited by 7
Jana, B. K., Singh, M., Dutta, R. S., & Mazumder, B. (2022) · Current Drug Delivery · doi:10.2174/1567201820666221128152010 · Cited by 7
Areca nut use among adolescents: How do we prevent and control this problem?
Chatterjee, N., & Gupte, H. (2023) · Journal of Global Health · doi:10.7189/jogh.13.03022 · Cited by 7
Itaki, R., & Taufa, S. (2024) · Tropical Medicine & International Health · doi:10.1111/tmi.13988 · Cited by 10
“While public health interventions have primarily focused on countering betel quid chewing in view of the increased risk for oral cancer [12], current policies and health promotion strategies overlook the emerging link to adverse cardiovascular outcomes.”
Background
Metadata
- Authors
- Mehrtash, H., Duncan, K., Parascandola, M., David, A., Gritz, E. R., Gupta, P. C., Mehrotra, R., Amer Nordin, A. S., Pearlman, P. C., Warnakulasuriya, S., Wen, C.-P., Zain, R. B., & Trimble, E. L.
- Affiliations
- National Institutes of Health (US)
- The University of Texas MD Anderson Cancer Center (US)
- Healis Sekhsaria Institute For Public Health (IN)
- National Institute of Cancer Prevention and Research (IN)
- King's College London (GB)
- National Health Research Institutes (TW)
- University of Malaya (MY)
- Corresponding author
- Mehrtash, Hedieh
- ORCID
- Venue
- The Lancet Oncology
- Publisher
- Elsevier BV
- Published
- 2017-12
- Volume
- 18
- Issue
- 12
- Pages
- e767-e775
- ISSN
- 1470-2045 (ISSN-L)
- OpenAlex
- W2773997905
- Cited by
- 221
- References
- 71
- Citations by year
- 2026: 20 · 2025: 27 · 2024: 22 · 2023: 27 · 2022: 43 · 2021: 22 · 2020: 39 · 2019: 13 · 2018: 7
- FWCI
- 2.26
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Lancet Oncology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Dentistry › General Dentistry › Oral Health Pathology and Treatment
- Health Sciences › Medicine › Otorhinolaryngology › Head and Neck Cancer Studies
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Global Public Health Policies and Epidemiology
- Keywords
- betel quid, areca nut, oral cancer, esophageal cancer, oral submucous fibrosis, oral leukoplakia, oral cancer screening, early diagnosis, prevention programmes, health policy, Asia-Pacific region, tobacco control
- MeSH terms
- Areca, Asia, Esophageal Neoplasms, Female, Humans, Male, Mouth Neoplasms, Policy Making, Research Design, Smoking, Global Health, Practice Guidelines as Topic, Early Detection of Cancer
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