Cited by 221Oral Health Pathology and TreatmentHead and Neck Cancer StudiesGlobal Public Health Policies and Epidemiology

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Defining a global research and policy agenda for betel quid and areca nut

Mehrtash, Hedieh, Duncan, Kalina, Parascandola, Mark, David, Annette, Gritz, Ellen R, Gupta, Prakash C, Mehrotra, Ravi, Amer Nordin, Amer Siddiq, Pearlman, Paul C, Warnakulasuriya, Saman, Wen, Chi-Pang, Zain, Rosnah Binti, Trimble, Edward L·2017·The Lancet Oncology

DOI 10.1016/s1470-2045(17)30460-6

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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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Background
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“Impulsivity was regarded as one risk factor for the development and maintenance of substance misuse problems, especially in alcohol (Lejuez et al., 2010; Ming et al., 2017), nicotine (Joos et al., 2013), and methamphetamine dependency (Simons and Carey, 2002).”
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Tseng, M.-F., Tsai, S. C., Wu, C.-Y., Lin, C., & Wong, R. (2021) · Substance Use & Misuse · doi:10.1080/10826084.2021.1892141 · Cited by 5
“Globally, approximately 10% to 20% of the population chew betel quid (Garg et al., 2014; Lo et al., 2016; Mehrtash et al., 2017).”
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Using Diet to Treat Diseases of Esophagus
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“It is noteworthy that some countries with high prevalence of betel quid use, such as India and Taiwan, have acted to reduce betel quid and smokeless tobacco use prevalence through product bans and taxes (Lin et al., 2017; Mehrtash et al., 2017).”
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The Past, Present and Future of Literature Pertaining to Betel (Areca) Nut: A Citation Analysis
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“However, no global standard policy controls the use of betel nuts (Mehrtash et al., 2017).”
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“To our knowledge, gastrointestinal mucosal lesions caused by ingestion of betel nut are common and typically accompanied by mucosal fibrosis or even cancer [1].”
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“include the risk of oral potentially malignant disorders and oral cancer.(10) Additionally, long-term BQD can also lead to changes in the nervous system,(11) resulting in decreased memory performance.”
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“In Taiwan and other countries, counselling based cessation programs for SBQ are rare, 13 result in improved health education about SBQ chewing, rarely have long term follow up and have small impact on quitting of chewing.”
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Background
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Large-scale structural covariance networks changes relate to executive function deficit in betel quid-dependent chewers
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“21 31 For example, the WHO MPOWER framework for tobacco control includes pictorial warnings on cigarette packaging, which effectively communicates the health risks associated with tobacco use and has demonstrated efficacy in reducing initiation and promoting cessation.”
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“Tobacco use (both smoked and smokeless), areca nut, betel quid, alcohol, and human papillomavirus (HPV) infection are considered to be the most well-studied risk factors for all types of HNC, but more specifically for oral and oropharyngeal cancers [4-6].”
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Microbiome evaluation revealed salivary dysbiosis in addicts of betel nut preparationsPreprint
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Oral cancer risk among people who smoke, have quit smoking, use smokeless tobacco, or former smokers that use smokeless tobacco observed from state-based cancer registriesPreprint
Noggle, B., Cheng, H., & Sarkar, M. A. (2023) · Research Square · doi:10.21203/rs.3.rs-2802108/v1 · Cited by 1
Prevalence of betel or areca nut (AN) use and its associated factors among Bhutanese population aged 15-69 years old : an analysis of national health data of non-communicable disease (NCD) survey in 2019
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“There are substantial evidence to associate the health effects of areca nut use on the “cardiovascular, gastrointestinal, metabolic, respiratory and reproductive system” (Mehrtash et al., 2017) including the aggravation of preexisting conditions such as “cardiac arrhythmias, asthma, central obesity, type II diabetes,…”
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Impact of habitual betel quid chewing on cardiovascular risk and outcomes: a systematic reviewPreprint
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Glittering potentially malignant shell: Arecanut
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“[11] Government needs to take strict action against manufacturers, its cessation and prevention programs.[11] Research has shown that taxation is one of the most effective interventions to reduce consumption at a population level, especially among those aged 13–25 years.”
BackgroundInfluential
Regulatory policy for smokeless tobacco
Parascandola, M. J., & Pickworth, W. B. (2020) · Elsevier eBooks · doi:10.1016/b978-0-12-818158-4.00009-1
Thinking globally about cancer research on World Cancer Day
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Altered Fluorescence of Buccal Cells as a Candidate Biomarker for Areca Nut Chewing
Biggs, L., Franke, A. A., & Farrar, C. E. (2020) · Substance Use & Misuse · doi:10.1080/10826084.2019.1683201
“Chewing this nut has cultural significance in many Asian and Oceanic countries and has been known to be used as early as 5 years of age in some communities (Mehrtash et al., 2017; Paulino et al., 2017).”
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Turkish Version of Oral Self-Examination (OSE) Form: Validity and Reliability Study
Erki̇n, Ö., & Göl, İ. (2020) · Ankara Medical Journal · doi:10.5505/amj.2020.44365
Wet fixation of potassium in an Iraqi soil, Ameriya silty clay loam.
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Cancer epidemiology and public health
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Areca Nut and its Products: A Culprit for Many Cancers
Pathan, A. K., Pathan, A. H., Phull, G. M., & Pathan, M. (2022) · Liaquat National Journal of Cancer Care · doi:10.37184/lnjcc.2789-0112.3.1
“Gutkha is a dry, generally marketable product of areca nut that contains lime, catechu, condiments and tobacco in powdered form, that are combined with different flavorings and sometimes sugars are added and packed in sachets [11].”
Background
Knowledge, Attitude and Diagnostic Ability regarding Pre-Cancerous and Cancerous Oral Lesions among Dental and Medical Students at a Medical College in Kathmandu
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Full Text
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AN IMMUNOHISTOCHEMICAL STUDY OF E-CADHERIN, VIMENTIN AND KI-67 EXPRESSION IN RESPECT TO CLINICOPATHOLOGICAL PROFILE OF ORAL SQUAMOUS CELL CARCINOMA IN A TERTIARY CARE CENTRE
Iqbal, T., Pathuri, N. K., & Padmaja, V. (2022) · Indian Journal Of Applied Research · doi:10.36106/ijar/2502709
Areca Nut, Morbidity, and Cardiovascular Disease (Acute Coronary Syndrome) – Implications for Policy and Prevention
Shafique, K., & Nasim, S. (2022) · Springer eBooks · doi:10.1007/978-3-030-67928-6_83-1
An Unusual Cause of Esophagitis
Yan, W., Zhao, X., & Fu, Y. (2022) · Gastroenterology · doi:10.1053/j.gastro.2022.09.022
Global Oral Health and Inequalities
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pH-responsive hydrogel microspheres for efficient antibacterial activity
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Carcinogenic Alkaloids Present in Areca Nut
Thakur, N., & Mehrotra, R. (2022) · Springer eBooks · doi:10.1007/978-3-030-92392-1_84
Areca Nut, Morbidity, and Cardiovascular Disease (Acute Coronary Syndrome): Implications for Policy and Prevention
Shafique, K., & Nasim, S. (2022) · Springer eBooks · doi:10.1007/978-3-030-92392-1_83
Behavioural Interventions for Areca Nut Cessation in the Prevention and Management of Oral Submucous Fibrosis
Herzog, T. A., & Palafox, N. A. (2023) · Textbooks in contemporary dentistry · doi:10.1007/978-3-031-12855-4_20
Systematic review of determinants and interventions of areca nut cessation: curbing a public health menace
Muralidhar, K., & Madhivanan, P. (2023) · Journal of Public Health · doi:10.1093/pubmed/fdad054
Arecoline promotes Akt‐c‐Myc ‐driven aerobic glycolysis in esophageal epithelial cells
Han, S., Chen, Y., Huang, Y., Jin, L., & Ma, Y. (2024) · Environmental Toxicology · doi:10.1002/tox.24159
“The primary psychoactive component of areca nuts, arecoline (Are), has been identified as a Group I human carcinogen by the International Agency for Cancer Research, 15,16 and has been shown to significantly increase the risk of oral and ECs.”
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Cellular senescence in malignant transformation of oral submucous fibrosis!
Misra, S. R., Sathyakumar, M., Baskaran, P., & Das, R. (2024) · Oral Oncology Reports · doi:10.1016/j.oor.2024.100271
Carcinoma Escamoso de Cabeza y Cuello: Prevalencia, Incidencia y Trascendencia
Castro, S., & Cardemil, F. (2025) · Revista de Cirugía · doi:10.35687/s2452-454920250022315
“Por otro lado, existen estrategias para disminuir la práctica de masticar betel 11 , especialmente en países asiáticos, describiéndose una disminución en la incidencia de cáncer de cavidad oral asociado a una disminución del consumo de betel 26 .”
“Prevalence and Determinants of Betel Quid Dependence in Rural Bangladesh: A Cross-Sectional Analysis of Sociodemographic and Behavioral Factors“Preprint
Karim, M. R., Akhter, S., Tanzil, T., Sajid, T., Afnan, S., & Zannat, T. (2025) · medRxiv · doi:10.1101/2025.06.24.25330179
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Smokeless Tobacco Products in India – A Scoping Review
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A Global Perspective of Cancer Prevalence: The Causative Agent, the Environment, or the Genes?
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Areca nut extract exposure disrupts myogenesis and metabolism in C2C12 cells
Chen, C.-W., Huang, T.-T., Chen, Y.-R., Liu, C.-H., Hsieh, C., Chen, T.-L., & Lai, K. (2025) · Current Research in Toxicology · doi:10.1016/j.crtox.2025.100264
“AN has been shown to be a carcinogen, and AN chewing is an established cause of oral cancer and oral cancer-related deaths (Mehrtash et al., 2017; Warnakulasuriya and Chen, 2022).”
Betel Quid Chewing: Cultural Practices and Associated Factors Among the Orang Asli in Peninsular Malaysia
Mohamed, N., Ya’akub, H. Y. @., Sharif, S., Chan, Y. Y., & Khalil, M. K. N. (2025) · Asia Pacific Journal of Public Health · doi:10.1177/10105395251389483
Investigation of the Curative Properties of Polyphenols Available in Green Tea on Oral Squamous Cell Carcinoma Cell Line
Vanka, S., Vanka, A., Wali, O., Vishwakarma, S. K., Akondi, B. R., & Khan, A. A. (2025) · Journal of the International Clinical Dental Research Organization · doi:10.4103/jicdro.jicdro_65_25
In vitro evaluation of cytoproliferative activity of areca nut varieties on murine fibroblasts
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“[6,11] OSMF is a potentially malignant disorder of the oral cavity, marked by the excessive deposition of fibrous tissue in the mucosal lining and adjacent areas of the upper aerodigestive tract.”

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: Mehrtash, Hedieh
Duncan, Kalina
Parascandola, Mark
David, Annette
Gupta, Prakash C
Mehrotra, Ravi
Pearlman, Paul C
Warnakulasuriya, Saman
Zain, Rosnah Binti
Trimble, Edward L
Venue: The Lancet Oncology
Publisher: Elsevier BV
Published: 2017-12
Volume: 18
Issue: 12
Pages: e767-e775
ISSN: 1470-2045 (ISSN-L)
DOI: 10.1016/s1470-2045(17)30460-6
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
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
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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Defining a global research and policy agenda for betel quid and areca nut

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