Addiction Biology (2002) 7, 77±83
ARECA NUT SYMPOSIUM
Global epidemiology of areca nut usage
P. C. GUPTA & S. WARNAKULASURIYA
Tata Institute of Fundamental Research, India and Guy’s, King’s and St Thomas’ Dental
Institute, Denmark Hill Campus, London, UK
Abstract
A substantial proportion of the world’s population is engaged in chewing areca nut and the habit is endemic
throughout the Indian subcontinent, large parts of south Asia and Melanesia. A large variety of ingredients,
including tobacco, may be used along with areca nut constituting a betel quid. The composition and method of
chewing can vary widely from country to country and these population variations are described in this review.
Some populations are known to use areca nut without tobacco providing good opportunities to further research
the carcinogenecity of areca nut. Some interesting trends on chewing patterns have emerged from recent data,
suggesting a decline in the habit in some countries such as Thailand while the prevalence of areca nut use is
rising in India and Taiwan.
Introduction
The usage of areca nut is indigenous to India, Sri
Lanka, Maldives, Bangladesh, Myanmar, Taiwan
and numerous islands in South Pacific. It is also
popular in parts of Thailand, Indonesia, Malaysia, Cambodia, Vietnam, Philippines, Laos,
China and in migrant communities from these
countries. In populations resident in south and
East Asia the use of areca nut is strongly
interwoven into local art and craft, folklore, social
customs, religious practices and cultural rituals.
In this supplement historical and anthropological
aspects of areca nut usage are described by
Strickland. 1 This paper presents a global perspective of the current usage of areca nut by
reviewing available information on its widespread
use by population groups to allow an appreciation
of the numerous public health problems associated with the use and abuse of this substance.
There are several palms under the genus Areca
native to South, South-East Asia and Pacific
islands. This tropical palm tree bears fruit all year.
Areca nut for chewing is obtained from Areca
catechu (Fig. 1). It is believed that Areca catechu
may be native to Ceylon (Sri Lanka), West
Malaysia and Melanesia.2 Areca nut is consumed
in large variety of ways and can be used by itself.
When ripe it is orange-yellow in colour and the
seed (endosperm) is separated from fibrous pericarp (Fig. 2). The nut may be used fresh, or dried
and cured before use, by boiling, baking or
roasting. In some areas, especially Eastern India
and southern Sri Lanka, fermented areca nut is
also popular. In Taiwan, areca nut is often used in
the unripe stage when it is green, like a small olive
(Fig. 3). Areca nut is known colloquially in the
Indian subcontinent in Hindi and Bengali as
supari, in Sri Lanka it is called puwak, in Sylheti
Correspondence to: Prof. Saman Warnakulasuriya, Professor of Oral Medicine, King’s Dental Institute, Caldecot
Road, London SE5 9RW, UK. Tel: 020 7 346 3608; Fax 020 7 346 3624; e-mail: s.warner@kcl.ac.uk
ISSN 1355-6215 print/ISSN 1369-1600 online/02/010077-07
Society for the Study of Addiction to Alcohol and Other Drugs
DOI: 10.1080/13556210020091437
Carfax Publishing, Taylor & Francis Ltd
78
P. C. Gupta & S. Warnakulasuriya
Figure 3. Unripe nut as consumed in Taiwan.
Figure 1. A diagrammatic illustration of areca palm. Areca
nut is obtained from the Areca catechu tree. Source:
1995± 2001 Missouri Botanical Garden Library http:/
/ridgwaydb.mobot.org/mobot/rarebooks/
accompaniments are the leaf of Piper betle (betel
leaf), lime, catechu and tobacco. The practice of
areca nut chewing in the form of a betel quid is
described explicitly in a monograph published by
the International Agency for Research on Cancer.3 The major components of betel quid are
illustrated in Fig. 4 and are listed in Table 1.
The most common accompaniment globally is
the leaf of Piper betle. This has led to areca nut
being labelled erroneously as betel nut in the
English literature. Apart from the leaf other parts
of the betel vine such as stem, inflorescence
(flower; pods) or catkins are also consumed with
as gua, in Thailand as mak, in Sarawak as pinang
and in Papua New Guinea as daka.
Areca nut chewing is practiced is several
different ways in various countries and often
mixed with several ingredients to make up a betel
quid known as pan in Hindi. The most popular
Figure 2. Areca nut.
Figure 4. A betel quid prepared in the traditional way using
betel leaves, sliced areca nut, cut tobacco and slaked lime.
Global epidemiology of areca nut usage
Table 1. Constituents of betel quid
Consituent
Preparation
Areca nut
Sliced fresh ripe nut
Roasted
Dried/baked
Boiled
Fermented
Immature
Fresh leaf
Inflorescence
From coral
From shell fish
From lime stone
Fermented
Sun dried
Powdered with molasses with lime
Extract of Acacia catechu
Extract of Acacia suma
Cloves
Cardamom
Aniseed
Coconut
Piper betle
Lime
Tobacco
Catechu
Spices
Sweetners
Modified from Ref 28
the nut. Consumption of the inflorescence (Fig.
5) is common in Melanesia and in parts of
Taiwan.
Lime (calcium hydroxide) is often used with
areca nut in combination. Lime is obtained in
coastal areas by heating the covering of shellfish
(sea shells) or harvested from corals. In central
areas of a country it is quarried from limestone.
In the Asian markets lime is sold as a paste mixed
with water (Fig. 6) which is white or pink. In
Papua New Guinea lime is available in the
powdered form.
Figure 5. Inflorescence (flower) of Piper betle mostly used
in Taiwan and Melanesia.
79
Catechu is an extract of the Acacia tree A.
catechu or A. suma. Catechu is often smeared on
the betel leaf that is used to wrap areca nut flakes.
Cut tobacco is consumed with areca nut often
in the quid mixture. This type of chewing tobacco
is made from sun-dried and partly fermented
coarsely cut leaves without further processing.
Sometimes tobacco is powdered and combined
with molasses or boiled before use.
Pan Masala is the generic term used for areca
nut-containing products that are manufactured
industrially and marketed commercially. These
are available in small convenient sachets for
individual use. Several trade brands are illustrated in Fig. 7. Pan masalas containing tobacco
are referred to as Gutka.
Global epidemiology
Areca nut is used as a masticatory substance by
approximately 600 million people worldwide. It is
estimated that 10±20% of the world’s population
chew areca nut in some form, often mixed in
betel quid (pan). A challenge facing researchers
documenting the prevalence of areca nut use in
populations is the difficulty in documenting
patterns of areca nut use as separate from betel
quid chewing which often contain a variety of
ingredients, including tobacco. Thus estimating
the population frequency of areca use by itself is
often frustrating, as some authors do not record
this explicitly in their publications. As areca is
often the primary ingredient in betel quid any
studies describing population data for betel quid
chewing is taken as a valid reference value. While
there are no nationwide surveys reported on
the prevalence of this habit, data from several
Figure 6. Slaked lime in paste form.
80
P. C. Gupta & S. Warnakulasuriya
Table 2. Prevalence of areca and/or betel quid chewing among adults in selected populations
Men
Country
India, Bombay
Pakistan, Karachi
Sri Lanka
Thailand
Taiwan, Kaohsiung
Sarawak
Cambodia
China, Xiangtang city
Women
Chewing
practice
All
n
%
n
%
n
%
40071
2661
316
986
511
195
366
6057
34.5
3.2
54
16
28.3
30
6.8
39.3
50527
2093
817
880
651
263
953
4989
27.2
8.2
42
19
1.4
63
40.6
30.5
99598
4754
1133
1816
1162
458
1319
11406
32.1
5.4
45.2
17
13.3
49.3
31.2
35.3
countries obtained in hospital-based, populationbased and school-based surveys are reviewed
here.
Data from several published studies arising
from a number of population groups studied
since 1970 are listed in Table 2. While the range of
point prevalence for areca chewing is wide
( < 1±54%) some important demographic differences are noted. Strickland1 has considered these
ethnographic differences in detail and the salient
points are that in these countries more women
than men chew and the prevalence of chewing
increases with age. Some particular characteristics relevant to each local population are outlined below.
India
India has the largest areca-consuming population
in the world. Much of the data arise from
extensive population studies conducted by the
TIFR group4 in the 1960s and 1970s. Data were
collected in a series of house-to-house surveys
Figure 7. Packaged areca nut products referred to as pan
masala. Those containing tobacco are referred to as gutka.
Nut only
x
x
x
Quid
Reference
x
x
x
x
6
8
13
15
24
28
30
32
conducted in rural areas from individuals aged 15
years or over with approximately equal proportions of males and females. Interviews were
conducted in five districts in India, Gujarat,
Andhra Pradesh, Bihar and Kerala, involving
50 915 people. The proportion chewing betel
quid varied from 3.3% in Sirikakulam in Andhra
Pradesh to 37% in Ernakulam in Kerala. Among
50 915 people surveyed in five districts, 0.6% of
those chewed areca nut alone (supari), compared
with 11.6% who chewed betel quid with tobacco.
The other large-scale study conducted in India by
Malaowalla et al. 5 on 57 518 industrial workers in
Ahmedabad, Gujarat Ða population different to
the above studies in that these were mostly urban
male textile workersÐreported pan and supari
chewing by 26% of 85% who admitted to an oral
habit. In a study of 99 598 adults ( > 35 years) in
Mumbai, some 32.1% reported chewing betel
quid with tobacco, whereas only 0.5% reported
chewing areca nut or betel-quid without
tobacco.6
Pakistan
Mahmood et al. 7 questioned 10 749 apparently
healthy subjects living in Karachi. He recorded
pan use without tobacco in 7.5% and pan with
tobacco in 15% of this population. A subcohort
of 3562 individuals from this group were reexamined by Jafarey & Zaidi.8 They reported that
at least 30% of these healthy individuals had a
pan habit compared with a hospital group of
1192 oral carcinoma patients, among whom 66%
had a pan habit. Their description of a pan habit
is not explicit, but as tobacco chewers are listed
separately the assumption is that this group
Global epidemiology of areca nut usage
reporting pan use chewed predominantly areca
nut and betel. Maher,9 in a recent house-tohouse study in a periurban area in Sindh,
recorded 35 different items that are consumed as
part of betel quid chewing by this population.
Sri Lanka
In Sri Lanka the habit of areca chewing stems
from ancient times, and traditionally the nut is
chewed with a betel leaf sprinkled with lime (Fig.
4). Tobacco may be added to the quid. Hirayama’s early studies in the 1960s10 indicated
that, among a group of healthy control subjects,
at least one in five men did not add tobacco to
their betel/areca recipe. A higher proportion of
women (who did not smoke) were reported to be
adding tobacco to the areca/betel quid mixture.
Other studies in the 1960s and 1970s confirmed
these patterns of chewing.11,12 Warnakulasuriya,13 in a large-scale epidemiological study in
rural villages in the Central Province of Sri
Lanka, reported around 50% of men and women
to be chewing betel quid.
In a nationwide survey14 conducted between
1994 and 1995 approximately 4000 adults over
35 years of age were interviewed on their betel
quid chewing habits. The reported prevalence of
betel quid chewing was 33.7% among
35±44-year-olds and 47.7% among 65±74-yearolds.
Thailand
The constituents of a betel quid which includes
fresh or fermented parts of areca nut as used in
Northern Thailand are very similar to those
illustrated in Fig. 4. Tobacco is almost always
added. A detailed study of several hill tribes
(Lahu, Karen, Lisu and Thai) living in Northern
Thailand by Reichart et al. 15 carried out in
1979±84 suggested a prevalence ranging from 5
to 44% in men and 9 to 46% in women. In the
Thai tribe the habit was less predominant and the
Meo tribe was the exception, preferring to chew
miangÐ fermented wild tea leaves.
The habit of betel quid chewing in Thailand is
declining, the only country in south Asia to
record such a trend. In 1955, Young16 commented on this and Reichart’s group17 substantiated this falling trend by observing that very
few villagers below the age of 35 chewed betel,
once a universal custom among Thai peasants.
81
The habit of betel chewing in cities such as
Bangkok and Chaing Mai has almost vanished.15
Axell et al. 18 reported that only three of 234
subjects (1.3%) attending a hospital unit reported
any form of betel or areca use. A decline in
frequency and mortality from oral cancer in
Thailand is linked to the continuously declining
chewing habit among Thais. 19
Guam
Guamians chew mainly the nut, without the
addition of tobacco or lime. Either the fresh
immature green areca nut with its husk and skin
or areca nut together with a betel leaf is chewed.20
This practice seems to be ancient and has not
changed, but the prevalence data for the chewing
habit have not been examined in any systematic
survey.
Papua New Guinea (PNG)
In PNG the quid is formed by chewing the kernel
of the areca nut, and by adding slaked lime using
the inflorescence of betel piper vine (Fig. 5)
moistened with saliva, dipped in powdered
lime.21 Together these three form the basis of the
quid habit and betel leaf or tobacco are traditionally not consumed22 Although several descriptive
papers refer to the habit of areca chewing among
Papuans, mainly from lowland and island areas,23
no detailed epidemiological studies on the use of
areca are available.
Taiwan
Betel quid chewing behaviour is viewed as a
predominantly male habit in Taiwan with 21:1
ratio of relative prevalence rates between men
(28.3%) and women (1.4%) among Kaohsiung
residents.24 Patterns of chewing among aborigines and Chinese were also reported to be
different;25 an aborigine would wrap a fresh areca
nut in a betel leaf while Chinese would sandwich
the betel infloescence (fruit) between two halves
of the areca nut smeared with lime (Fig. 3).
Among the general population in Taiwan, 6%
were reported to be current chewers (9.8% for
men; 1.6% for women) while among the aborigine people the prevalence was 42.1% (46.5% for
men; 38% for women). Analysis of sociodemographic factors suggested that men, older people,
less educated people, blue-collar workers, aborig-
82
P. C. Gupta & S. Warnakulasuriya
ines, smokers and drinkers were more likely to
chew areca nut.25 Lu et al.26 estimated that the
age of beginning areca nut chewing in Changhua
county was around 12 years, corresponding to the
last year in the primary school. During school
years from junior high school to vocational school
prevalence rates rise from 2% to 10%.27 Stich et
al.,20 examining chewing patterns in the Hualien
district in Taiwan, reported that on average a
Taiwanese uses 44 areca nuts a day and a
significant number of chewers may chew up to
120 nuts a day.
Sarawak and Malaysia
In rural Sarawak, areca nut is essentially an item
of local produce. Following a field study Strickland & Duffield28 reported that 22% of men and
47% of women interviewed in 1996 used areca
daily. The habit tended to begin in young
adulthood and women were more regular chewers than men. Among indigenous people of
Sarawak living in Malaysia, Zain et al. 29 reported
37 of 164 (22.5%) were current chewers. Again,
the habit was more prevalent in women. However, compared with Sarawak people among
Indians working on estates in the same region the
habit of quid chewing was more popular and 91
of 147(62%) were identified as habituÂe s. Malay
quid chewers are noted not to use tobacco in their
quid mixture.
Cambodia
Few epidemiological studies on chewing habits
are reported in selected Cambodian populations.
Ikeda et al.,30 in the early 1990s, interviewed
1319 individuals in nine villages in Cambodia.
Chewing betel quid was reported by 408 subjects
(31%). Among these Cambodian chewers 28%
reported use of the nut only. Reichart also
reported on the popularity of the areca chewing
habit among elderly Cambodian women.31
subjects in Hainan island of the People’s Republic
of China 95% of the study population chewed
areca nut.33
Conclusions
There are clearly many differences in the way
areca nut is consumed, on its own or often in
combination with many other ingredients,
including tobacco. In India alone, Pindborg et
al.,34 in the 1960s, described 38 different combinations of areca nut and tobacco use according
each person’s recepe. In some populations the
chewing of areca nut begins at a young age and
their first experience of areca use is during
elementary school years. 35 During the last two
decades, with the availability of commercially
available products, the pattern of use of areca has
changed rapidly and the practice of chewing areca
nut has received a boost. More precision is
required in defining what is chewed36 and the risk
of carcinogenecity of the betel quid may well
relate to the type, duration and frequency of the
habit. This review identifies some ethnic groups,
mainly in Melenesia, that do not use tobacco in
areca/betel quid chewing and there are thus good
opportunities for further research into the carcinogenecity of areca nut in these populations.
While in some countries such as Thailand areca
chewing is declining, there is new evidence that
areca usage is increasing in other countries,
notably in India and Taiwan, thus increasing the
risk of these populations to develop oral submucous fibrosis and oral cancer.
Acknowledgements
We thank the Novartis Foundation for a travel
grant awarded to Dr Prakash Gupta to speak on
this topic at the London conference. We acknowledge Dr Chu for providing Figures 3 and 5.
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without tobacco, while bitter and hot pepper were
usual additives. Thirty-five per cent of the subjects chewed areca nut. In a pilot study of 100
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