Study Betel Nut Before You Finalize Your Public Health or Harm Reduction Policy

December 10, 2021
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In the most recent 10 years especially, I’ve been noticing some activity in our field concerning advancement of public health measures (e.g. cigarettes) and harm reduction strategies (e.g. opioids).  Some of these efforts seem to include the notion that widespread harms would be reduced, and widespread health would be advanced, if use of drugs was:

  • Culturally accepted
  • Low cost
  • Widely available
  • Natural, not a tainted supply
  • Low or lower potency

Backing up a bit, I’ll say this.  I grew up in Southeast Asia and moved to the USA in the late 1970’s, just before my teenage years.  I experienced culture shock upon moving to the USA, and have many, many stories about it that remain quite clear to me.  Some of those stories pertain to drugs and drug use, but most of them pertain to the basics of everyday life.

In SE Asia, I saw the use of betel nut all the time.  After moving to the USA, I never saw betel nut or the use of betel nut, ever again.

Effects of the use of betel nut (as quoted below) include:  addiction, various cancers, neuronal injury, myocardial infarction, cardiac arrhythmia, hepatotoxicity, asthma, obesity, type II diabetes, hyperlipidemia, metabolic syndrome, hypothyroidism, prostate hyperplasia, infertility, suppression of T-cell activity, and harmful fetal effects if used during pregnancy.

In Southeast Asia, betel nut has traditionally been low-cost, culturally accepted, widely available, natural and not from a tainted supply, and of low potency.  And despite those factors, betel nut has long been a public health nightmare.

I often think of betel nut while I listen to arguments in favor of heroin that could be:

  • low-cost
  • widely available
  • pharmaceutically pure
  • culturally accepted, and
  • not tainted with high potency but pure opioid additives like fentanyl.

I encourage the reader to read on through some recent findings below, and a question at the end.

Some Recent Findings

Garg, A., Chaturvedi, P. & Gupta, P. C.  (2014).  A Review of the Systemic Adverse Effects of Areca Nut or Betel Nut.  Indian Journal of Medical and Paediatric Oncology.  35(1):3-9.

Areca nut is widely consumed by all ages groups in many parts of the world, especially south-east Asia.

There is substantial evidence for carcinogenicity of areca nut in cancers of the mouth and esophagus. Areca nut affects almost all organs of the human body, including the brain, heart, lungs, gastrointestinal tract and reproductive organs. It causes or aggravates pre-existing conditions such as neuronal injury, myocardial infarction, cardiac arrhythmias, hepatotoxicity, asthma, central obesity, type II diabetes, hyperlipidemia, metabolic syndrome, etc. Areca nut affects the endocrine system, leading to hypothyroidism, prostate hyperplasia and infertility. It affects the immune system leading to suppression of T-cell activity and decreased release of cytokines. It has harmful effects on the fetus when used during pregnancy.

Little, M. A. & Papke, R. L.  (2015).  Betel, the Orphan Addiction. Journal of Addiction Research and Therapy.  6:e130.  doi: 10.4172/2155-6105.1000e130.

…there is virtually no public awareness or concern in Western nations about the fourth most widely used addictive substance, commonly known as “betel nut”, even though 300 to 600 million people worldwide are potentially addicted and at increased risk for oral disease and cancer. Of course, for much of the Western world, the ignorance and indifference to this widespread addiction can be attributed to what Douglas Adams identified in his Hitchhiker novels as the closest thing to invisibility, the SEP (somebody else’s problem) field. For thousands of years the use of areca nut (betel) has been endemic throughout South Asia and the Pacific Islands.

The main psychoactive ingredient of the areca nut is arecoline, which is known to be a muscarinic cholinergic agonist. Since arecoline is a weak base, another important ingredient in the betel quid that is required to alkalinize the saliva and permit absorption is some form of slaked lime, often from burnt sea shells or coral.

Historically, betel use cut through all levels of Asian society and was very common amongst the nobility.

The global health burden associated with areca use worldwide necessitates attention towards this addictive behavior. Given that it has been demonstrated that users do indeed become dependent, and that a substantial portion of the areca users have the desire to quit, it seems to be an addressable problem.

Papke, R. L., Hatsukami, D. K. & Herzog, T. A.  (2020).  Betel Quid, Health, and Addiction.  Substance Use and Misuse. 55(9): 1528–1532. doi:10.1080/10826084.2019.1666147.

Areca addiction. Betel quid use (areca with or without tobacco) is an orphan addiction (Little and Papke, 2015), little studied and poorly understood. But there is an ever-growing appreciation for the global health impact of this form of drug addiction (Mehrtash et al., 2017; Niaz, et al., 2017). The majority of the betel quid users are stuck in a cycle of use and dependence while aware that they put their health at risk

Tungare, S. & Myers, A. L.  (2021).  Retail Availability and Characteristics of Addictive Areca Nut Products in a US Metropolis.  Journal Of Psychoactive Drugs.  53(3):256-271.

In this field observational study, we found that areca products were relatively inexpensive, readily available, and easily purchased in grocery stores visited in Houston, TX.

Sumithrarachchi, S. R., Jayasinghe, R. & Warnakulasuriya, S.  (2021).  Betel Quid Addiction: A Review of Its Addiction Mechanisms and Pharmacological Management as an Emerging Modality for Habit Cessation.  Substance Use and Misuse.  56(13):2017-2025. 

Even though literature reveals a few cessation programs through behavioral support for (betel quid) addiction, its success has been limited in certain instances mainly due to addictive properties of (areca nut), resulting in withdrawal and relapse.

Consider the research side of the question. 

I wonder if there would be interest in conducting a naturalistic study, with as many subjects as the size of a whole population, and carried out prospectively over thousands of years – to see if culturally accepted drug use, at low cost, with wide availability, natural and not from a tainted supply, and of low or lower potency, is sufficient? 

Before we finalize our public health policy and harm reduction measures, we can study betel nut for lessons.

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