The thought of a diet rich in nuts conjures up healthy images, but for the areca nut this could not be further from the truth. Areca catechu, often erroneously referred to as the betel nut as it often consumed with the totally unrelated leaf of the betel piper vine (see Figure 1), is a major public health concern across South and East Asia. Data suggests that the areca nut is consumed by a quarter of the world’s population and is the third most common substance of abuse after tobacco and alcohol. The habit of chewing areca products is steeped and ingrained so deeply in many of the South and East Asian cultures that it has gained immense popularity in these communities. The habit of areca nut chewing has moved with migratory communities and it is not uncommon to see the tell-tale signs of red spittle (produced as a by-product of chewing areca products) in the streets of London, Birmingham, Leicester and Leeds. Unlike tobacco and alcohol, which are forbidden in some Asian cultures, areca nut is well accepted and even encouraged as an aid to promote digestion after a meal. For children it may be given as a sweet after meals, and as a child growing up in London it was not uncommon to go to the local areca nut (paan) shop on a Friday night after dinner for a round of sweet paan (areca nut with coconut and spices, wrapped up in a betel leaf). The adults would have a different variety of paan, consisting of areca nut mixed with raw tobacco, slaked lime and a mixture of spices. Today this is still a common tradition in many households, even though these practices date back thousands of years to the early Vedic scriptures in ancient India. Further, many religious ceremonies will have the areca nut as its centre and it is often used to mark auspicious events and even as dowry in some cultures. So deep is the cultural and societal acceptance of this humble little nut that the deleterious affects from chewing have been grossly understated.
The areca nut habit has taken a nasty turn since the development of a commercial product known as pan masala. This consists of plastic-packed powdered areca and tobacco and, despite attempts at legislation, is sold on street corners across Asia for a few Rupees – significantly cheaper than cigarettes. It has caused a massive surge in the popularity of areca products and, as there is poor labelling, the tobacco content.
A report appearing in the Economist found that areca products represented an industry worth 10 billion dollars in India alone in 2012. The global production of areca was estimated to be nearly 0.8 million tonnes in 2009 with over 55% of this production from India, and 25% from China. Furthermore the industry provides employment to many millions, including over 30 million people in India. Despite its harmful effects, the growth in consumption and production are mirrored at a growth rate of about 4% annually, suggesting that the habit is far from being in decline.
So what is it about areca that makes it so popular? Studies have shown that areca is as addictive as heroin and have demonstrated an areca dependency syndrome in chronic chewers. Its stimulant properties make it popular with those who need to stay awake – drivers, labourers and factory workers all use areca in societies where a double espresso or a Red Bull would be an unaffordable luxury. However, the heroin-like dependency is just one of its many dangers. Reports also show that in India there are over 5 million children under the age of eight who are addicted to areca-related products.
Head and neck cancer has been described as an epidemic across South and East Asia (see Figure 3), with approximately 70,000 new cases in India every year. The prognosis is poor, due to late detection, and head and neck cancer is responsible for ~48,000 deaths across India. Rates of oral squamous cell carcinoma in countries such as India are the highest in the world. Oral submucous fibrosis (OSF) is an areca-related pre-cancerous condition that results in patients only being able to open their mouth by a few millimetres. Eight percent of patients undergo malignant transformation. There is still no cure for this condition since its discovery in South Africa in 1952. The author’s discovery over a decade ago that high levels of copper in the nut causes an up-regulation of the enzyme lysyl oxidase is a still a front runner in the race to explain this enigmatic disorder. 
So what is the future for this not so healthy nut? In many countries in South and East Asia, areca consumption remains a scourge of society and despite attempts to legislate and even ban it, sales continue to surge. Compared to smoking and alcohol, areca has received a fraction of the attention attributed to other public health issues in developing countries and has largely remained under the radar for public health researchers in the West, making this a tough nut to crack!
— Dr Chet Trivedy, NIHR Academic Clinical Lecturer in Emergency Medicine, W-CAHRD
- Strickland SS. Anthropological perspectives on use of the areca nut. Addict Biol. 2002;7(1):85-97.
- Gupta PC, Warnakulasuriya S. Global epidemiology of area nut usage. Addict Biol. 2002; 7(1): 77-83.
- The Economist. Chewed out. Oral cancer in India. 2012.
- Prakash Kammardi TN, Raganath L, Ranjith Kumar PS. A report on the areca nut in the national economy. University of Agricultural Science, Bangalore.
- Winstock AR, Trivedy CR, Warnakulasuriya S, Peters TJ. A dependency syndrome related to areca nut use: some medical and psychological aspects among areca nut users in the Gujarat community in the UK. Addict Biol. 2000;5(2):173-9.
- Gupta B, Ariyawardana A. Johnson NW. Oral cancer in India continues in epidemic proportions evidence base and policy initiatives. Int Dent J.2013;63(1): 12-25.
- Trivedy C , Warnakulasuriya S, Peters TJ. Areca nuts can have deleterious effects. BMJ.1999;318:1287.
- Warnakulasuriya S , Trivedy C , Peters TJ. Areca nut use: An independent risk factor for oral cancer. BMJ. 2002; 324:799-800.
- Trivedy C , Craig G, Warnakulasuriya S. The oral health consequences of chewing area nut. Addict Biol. 2002; 7(1):115-25.
- Trivedy C, Baldwin D, Warnakulasuria S, Johnson N, Peters TJ. Copper content in Areca catechu (betel nut) products and oral submucous fibrosis. Lancet.1997;340: 1447.
- Trivedy C, Meghil S, Warnakulasuriya S, Johnson NW. Harris M. Copper stimulates human oral fibroblasts in vitro: a role in the pathogenesis of oral submucous fibrosis. J Oral Pathol Med. 2001; 30(8):465-70.