The Betel Nut: An Emerging Public Health Threat?

By S. Van McCrary, Health Law & Policy Institute

In some large metropolitan areas of the U.S., a significant risk factor in oral cancer appears to be growing--use of the betel nut.

Betel nuts are the fruit of the areca palm (name: areca catechu, family: palmaceae) which grows in tropical environments. The palm is indigenous to India and the South Pacific, but apparently can be grown in many other warm locations including Florida and California. The nut is most typically used in the form of a "betel quid," in which powdered betel nut is combined with tobacco, betel leaves, lime, and various flavorings such as fennel seed. The quid is placed between the cheek and gum and remains for an extended time, sometimes overnight. Betel is believed by users to be a mild stimulant, which produces an increased awareness of one's surroundings. There is little documented evidence of significant psychoactive properties of betel, but its use is believed by many to be addictive psychologically. The nut is used extensively on the Indian subcontinent, as well as Taiwan, Cambodia, Malaysia, and to a lesser extent China. It is estimated that 10 to 25 percent of the world's population chews betel quid, although it has been relatively unused in the United States to date.

Squamous cell carcinoma of the oral mucosa is the most common malignant tumor of the oral cavity, tongue, pharynx, and larynx. Globally, oral carcinoma is the sixth most common cancer. Numerous epidemiologic studies have found an association between the use of betel and various oral cancers. Concurrent tobacco and alcohol use are common factors that increase the risk of cancer from betel quid. One study found that the incidence of oral cancer was 123 times higher among patients who chewed betel quid, smoked, and drank alcohol, than among abstainers. Other studies have found an association between the use of betel and infection with human papilloma virus, which may exacerbate the nut's carcinogenic properties.

Thirty-five percent of all cancers occurring in persons living on the Indian subcontinent are oral carcinomas. Further, studies have found oral cancers to be prevalent among young women in India, who use betel but traditionally do not smoke tobacco products.

The status of the betel nut under federal law appears unclear. Preliminary research indicates that the U.S. Food and Drug Administration (FDA) has issued, and maintains, an import alert resulting in automatic detention of betel if it is detected by U.S. Customs officers (IA #23-06; revised July 17, 1992). The problem identified in this alert is that the substance is "adulterated, contains a poisonous or deleterious substance or appears to be an unsafe food additive." The alert also recognizes the carcinogenic propensities of betel products and calls attention to the fact that some importers use misleading names for labeling containers of betel nuts in order to avoid Customs scrutiny, for example "fragrant wood slice." The U.S. Department of Agriculture also enforces a prohibition against importation of betel nuts, which seems to apply only to nuts in raw or unprocessed condition (51 Agric. Dec. 1278, 1992 WL 515928 (U.S.D.A.) and 7 C.F.R. § 318.13). In contrast, the U.S. Customs Service has issued a formal letter opinion advising an importer of the official tariff classification and dutiable rate of dried betel nuts at 11 cents per kilogram (U.S. Customs CLA-2 CO:R:C:F 956191; May 3, 1994). This apparent conflict between formally assessing a tariff on an item whose import is legally prohibited has not yet been resolved. There also may be a lack of clarity in the federal regulations according to the form in which the betel nut is imported, i.e., raw or dried. A search of federal statutes revealed no laws directed at the use of betel nuts or products of the areca palm.

A brief search of state law revealed only one state statute applicable to human use of betel nuts--possession or use of betel nuts on public elementary and secondary school property in California constitutes grounds for suspension of a student from school (West's Ann. Cal. Educ. Code § 48900). The specific inclusion of betel in such a law suggests that its use is not unknown in California.

Dried, ground betel nut is readily available via mail order from companies in other countries through the Internet, although it is less clear that a shipment would be able to pass through U.S. Customs successfully. The U.S. Customs Service reports dozens of detentions of shipments of betel originating from India, Pakistan, and other countries, as well as from Guam itself. Nonetheless, significant amounts of betel are available for sale in the United States. Recent informal investigations in the Houston area indicate that betel quid is readily available in certain specialty stores in Asian neighborhoods, and anecdotal evidence suggests that the use of betel in major cities around the country is increasing. This evidence is supported by the medical literature--a 1994 article in the Western Journal of Medicine documents the use of betel quid among Cambodian immigrants in California.

The public health implications of the apparent increase in betel use are significant. Given the increasing diversity of the American population, especially in large urban areas, substantial portions of the population may be at risk for substantially elevated rates of numerous oral cancers. As immigration to the U.S. from the Indian subcontinent and other parts of Asia continues to expand, many of these persons may bring with them the habit of betel use. Sound public policy should prompt lawmakers to consider further regulation of betel nut products at the federal and state levels. Further, good public health demands that health care professionals, especially dentists and physicians, become more aware of this problem and learn to recognize signs of its use. A plausible response would be for hospitals and dental clinics in areas with substantial Asian populations to add items to their routine patient questionnaires asking patients about their use of betel products. Epidemiologic evidence indicates that many oral cancers are easily preventable through primary prevention efforts and early detection. Rapid response in the form of increased screening and regulation may be able to head off this potential public health threat.