Introduction to the Special Issue: International Research on Areca Nut and Betel Quid Use

Areca or betel nut, the fruit of a type of palm, Areca catechu, contains a number of psychoactive alkaloids, which have stimulating effects on the autonomic nervous system (Chu, 2001). As a result, areca nut is widely consumed across several regions of the world as a psychostimulant. Although the patterns and mode of areca nut use may vary by cultures, customs, and individual preferences, areca nut is commonly consumed by itself, in ripe or unripe forms, or chewed wrapped in the leaf of a pepper plant (Piper betle), along with slaked lime (calcium hydroxide), spices (e.g. clove, catechu), and tobacco (Gupta & Warnakulasuriya, 2002; Paulino et al., 2011). The betel wrap is referred to as betel quid.

Some readers outside of the Asian-Pacific region may be unaware of the fact that areca nut and betel quid (ANBQ) is the fourth most consumed psychoactive substance in the world following only alcohol, tobacco, and caffeine. ANBQ is consumed by an estimated 600 million people worldwide, which is approximately 8% of the world’s population. The use of ANBQ carry social, cultural, and in some cultures, religious importance to those who chew it. However, ANBQ use is also associated with a variety of health problems, most seriously with head-and-neck cancers, and other oral diseases and precancerous conditions (IARC, 2004).

Despite the global reach of ANBQ, and the health risks associated with its use, ANBQ use remains understudied and unappreciated as a public health issue and as a research topic. Published ANBQ research has increased during the past 20 years (as documented in the current special issue), particularly in countries such as Taiwan, India, and Malaysia, which have large ANBQ chewing populations. It remains, however, an obscure and understudied scientific topic in Europe and North America, and is mostly absent from major journals on addictive substances and cancer control. Further, unlike with tobacco, there is no accepted framework of ANBQ control, and evidence-based practices regarding prevention and cessation are very limited.

The current special issue has been put together with the goal of highlighting the global significance of ANBQ research, as it pertains to disease prevention and health promotion. To that effect, we present literature reviews, commentaries, and original research in various areas of ANBQ research, ranging from basic science on biomarkers of ANBQ use (e.g., Franke et al.; Briggs et al.) to epidemiology, prevention, and ANBQ cessation. Past research on ANBQ has focused mostly on epidemiology and biological mechanisms. Two articles in the current issue (Vashney et al.; Yoo et al.) introduce the reader to the current discrepancies in areca nut use research. Overall, research in areas other than epidemiology and biological mechanisms has been scarce and less visible to the general scientific audience. The present special issue has attempted to redress this by placing an increased emphasis on the relatively neglected topics of dependence, intervention, and cessation. For example, Das et al. provide a succinct overview of the literature on ANBQ prevention and cessation published in the last two decades or so. They note limited research but are generally optimistic about the direction that intervention research in the area is taking.

Thus far, the ANBQ research community has also lacked a forum to discuss major barriers faced by ANBQ research and practice and the appropriate ideas and resources to move forward. Included in the issue are expert commentaries that elucidate problems that the field of ANBQ research is currently grappling with and the potential solutions to those problems. Papke et al. discuss the complex nature of areca nut addiction and strategies for cessation that may be informed by research on smoking cessation. Thakur et al. discuss a global database of areca nut literature that may help researchers in addressing various areca nut related questions. Similarly, Joo et al. highlight an e-learning tool that may be utilized to educate health care practitioners about areca nut and related issues, especially in the Pacific region. By innovative use of qualitative analysis techniques, Buente et al. illustrate how social media data may be mined to better understand the cultural aspects of areca nut use. Such techniques may be helpful in developing local areca nut control policies. Singh et al. discuss the increased global relevance of areca nut control policies and research due to growing migration of South and Southeast Asians to Europe and North America.

Finally, previous research also has focused on a limited number of countries in which betel nut research is more common (e.g., Taiwan, India, and Malaysia.) The current issue expands this focus to other countries, which have been previously understudied. For example, Wangdi and Jamtsho present data on the prevalence of areca nut use in Bhutan. Orlan et al. analyze the data from the Global Adult Tobacco use survey to examine areca nut use in Indonesia. The commentary by Zhao and Davey draws attention to the high prevalence areca nut among an ethnic minority in China, namely the Dai from the Yunan province of China. In addition, Hou et al. highlight the increasing relevance of areca nut use prevention to cancer control in China. Joo, Newcombe et al. focus on a novel way to combat areca nut use in Vanuatu. In total, the special issue comprises articles about ten countries, and highlights the diversity of chewing styles, quid ingredients, regional practices, and country-specific issues. The special issue also provides regional updates regarding epidemiological data on areca nut chewing prevalence and associated behaviors.

The inspiration for this special issue has origins in the International Conference on Betel Quid and Areca Nut held in 2016 in Kuala Lumpur, Malaysia (see Mehrtash et al., 2017.) This meeting brought together 130 conferees from 21 countries to focus specifically on ANBQ research and policy. The conference was successful in many respects, and resulted in increased networking capacity and collaboration among global ANBQ researchers and policy makers. This special issue represents a continuation of the momentum built at the Kuala Lumpur 2016 conference.

In conclusion, the current special issue illustrates some of the progress made by areca nut researchers in recent years. However, ANBQ remains a vastly understudied topic. In particular, areca nut intervention research – both cessation and prevention – remains in its infancy. We look forward to the acceleration of areca nut research in the coming years as we aim to curb the epidemic of oral cancer and oral disease in the Asia-Pacific region.