Addiction Biology (2002) 7, 127± 132

ARECA NUT SYMPOSIUM

Areca nut use following migration and its

consequences

S. WARNAKULASURIYA

Department of Oral Medicine & Pathology, Guy’s, King’s and St Thomas’ School of Dentistry,
WHO Collaborating Centre for Oral Cancer and Precancer, King’s College London, Denmark
Hill Campus, London, UK

Abstract
Areca nut use is widespread in the Oriental countries, affecting approximately 20% of the world’s population.
The combined use of areca nut and smokeless tobacco (ST) is practiced particularly in the Indo± Chinese
continents. While there is considerable global variation in the use of these products, migrant studies relevant to
areca nut use is of considerable interest to epidemiologists in suggesting the extent to which these environment
exposures are important in the aetiology of different cancers and other health-related consequences. Studies on
Indian migrants to the Malay peninsula, South and east Africa and various Asian ethnic groups resident in
several parts of the United Kingdom have shown that the consumption of areca nut (often mixed with ST) is
highly prevalent in these communities. Available data on the prevalence of areca chewing among these migrant
populations are reviewed here. The carriage of these risk factors from South Asia to other countries has resulted
in excess risk of oral cancer in these new settlements. There is also a high incidence of cardiovascular disease,
hypertension and late onset diabetes among Indians living in the United Kingdom and there is new evidence
to suggest that the combined roles of areca and ST may be contributory. Because of their enhanced financial
situation, substance abuse may increase in their new country of domicile. The two products are psychologically
addictive and a dependency syndrome related to their use among Asian immigrants to the United Kingdom has
been described recently.

Introduction habit is areca nut mixed with betel leaf (pan)

Among Asian populations, areca nut (fruit of
the Areca catechu L. tree) is combined with
many other naturally occurring ingredients and
consumed in quid form. Tobacco is often con-
sumed with areca nut. These categories of
behaviour associated with areca nut use are
illustrated in Fig. 1. The ingredients that are
mixed with areca nut to conform to a specific
chewing habit are outlined in detail by Gupta et
al. 1 Among Asians the predominant chewing
and is referred to as betel quid or pan chewing.
Areca nut and pan may be chewed with or
without cut and cured tobacco. As tobacco is
often added, pan chewing is also the most
common form of smokeless tobacco use among
Indians and other south Asian communities.
The terminology concerning betel quid con-
stituents has not been explicit in many publica-
tions and these are outlined by Gupta et al. 1 in
this issue.

Correspondence to: Prof. Saman Warnakulasuriya, Department of Oral Medicine & Pathology, Guy’s, King’s
and St Thomas’ School of Dentistry, Caldecot Road, London SE5 9RW, UK.

ISSN 1355-6215 print/ISSN 1369-1600 online/02/010127-06

€ Society for the Study of Addiction to Alcohol and Other Drugs Carfax Publishing, Taylor & Francis Ltd
DOI: 10.1080/13556210120091491
128 S. Warnakulasuriya
Figure 1. Categories of behaviour associated with areca nut use.
The most detailed account of the betel quid-
chewing habit is contained in an International
Agency for Research on Cancer (IARC) mono-
graph that evaluated the carcinogenic risk of betel
quid and areca nut to humans.2 Two later
reviews3,4 highlight the importance of recognizing
and recording whether or not smokeless tobacco
is included in the quid habit. This is particularly
important when analysing its carcinogenecity in
population studies. The latter publication4 arising
out of an expert symposium provides a classifica-
tion of the Asian chewing habits under the
following categories: (a) areca quid; (b) areca and
tobacco quid; and (c) tobacco quid. Epidemio-
logical studies that reported the prevalence of
these habits among populations living in the
Indian subcontinent, the whole of south Asia and
some Pacific islands are reviewed by Gupta et
al. 1
This review will highlight the continuance of
areca and betel quid chewing habits associated
with ST use in several populations after migration
and its social and health consequences.
Migration studies
Studies of migrant populations have proved of
considerable interest to epidemiologists working
in the field of cancer research in suggesting the
extent to which environmental exposures are
important in the aetiology of specific cancers.
Migrant studies on oral cancer risk have included
Indians living in the Malay peninsula5 and Natal
province in South Africa6 and several Asian
groups who have migrated and settled in Britain.7
Examination of these risk habits among Asian
migrants has shown that the use of areca nut
alone or in the form of betel quid is prevalent in
these communities and the patterns of use are
closely similar to the local chewing customs
prevalent in their countries of origin. Several
population studies conducted among Asian eth-
nic minority groups resident in the South Africa
and in the United Kingdom are reviewed below.
Prevalence of chewing habits among Asians
in South and East Africa
The first description of oral submucosis fibrosis
in the medical literature was on five Indian
women from East Africa.8 Although at the time
the significance of the association of this disease
with the areca habit was not clear, Schwartz’s
observations 8 confirm the prevalence of the
chewing habit among these populations in East
Africa at the time who had emigrated from the
Indian subcontinent a generation or two ago (Fig.
2). Schonland & Bradshaw9 carried out a preva-
lence study of the chewing habit in Durban
among 500 households. They reported that
 Areca nut use following migration 129

Figure 2. Asians in Britain. Map 1 shows the origins of Asians in Britain, map 2 shows the six areas in the Indian
subcontinent from where most of Asians have emigrated and map 3 shows from where most of the East African Asians have
come.

30.7% of Indian women practiced the chewing
habit while only 5.5% of men were chewers. The
habit was more common in the elderlyÐ 71.9%
of women over 60 years and 10.3 of men of the
same age were chewers. A more comprehensive
prevalence study was undertaken in 38 Indian
suburbs in the city of Durban by Seedat and van
Wyk in early the 1980s.10 Among 2058 subjects
interviewed 9% indulged in chewing. The habit
was found to be age-related and females out-
numbered males in all age groups. The over-
whelming preponderance of female chewers
reflects the pattern of areca nut chewing among
South African Indians.
Prevalence of chewing habits among Asians
in Britain
Asians in Britain refers to people from the
subcontinent of India, Pakistan, Bangladesh and
Sri Lanka and to people from East Africa whose
families originated in the subcontinent (Fig. 2).
They constitute almost 3% of the total UK
population and are one of the fastest-growing
minority ethnic groups. 11 The Asian community
in the United Kingdom is diverse and should
not be considered as being a culturally homoge-
neous group. Among the ethnic migrants who
came from the Indian subcontinent, most are
Sikhs from the Punjab, Hindus from Gujarat
and Moslems from Pakistan and Bangladesh.
Several methodological difficulties arise in
research on ethnic minorities and these prob-
lems have to be addressed by appropriate sam-
pling.12 The Pakistani and Bangladeshi groups
are all distinctive in having large proportions of
children, and just under one-half of the Asian
ethnic minority population as a whole was born
in the United Kingdom. There is also a concen-
tration of Asian ethnic minority groups in some
areas of Britain, particularly in Inner and
Greater London and West Yorkshire and the
130 S. Warnakulasuriya

Table 1. Areca nut and betel quid use by migrant ethnic groups resident in the United Kingdom

Region Year n Community Habit %use

Yorkshire 1994 296 Bangladeshi Pan 95

Zarda 27
Birmingham 1995 334 Bangladeshi Betel quid 92± 96
London East 1995 158 Bangladeshi Betel quid 78
London West 1995 183 Mixed Asian Betel quid 47
London north West 1999 367 Mixed Asian Betel quid 27
Leicester 2000 519 Mixed Asian Betel quid 33

West Midlands. The majority of the recently
reported prevalence studies examining chewing
habits among British Asians have originated
from these regions.
Table 1 summarizes the chewing habits recor-
ded from several adult Asian migrant commu-
nities living in Britain.13± 18 It is recognized that
the sample sizes used for these studies are small
and many have interviewed selected community
groups that could be labelled as convenient
samples, introducing biases related to sampling
and data collection. It is clear from the three
studies that sampled the UK Bangladeshi popula-
tion that their betel quid-chewing habits are
rampant (78± 96%), while among the mixed
Asian groups the habits are recorded as moderate
(27± 47%).
Three studies19± 21 which examined the betel
quid habit among Asian adolescents living in
Britain suggests that the habit is prevalent at a
young age (Table 2). Areca chewing in adoles-
cents is an event that goes through a series of
behavioural intentions before becoming a habit.
The majority in the younger ages were occasional
chewers. However, on reaching school-leaving
age they had become regular users of areca nut
and often added chewing tobacco to the quid
mixture.
Comparison of chewing and tobacco habits
among first- and second-generation Asians living
in Leicester suggests that the betel quid-chewing
habits and use of tobacco are continued long after
migration by cultural bonding of ethnic groups. 18
Examining distinct ethnic groups interviewed in
this study it is clear that Sikhs from either first or
second generations do not indulge in tobacco or
betel quid-chewing, while Hindus from both
generations continue chewing betel quid or pan
masala in their country of domicile. Muslims and
Jains in the second generation, on the other hand,
appear to be less likely to chew these products.
Tobacco in betel quid
In the two adolescent studies quoted above the
majority of the youngsters began quid chewing
without the use of tobacco, but some converted to
adding tobacco to the quid during senior school
ages, or used commercially packaged products
which contained predominantly areca nut and ST
referred to as Gutka. The social pressures on
young Bangladeshi women in the United King-
dom to introduce chewing tobacco to their betel
quid are presented by Bedi.22 Among older Asian
adults, up to 50% are recorded to add tobacco to
the betel quid when this was made up at home to

Table 2. Areca nut and betel quid use by adolescent Asian ethnic groups resident in the United Kingdom

Region Year n Community Habit %use

Luton 1996 739 Mixed Asian Betel quid 22

London East 2001 204 Bangladeshi Betel quid 28
London East 2001 704 Bangladeshi Areca nut 77
Pakistani

Refs 19± 21.


their own recipe. For older aged Bangladeshi
women it may reach close to 80%.22,23 A further
proportion chewed predominantly sweetened
tobacco products such as Zarda. With the emer-
gence of commercially packaged areca products
popularly referred to as pan masalas it is increas-
ingly difficult to disentangle the confounding
effect of tobacco, as these products are often
mixtures of sun-dried tobacco and cured areca
nut, labelled misleadingly in many ways.
Determinants of chewing habits among
ethnic Asians
Ethnic variations in chewing of betel quid and
tobacco are recognized in several studies reported
so far. The predominant group retaining chewing
habits in Britain are the Bangladeshi adults.24
Lower socio-economic status, social deprivation
and inability to speak in English have been
recognized as positive determinants for quid
chewing and these factors may contribute to a
lack of acculturation, which reinforces the cul-
tural habits of the native country.25 Gender
differences are minimal17 and there are recent
data to indicate that chewing practices have
extended to Asians born in Britain.18 Examining
the attitudes and perceptions of Bangladeshi
teenagers who used betel quid regularly, it was
surprising that some reported the quid to have a
good taste and that it gives a refreshing feeling.20
To deter young people having access to areca nut
and smokeless tobacco interventions with retail-
ers may be helpful. Few studies have examined
the knowledge and attitudes of shopkeepers
serving Indian and Bangladeshi communities in
parts of the United Kingdom. These inquiries
suggest that shopkeepers who sold these products
did not perceive that pan, areca nut or chewing
tobacco caused any health risks and therefore
placed no age restrictions on their sales.22,26
Oral cancer risk among Asian migrants
Early studies examining the oral cancer risk
among migrants compared the relative frequency
of oral cancer among native Malays and Chinese
residents in the Malay peninsula with Indian
migrants who were later settlers. A high relative
frequency of oral cancer close to that experienced
in home countries was noted among the migrant
Indians, who predominantly used betel quid in
Malaysia.27 van Wyk et al. 6 reported that the odds
ratio was 43.9 for oral cancer in South African
Areca nut use following migration 131
Indian women aged 25 years and older who
chewed only the nut. The reported attributable
risk was 89% among areca chewers. Swerdlow et
al. 28 examined the risk of cancer mortality in
people born in the Indian subcontinent who
migrated to England and Wales. Of the many
cancers examined, substantial highly significant
risks in Indian ethnic migrants were noted for
cancers of the mouth and pharynx (OR 5.5; CI
3.7± 8.2). A later study in the Thames region,
which has dense pockets of Asian ethnic commu-
nities, confirmed these observations. 29 The inci-
dence of oral cancer among migrant Asians is
therefore more similar to that in the countries of
birth and Asians appear to retain their increased
risk for oral cancer even several decades after
migration. Ethnicity, rather than race, appears to
strongly influence the oral cancer risk of this
population, largely as a result of retaining social
and cultural practices following migration.30
Conclusion
Examining several prevalence studies completed
during the 1990s among Asians living in Britain,
it is clear that the chewing habits associated with
areca nut and betel quid are widespread and the
areca habit has gained social acceptance in this
community. Longitudinal studies involving young
people are important. Formal intervention stud-
ies targeted to this community have been minimal
and the provision of selective health education
materials appears timely.
Acknowledgements
Figure 1 is reproduced from a booklet published
by the DHSS and King Edward’s Hospital Fund
for London.
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