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Tackling the use of supari (areca nut) and smokeless tobacco products in the south asian community in the united kingdom Milan Chande Krishna Suba Dental Update 2024 43:5, 707-709.
Authors
MilanChande
BDS
Dental Foundation Trainee, Boutique Dental 23, 23 Bryn Street, Ashton-in-Makerfield, Wigan, WN4 9AX, UK
The use of supari (areca nut) and smokeless tobacco products are seen as a major risk factor for oral cancer. There are increasing rates of oral cancer across the United Kingdom, along with the increase of the use of these products. This article examines the uses of such products amongst the South Asian Community and explores sensitive issues associated with the cessation of their use. Evidence-based recommendations are provided on how to provide advice and treatment to patients that regularly use these products. A rethink is also suggested on the policy of taxation of such products.
CPD/Clinical Relevance: With the rates of oral cancer increasing across the United Kingdom, it is important for us as dental professionals to tackle the use of areca nut and smokeless tobacco products.
Article
A diagnosis of oral cancer can have a significant impact upon a person's life. Ensuring that patients have the best possible advice available to them, in order to reduce the risk of developing oral cancer, should be fundamental in practice. Whilst smoking is a major factor in developing oral cancer and lung cancer, recent evidence has shown that the incidence of lung cancer has begun to decrease, since more people have ceased smoking and fewer are taking up this dangerous habit.1 It therefore may seem unusual that there is an increase in the incidence of oral cancer.2 There are two recently identified risk factors that are contributing towards this increase.
First, human papillomavirus-linked oropharyngeal cancer is on the increase.3 Another factor, influenced by the increasing migrant population in the United Kingdom, is the availability of carcinogenic products: smokeless tobacco and areca nut, also known as ‘betel nut’ or ‘supari’.
This article aims to explore the use of areca nut in the South Asian community and looks at the current evidence around its damage to patients orally and systemically, as well as examining the most appropriate cessation advice that we can offer.
Areca nut
Areca nut is the seed from the areca palm, which is grown in large quantities in Asia and countries surrounding it. Its uses vary from being chewed habitually in South Asia, to playing a role in Hinduism and Buddhism. It is not a true nut, but rather a drupe. When fresh, the inside of the nut is soft and can be cut with a knife, but as the fruit ripens, it turns into a wood-like consistency, after which it can only be cut with purpose-built scissors.
It has been estimated that approximately 10% of the world's population (ie around 600 million people) chew areca nut regularly.4 The nut has been labelled as the fourth most commonly used psychoactive substance after alcohol, caffeine and nicotine.5
In order to make improvements in the consumption of areca nut, education is key, but on a two-way basis. In order for healthcare professionals to be able to provide advice and explain the health risks of the nut, they must first be able to understand and appreciate the role of the nut in many communities. It is also important for cessation advice and techniques to be based upon the strongest available evidence so that advice provided is effective in helping patients to discontinue its use.
Tradition and habits involving the use of areca nut
The difficulty that dental care professionals often have is in explaining how the nut can be of risk to the patient's health. Until recently, the carcinogens inside the nut and their actions were poorly understood. Furthermore, social barriers prevent dental professionals from understanding fully the role of areca nut chewing in patient communities. In addition to habitual chewing, the nut is considered an important ingredient in many religions and cultures. For example, in Hinduism the nut is often used in worship as an auspicious offering towards god, as well as representing deities in many rites and rituals (Figure 1). Being such a customary and traditional object in the lives of certain communities, it may be very difficult for patients to understand the harm that this nut could cause, particularly for those with English as a second language.
Figure 1. Offerings made towards god in a Hindu ceremony. These include fruits, flowers, lentils and areca nuts.
The nut is used in ‘paan’, which is made from slaked lime, catechu and tobacco wrapped up in a betel leaf (Figure 2). The habit of chewing paan is commonly known to the South Asian community as being hazardous to health.
Figure 2. This is ‘paan’ before being folded: on the left is a paan-containing tobacco and on the right is a sweetened tobacco-less version.
Another type of paan preparation is usually a betel leaf containing areca nut, slaked lime, catechu, sweetened rose petal leaves, sweetened fennel seeds, tutti frutti, coconut powder and coriander dal. Many paan makers add further sweet ingredients to differentiate their products from the competition. This version may be seen as of a much more worrying nature due to this habit being viewed as socially acceptable, with no health risks claimed owing to the lack of tobacco.
The nut can be roasted, consumed plain or be sweetened. It is widely available from Asian grocery shops around the country as a whole, or as small pieces or slices in packaging (Figure 3).
Figure 3. The different presentations of areca nut that are consumed in the South Asian community: from the left, whole raw areca nut; cut uncooked areca nut; cut cooked areca nut; sweetened areca nut flakes.
The nut is also often consumed as part of a mixture with flavoured tobacco, slaked lime and catechu. This freshly made mixture is available for sale from many paan shops across the country. Manufactured preparations are also available, which often incorporate sweet or savoury flavourings. Such preparations are marketed as ‘gutkha’ (Figure 4). Paan or gutkha is often held inside the mouth for hours, between the teeth and buccal mucosa.
Figure 4. The popular ‘gutkha’ that is available from Asian grocery stores.
Oral submucous fibrosis (OSF)
The role of areca nut in the aetiology of the potentially malignant condition, oral submucous fibrosis, is well known, especially in people of Asian origin. It is thought that arecoline, a substance found in areca nut, is the main culprit in the pathogenesis of OSF.6 Its interaction in many pathways leads to the accumulation of collagen as well as fibrosis, which in turn causes patients with OSF to present with loss of elasticity of oral tissues and limited mouth opening.7 The possibility of malignant transformation of OSF is also contributed to by arecoline, with genetic damage, interference in cell cycle regulation and hypoxia.6
The link of areca nuts to other systemic diseases
In addition to the negative effects of areca nut seen inside the oral cavity, its role in systemic diseases has also been investigated.
Chu8 stated that betel nut-chewing produces complex reactions and interactions. In the presence of lime, arecoline and another substance found in areca nut, guvacoline, betel nut is hydrolysed into arecaidine and guvacine, which are both strong inhibitors of GABA uptake. It was also shown that betel nut-chewing caused an increase in heart rate, blood pressure, sweating and body temperature. Electroencephalography showed signs of widespread cortical desynchronization, which indicated a state of arousal. Furthermore, betel nut chewing also raised plasma levels of norepinephrine and epinephrine.
Hsu et al9 investigated the role of arecoline in metabolic syndrome disorders. The results of the study in mice showed that areca nut chewing has the potential to modulate adipose cell metabolism. This would help explain the association of areca nut chewing and metabolic syndrome disorders.
Taylor et al10 stated that areca nut chewing could affect asthma control and severity of attacks. The study showed that areca nut chewing caused bronchoconstriction. Furthermore, data also showed that the rate of hospital admissions for acute asthma attacks is higher amongst Asians than other groups of the population.
Evidence also exists to show that areca nut chewing during pregnancy increases the incidence of low birth weight, low birth height and preterm births.11
A recent meta–analysis of case-controlled trials by Akhtar12 examined areca nut consumption and its link to oesophageal carcinoma risk. It concluded by stating that areca nut chewing is an independent risk factor that increases the risk of developing oesophageal carcinoma. Furthermore, a combination of smoking tobacco and chewing areca nut seemed to have a manifold increase in the risk of oesophageal carcinoma.
Public health spending on tobacco cessation
Whist public health campaigns from all over the world have attempted to educate people in the developed and developing world about the risks associated with tobacco use in any form, there has not been an equal force in educating people about the carcinogenic effects of areca nut and smokeless tobacco products.
With a huge amount of public health spending placed on campaigns to encourage patients to stop smoking, the messages behind these campaigns have put emphasis into the fact that tobacco contains many hundreds of carcinogens that can cause cancer in many parts of the body. These campaigns are seen as successful, as many countries are now reporting reducing numbers of smokers and lung cancer rates. However, analysing these campaigns further reveals that some may misinterpret messages. It is now widely understood by patients that tobacco is a major risk factor of cancer and therefore tobacco mixed with areca nut, for example in paan, is dangerous and hence should be avoided. However, eating areca nut alone has no negative image whatsoever associated with it, and consuming this is not seen to be dangerous, especially to those with English as a second language.
A sales tax
Currently in the United Kingdom there are taxes on several harmful items. This type of sales tax regimen allows governments to increase tax receipts that could help to pay for public services that are needed as a consequence of the use of these substances. An example of such a tax regimen is the tobacco tax duty. Currently, 16.5% of the retail price plus £3.79 per 20 cigarettes is taken by the government as a tax on cigarettes.13 Whilst the tax does not always account for the expenditure for extra public services needed for sufferers of smoking-related diseases, it does give a significant contribution towards the public purse. However, more importantly, it means that these products are relatively expensive to purchase and therefore this acts as a deterrent for their use.
Furthermore, the tax brings with it a stigma to the product; it is seen by the public that the government tends to charge tax on a product which has a negative impact on health. Healthcare professionals can view this stigma from a positive point of view as it allows the public to be educated about the harmful effects of using such substances. With success being seen through the use of a tax system on tobacco, it raises the question whether such a system can help us tackle other health problems. There have been many suggestions by leading healthcare professionals in asking for a fat tax or a sugar tax. This levy would apply to products consumed that often contain large amounts of fat or sugar that can be detrimental to the health of members of the public.
Furthermore, there is now an increasing level of acceptance and evidence for the idea of having a minimum price per unit of alcohol. A modelling study by Brennan et al14 for England showed that, with a minimum price of 45p per unit in England, 624 deaths and 23,700 hospital admissions could be avoided.
There currently is no tax or policy regarding the use of areca nut or smokeless tobacco products for citizens of the United Kingdom. The ingredient remains available cheaply through Asian grocery stores. Thought may be given to creating a national policy to reduce the use of areca nut or limit its supply. Products such as ‘gutkha’ have been banned in over 24 states across India, yet their sale seems unrestricted in Asian grocery stores in the United Kingdom.
The number of outlets selling such smokeless tobacco and areca nut appears to be growing.15 With more local Asian grocery shops opening, the availability of such smokeless tobacco and areca nut products seems to be increasing rapidly. The HM Revenue & Customs and the UK Border Agency reported in 2008 of a recent rise in illegal imports.16 There has also been a suggestion that the packaging of these products appears to be targeted towards a young audience.17
The global use of smokeless tobacco products
The use of smokeless tobacco products is not only a problem for the South Asian countries; its use has been documented in several countries across the world. The USA has a significant issue regarding the consumption of chewing tobacco. A 2009 survey by the US Centre for Disease Control showed that 8.9% of US high school students had used a smokeless tobacco product within the last 30 days.18
The consumption of a smokeless tobacco product termed ‘snus’ is common in Sweden. Snus is made from tobacco, salt and sodium carbonate. It is banned from sale in the European Union,19 but has been given a special exemption to be produced and sold in Sweden, Norway, Finland and Denmark. It is also sold by the company, Swedish Match, in the USA. Currently, the product carries the label ‘this product can cause mouth cancer’. The company petitioned the Food and Drug Administration to try softening the warning, as it claims that some evidence shows that the product poses no increased risk of oral cancer.20 This has caused a controversy around the use of snus and the selling of it.
Methods to help patients quit their habits
A systematic review by Ebbert et al21 published on the Cochrane database analysed all intervention techniques currently available to healthcare professionals to help patients with the cessation efforts of smokeless tobacco.
The systematic review showed that nicotine replacement therapy, used as patches or gum and Bupropion, both of which are the mainstay in cessation for cigarette smoking, are not effective in helping patients to stop using smokeless tobacco.
Behavioural interventions incorporating telephone counselling or an intra-oral examination were likely to increase cessation rates.
NICE guidelines
In 2012, the National Institute of Health and Care Excellence (NICE) produced a set of guidelines aimed to ‘help people of South Asian origin who are living in England to stop using traditional South Asian varieties of smokeless tobacco'.22
The set of guidelines highlighted six key areas of investigation and planning:
Assessing local need;
Working with local South Asian communities;
Commissioning smokeless tobacco services;
Providing brief advice and referral: dentists, GPs, pharmacists and other health professionals;
Recommendations for the general dental practitioner (GDP)
Understanding the concept of areca nut use may be difficult for GDPs with an ethnic background other than South Asian, or for those who have relatively little experience of treating patients of this descent.
Using some important recommendations provided by the above NICE guidelines, some examples of how GDPs can offer helpful and effective cessation advice to patients include the following:
Recommendation 2: Working with local South Asian communities
GDPs can raise awareness by working in conjunction with local smokeless tobacco cessation services. This may include:
Increasing awareness through advertising in the practice, for example, obtaining and placing posters and leaflets in waiting rooms, as is often seen for smoking cessation campaigns;
Providing advertised information in a range of South Asian languages, since many areca nut and smokeless tobacco users may not have English as a first language;
Providing campaign information in non-written format, eg audio, video or pictorial, in order to increase the availability of this information to a wider range of people.
Recommendation 4: Providing brief advice and referral: dentists, GPs, pharmacists and other health professionals
Prevention advice is one of the fundamental practices for GDPs in the community. This includes prevention of dental caries, periodontal disease as well as oral cancer. In order for the prevention of mucosal changes such as oral submucous fibrosis, and possibly further malignant changes leading to oral cancer, it is important that advice is provided routinely. Therefore it is important for GDPs to note that:
Patients should be asked about their use of smokeless tobacco and areca nut products as part of a comprehensive history taken from every patient;
Products should be referred to in their locally used names, and visual aids and photographs may be used to help patients understand, especially if they struggle to understand English;
Perceived benefits of areca nut and smokeless tobacco products, which are common myths, should be challenged and corrected;
Patients should be notified of the health risks of these products, systemically as well as orally;
It is important to discuss addiction in ways which are sensitive to patients' cultures, beliefs and religions (for example using the word ‘habit’ may be a more appropriate word as opposed to ‘addiction’);
Any attempts to encourage cessation should be recorded in patient notes, as well as patients' responses to this encouragement;
Dentists may consider providing specialist smokeless tobacco/areca nut cessation services within their practices, however, if this is not feasible, they should be aware of, and be able to refer patients to, their local service when necessary.
Conclusion
From the evidence currently available to dentists, it is clear that the use of areca nut and smokeless tobacco products is a significant problem across the world. However, the incidence of United Kingdom-based dentists dealing with patients using areca nut seems to be increasing as we move towards a more diverse society. It is therefore important for all members of the dental team to be aware of the risks associated with areca nut chewing. Both oral risks and systemic risks must be explained to patients to help them understand how their habits are affecting their bodies. As the habit is often based on addiction, it is important that we understand this and aid patients by carrying out behavioural intervention techniques and referring them to our medical colleagues for an opinion if we feel that medication, such as varenicline, could help a motivated patient end his/her habit.
Action should also be considered on the continued sale of products containing areca nut without any restrictions. If alcohol minimum pricing and future fat or sugar taxes are implemented, consideration must also be given to placing a tax on other harmful substances, such as areca nut, in order to increase the awareness of communities across the United Kingdom of their harmful effects.
