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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 31  |  Issue : 2  |  Page : 159-161

Glittering potentially malignant shell: Arecanut


Department of Oral Medicine and Radiology, Saraswati Dental College, Lucknow, Uttar Pradesh, India

Date of Submission15-Feb-2019
Date of Acceptance19-Apr-2019
Date of Web Publication24-Jun-2019

Correspondence Address:
Dr. Siddharth Kumar Singh
Department of Oral Medicine and Radiology, Saraswati Dental College, 233 Tiwari Ganj, Faizabad Road, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_35_19

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   Abstract 


Areca nut is consumed extensively throughout the world with significant public health and oral implications. This habit is more prevalent amid communities belonging to India and the South-East Asia region (SEAR). In the past few decades, surveys have reported that consuming areca nut has increased among population and a high proportion of school children use areca-nut daily in some form. Low cost, easy availability, advertising, role modeling, social acceptance and perception of areca nut as harmless is what contributes to its use. Areca nut users are at high risk of oral submucous fibrosis, a debilitating and potentially malignant condition and also suffer adverse health outcomes. Though industrially made areca nut products have been banned in all states and union territories of India, but it is still widely available. WHO Framework Convention on Tobacco Control provides evidence-based policies for reducing tobacco use, but no global policy exists for the control of areca nut use. Associative research is needed to sermon this nugatory global public health emergency and to mobilize efforts to control areca nut use. In addition, possible prevention and cessation programs for areca nut users, effective actions to increase awareness regarding health risks among general public and to minimize its use both at personal and government levels should be undertaken.

Keywords: Areca nut, oral cancer, oral sub mucous fibrosis, potentially malignant condition, tobacco


How to cite this article:
Singh SK, Faizi S, Chandra S, Sinha S. Glittering potentially malignant shell: Arecanut. J Indian Acad Oral Med Radiol 2019;31:159-61

How to cite this URL:
Singh SK, Faizi S, Chandra S, Sinha S. Glittering potentially malignant shell: Arecanut. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2019 Sep 18];31:159-61. Available from: http://www.jiaomr.in/text.asp?2019/31/2/159/261088




   Introduction Top


The word 'areca' is originated from the Malay word adakka or adakeya.[1] It is also known as Chaalia, catechu palm or Supari.[2] It is the nut of the Areca catechu tree which is the member of Arecaceae family.[2] The four main alkaloid constituents of the nut are arecoline, arecaidine, guvacine, guvacoline. Other components include carbohydrates, fats, proteins, crude fibre, polyphenols, gallic acid, (flavonols and tannins) and other mineral matter.[3] The contents of the areca-nut that are proven to be carcinogens are tannins, poly-phenols including safrole and hydroxychavicol, and catechins, of which arecoline is the main causative agent.[1] These constituents are involved with the collagen pathways as they increase the collagen production and inhibit the collagen degradation thereby causing fibrosis.[1]

The current production of areca nut in the world is about 0.613 million tons from a cultivated area of 0.476 million hectares.[3] It is mainly cultivated in Sri Lanka, Malaysia, Indonesia, Taiwan, Polynesia, Micronesia, and most places in the South Pacific Islands and the Philippines.

Areca nut is chewed by approximately 600 million people worldwide.[4],[5] It is the fourth most commonly used substance of abuse in the world after nicotine, ethanol and caffeine.[3],[6] It has been reported that prevalence of consuming areca nut irrespective of other additives has reached 20-40% among 15 year olds and the older population of South-East Asia.[7] In India, areca nut is used either alone as a nut or as a raw or processed form mainly along with tobacco.[1] It is more often used as an ingredient in different products such as in betel quid (pan), in mawa or as gutka and pan masala – which are the major forms of its consumption. Sweet/scented supari also contains areca nut, sugar or artificial sweeteners, often spices (e.g. cardamom, anise seed) and other flavoring and coloring agents.[2],[4],[8] The most common smokeless tobacco products or mixtures used by men are khaini (tobacco containing slaked lime) and gutka. The products used mostly by women are khaini and betel quid with tobacco.[4] It has become very popular with all sections of Indian society, including school children and adolescents.[2] The intake usually begins with munching a packet or two a day.[1],[6] Children are getting addicted to it as they find it more attractive than candy and toffees.[1] The youth is also fascinated by celebrities and famous public figures endorsing such areca products and brands. These products are easily available in shiny, glittery attractive looking packets in local shops at cheap rates.[1],[5]


   Areca Nut and Its Adverse Effects Top


Areca nut chewing has deleterious oral health effects and is classified as a Group I carcinogen by International Agency for Research on Cancer (IARC) other than betel quid with and without tobacco.[9] The toxic effect of areca nut extract (ANE) is mainly seen in splenic T-cells markedly as activation of suppressed T-cell and production of Th1 cytokine. Areca nut used in any form can cause oral cancer in humans.[3],[4] Those using areca nut products daily have an extremely high risk of mouth cancer in their lifetime.[4] In a case-control study with 134 cases of oral cancer and 268 controls, adjusted odds ratios for getting oral cancer were 5.1 for gutka consumption, 11.4 for supari, 6.4 for betel quid and 6.0 for chewing tobacco, all with significance at the level of P < 0.0001.[4] Many studies have also found that betel quid (with or without tobacco) is linked with pharyngeal, esophageal and liver cancer.[2],[7],[10]

There is also a strong link between areca nut use and the development of oral submucous fibrosis, which is a pre malignant condition in which there is severe scarring of inner cheek and soft palate and fibrous bands are form directly under the mucosal surface.[1] In severe cases, it can extend throughout the oral cavity, the hypopharynx and the esophagus. This scarring worsens over time, resulting in pain and progressively to inability to open their mouths.[4] Areca-nut chewing may also lead to broncho-constriction and may aggravate asthma and airway obstruction in children.[1],[4],[10] The euphoric effects as a result of consuming areca-nut are due to its alkaloid contents such as arecoline (a cholinergic agent and central nervous system stimulant that increases the amount of acetylcholine in the brain), and arecaidine (a hydrolyzed product of arecoline).[1],[3] Other complications related to consumption of the areca nut included gingivitis and staining of teeth.[1],[3] A number of systemic diseases such as diabetes mellitus, hypertension, cardiovascular diseases and systemic inflammations have been found to occur in connection with areca nut consumption.[3],[7],[10] Also, expectant mothers who chew areca nut and other formulations during pregnancy have significantly increased rate of lower birth weight, reduced birth length and early term.[3],[10]


   Policies Regarding Areca Nut in India Top


Using available data, during 1961 through 2016 in India, areas used for areca nut cultivation nearly tripled, while its production increased five times.[4] From 1995, with increasing demand, the industry began to import low-cost areca nut, leading to low domestic prices.[4] In 2002, in response to complaints from farmers incurring losses, the Government of Karnataka included areca nut under the Market Intervention Scheme of the Central Government, which included the application of a Minimum Support Price.

Under the Prevention of Food Adulteration Act 1954, India is successful in making the consumers aware about the deleterious effects of areca nut by making the manufacturers write about the dangers of areca nut on their packets through simple text warnings in small font, generally in English.[4] Notwithstanding these warnings, consumption of areca nut products has reached high levels. Unlike tobacco, areca nut has no global policy treaty or framework to provide an evidence-based platform for reducing the burden of areca nut use.[4]

Many countries in South-East Asia Region (SEAR) have initiated steps to regulate smokeless tobacco. Bhutan has banned the manufacture and sale of tobacco (smoke and smokeless) products. Thailand has ban on import of smokeless tobacco products. Nepal has banned the use of smokeless tobacco products in public places. Myanmar has banned the use of betel quid chewing in government premises. Democratic People's Republic of Korea (DPRK) has banned smokeless tobacco products through a recent legislation.[8] India also has examples of sub-national ban on production and sale of flavored and packaged smokeless tobacco products with some state governments imposing such bans for regulating smokeless tobacco.[4]

The Food Safety Standards Prohibition and Restrictions on Sales Regulation No. 2.3.4 and Food Products Standards and Food Additives Regulations No. 3.1.7 of 2011 has banned the manufacture and sale of products containing areca nut with tobacco or nicotine and food products containing magnesium carbonate, respectively, in some state and territories like Delhi, Odisha, Maharashtra, Chennai, Goa.[4] However, these policies have not been uniformly enforced in all the states and still manufacturers have continued to make and sell such products locally in the guise of exports, typically evading taxes.[4]

Despite knowing its menace, areca nut with or without tobacco is still promoted, advertised and aggressively marketed in many other states as its production is encouraged as a commodity for both local consumption and for export, thereby having a great source of income.[11] Government needs to take strict action against manufacturers, its cessation and prevention programs.[11] Research has shown that taxation is one of the most effective interventions to reduce consumption at a population level, especially among those aged 13–25 years.[11] Also, crop substitution should be considered in any policy approach to reduce areca nut uptake and use.[11] Proper implementation of laws prohibiting the sale to minors and in the vicinity of schools would help to prevent the products containing areca nut from being used by children. School-based areca nut control programs should be conducted to prevent its harmful effects and also to prevent the initiation of these products – something that should not be left entirely to non-government agencies.[4],[2]

Meeting of experts was held in India 2018 with the agenda to tackle the increase usage of areca nut.[8] Global Knowledge Hub on Smokeless Tobacco Products—in accordance with Framework Convention on Tobacco Control (FCTC)—has been setup in India with support from the WHO FCTC Secretariat and Indian Ministry of Health. It aims to solve the existing research gaps in respect of smokeless tobacco products, including identification of the ingredients in the products available in the market, fixation of standards and validation methods to identify the contents of different smokeless tobacco products, based on their properties, constituents, and manufacturing methods.[8]


   Measures to be Taken Top


There is an urgent need for good polices and regulatory measures in view of increased availability and consumption of areca nut products and their associated health risks.[8] There is no testing facility for tobacco products in the region. India has been making efforts to establish tobacco testing laboratories for more than a decade.[8]

Once established, these laboratories can serve a regional reference for testing the contents and emissions of various smokeless tobacco products and claimed non-tobacco products, such as supari and pan masala. Also, along with the laboratories, it is important to develop practical and scalable guidelines for testing and measuring the “main” contents of popular and commonly prevalent smokeless tobacco products.[8]


   Conclusion Top


Thus, it can be seen that areca nut is addictive and highly dangerous. It is consumed in many parts of the world by people of all the age groups and poses a number of health risks. There is substantial evidence for carcinogenicity of areca nut in oral cavity, pharynx, esophagus, liver. As most states appear reluctant to enforce notified bans of areca nut products containing tobacco or to ban areca nut-only products, effective policies and strategies are required to regulate the use of smokeless tobacco and related products. Effective actions should be undertaken to increase awareness regarding health risks among general public and to minimize its use both at personal and government levels. It is hoped that in the not too distant future, an international policy framework will come into being, along the lines of that for tobacco.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Khandelwal V, Nayak AU, Nayak PA, Khandelwal S. Sweetened areca-nut chewing habit: A public health issue among school children of Indore, India. South East Asia J Public Health 2012;2:73-6.  Back to cited text no. 1
    
2.
Srivastava R, Devi P, Jyoti B, Wazir SS. Prevalence of arecanut chewing habit among high school children in Kanpur- A Cross Sectional Study in North India. I J Pre Clin Dent Res 2014;1:15-2.  Back to cited text no. 2
    
3.
Chandak RM, Chandak MG, Rawlani SM. Current concepts about areca nut chewing. J Contemp Dent 2013;3:78-81.  Back to cited text no. 3
    
4.
Gupta PC, Ray CS, Papke RL, Stepanov I, Khariwala SS, Chaturvedi P, et al. Perspectives on areca nut with some global implications: Symposium report. Translational Res Oral Oncol 2018;3:1-8.  Back to cited text no. 4
    
5.
Wali A, Siddiqui TM, Shahab A, Ejaz A. Knowledge, attitude and practice of areca nut, gutka and tobacco smoking amongst school children in Karachi. Res Rev J Dent Sci 2016;4:39-42.  Back to cited text no. 5
    
6.
Khandelwal A, Khandelwal V, Saha MK, Khandelwal S, Prasad S, Saha SG. Prevalence of areca nut chewing in the middle school-going children of Indore, India. Contemp Clin Dent 2012;3:155-7.  Back to cited text no. 6
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7.
Qureshi A, Dawani N, Shaikh AA. Areca nut consumption patterns among primary school children of Karachi. J Dow Uni Health Sci 2013;7:25-9.  Back to cited text no. 7
    
8.
Kaur J, Thamarangsi T, Rinkoo AV. Regulating smokeless tobacco and processed areca nut in South-East Asia region: The journey so far and the road ahead. Indian J Public Health 2017;61:S3-6.  Back to cited text no. 8
    
9.
Singhvi A, Joshi A, Bagul N, Bhatia S, Sngh G, Gupta R. The insight for initiation and maintenance of areca nut chewing habit and its effects on oral health status among school age population in Western Rajasthan, India. J Clin Diagn Res 2016;10:15-8.  Back to cited text no. 9
    
10.
Garg A, Chaturvedi P, Gupta PC. A review of the systemic adverse effects of areca nut or betel nut. Indian J Med Paediatr Oncol 2014;35:3-9.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Mehrtash H, Duncan K, Parascandola M, David A, Gritz AR, Gupta C, et al. Defining a global research and policy agenda for betel quid and areca nut. Lancet Oncol 2017;18:767-75.  Back to cited text no. 11
    




 

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