The risks of betel-quid and tobacco chewing

Prof Kasturi Warnakulasuriya - Kings College London, London, UK

My talk today at the International Association of Oral Oncology relates to the epidemiology of risk factors for oral cancer. We have known for a long time that there are major risk factors but today we discussed the emerging risk factors and new findings. Human papilloma virus, indeed, is an emerging risk factor in many populations and some of the speakers were talking about the data from the USA, from Brazil, as well as from Europe. My talk today was mainly focussed on the South Asia and Asian Pacific region and what was not known to us before 1985 was that areca nut, which is a substance which is chewed by 600 million people in that part of the world, is a carcinogenic substance. We thought that you had to add tobacco to the betel-quid for it to become carcinogenic but the evidence which has been evaluated by the IARC, or the International Agency for Research on Cancer, has clearly shown that areca nut alone or betel-quid without tobacco can cause oral cavity cancers and does cause oral cavity cancers. We have looked at the relative risk and the attributable risk of this particular habit, confirming its carcinogenicity.

So it’s important in terms of population, education and public education to make sure that this message is fairly well established in these countries where there is a high incidence of oral cancer.

Is there going to be a drive to getting the substance controlled, as with tobacco?

At the moment there are no control measures at all because it’s sold freely in most shops and it’s available to children as well. One of the studies we did in Micronesia was that school children aged 13 were chewing this. So we need to really bring forward control measures and I think agencies such as the WHO should initiate such activity. But what we can do as public health people is to first make sure that the public is aware of this and through informed nuclei in the society we can bring forward this message to people.

How can you persuade governments to make this a public health issue?

The governments need to look at the health economics of this and take into account the amount of suffering as a result of the disease. Perhaps it has to come from global organisations to individual governments to take action. The WHO is doing this at the moment but we need to take this forward as an agenda for many member countries in this region.

What’s the take-home message?

Betel-quid without tobacco or areca nut, which is the primary substance in the betel-quid, is carcinogenic to man. This is proven from epidemiological studies, from animal experimental studies, and this needs to be embedded in public health education messages in the countries in South Asia in the Asian Pacific region so that we can reduce the incidence of this disease for the future.