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Indian Journal of Medical Sciences, Vol. 61, No. 6, June, 2007, pp. 319-321 Editorial Areca nut : The hidden Indian 'gateway' to future tobacco use and oral cancers among youth Chandra PrabhaS, Mulla Uzma Department of Psychiatry, NIMHANS, Bangalore Code Number: ms07049 The article ′Areca nut use in rural Tamil Nadu: a growing threat′ [1] in this issue highlights the problems related to what is considered a benign and socially acceptable habit among Indians. The nature of areca nut use in the country is changing in its content and pattern and hence is poised to become a major health threat, particularly to the impressionable and hence vulnerable youth of India. Recent literature has highlighted three issues. Firstly, the prevalence of, and dependence on, areca nut use in India is increasing rapidly, in the form of consumption of pan masala, especially by the youth. [2] This is in contrast to earlier forms of use with betel quid and mainly on social occasions. Pan masala is easily available in both rural and urban areas, and there are no age bars to the purchase and use of this substance. [3] Secondly, most pan masala preparations, in addition to areca nut, have tobacco in them and also include other substances such as arecoline, catechu, tannin. These have been found to promote excessive and harmful use and also lead to dependence. [4] What is considered benign areca nut use hence acts as a gateway to tobacco use very early in life. A study from Delhi reported the prevalence of areca nut use to be 11.74% among high school students. What is also interesting is the finding that the prevalence of combined areca nut and tobacco chewing in this population was equal among girls and boys. This form of tobacco use hence seems to be less of a social taboo for young women compared to smoking. [5] A recent study on television advertising of pan masala raised a possibility of pan masala advertisements being a surrogate for tobacco products. [6] Thirdly, unlike what is commonly understood, there is enough evidence to suggest that all areca nut products, even those without tobacco, are associated with oral submucous fibrosis (OSF), with the risk being greatest for pan masala. The duration of the habit is more significant than the frequency of the chewing habit, which again underlines the fact that the younger the age of onset, more is the risk for OSF. Both the duration and daily frequency of areca nut use increase the risk of cancer, suggesting a dose-response relationship. [7],[8] An increased risk for the development of oral malignancy (oral squamous cell carcinoma) and its precursors leukoplakia and submucous fibrosis has been reported in various studies of ′areca nut′-only users, with adding tobacco further increasing the risk. [7] A chemical and toxicological evaluation of pan masala revealed the presence of well-established carcinogens like polyaromatic hydrocarbons; nitrosamine; toxic metals such as lead, cadmium, nickel; residual pesticides like DDT and BHC; various types of fungi like Aspergillus, which is known to produce aflatoxin, a potent liver carcinogen. Also, arecoidine, tannin in catechu; and super oxide ions generated due to auto-oxidation of polyphenols and interaction of catechin with lime are all suspected to have carcinogenic potential. [8] Apart from the carcinogenic potential, areca nut has been shown to be addictive, and development of typical dependence symptoms has been described. [8] Public perceptions appear to have a major role to play in maintaining this habit. The general level of awareness regarding the ill effects of areca nut use on health has been found to very low, as reported by the study in this issue. Regarding the health effects of chewing areca nut, the older generation believed that the use of areca nut products could cause no harm as they themselves have been pursuing the habit for a long time without any health problems. One study revealed that there was awareness in the community regarding gutkha and tobacco use leading to cancer, but it did not apply either to areca nut alone or the areca nut component of the gutkha. [9] A rural community study showed that initiation of the chewing habit was approximately between the ages of 13 and 15 years, and young boys who were employed (as opposed to those who went to school) were under the impression (provided by their peers) that chewing areca nut products would give them relaxation and thus would help them forget their problems. The older people considered areca nut to be part of their life and were not alarmed by the fact that young kids indulged in high-risk behavior. The mentioned community study also revealed that since chewing areca nut products was considered a personal habit, the community thought that no action could be taken at the village level and that only self-realization could decrease the prevalence in the community. While some felt that it might not be possible to ban areca nut products with tobacco, which have a large consumer base, from the community, some adolescents viewed that if these products were made unavailable in the local markets, the prevalence of the habit would consequently decrease. [9] To conclude, it appears from the above evidence that areca nut use in its current form is becoming a potential health threat that will affect the younger generation in India. Existing tobacco control programs are a good medium to incorporate education related to the risks of areca nut use, with or without tobacco. We need to start young and discuss areca nut, particularly the use of pan masala, with school children. The challenge will be to make the prevention programs for areca nut and pan masala as catchy and attractive as the advertisements that propagate them! References
Copyright 2007 - Indian Journal of Medical Sciences |
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