Perspectives Regarding the Betel Nut Industry: Sustainability and Public Health Open Access

Betel nuts have traditionally been consumed in some countries. The seed may be prepared in several ways and chewed directly or combined with ingredients like betel leaves, slaked lime, tobacco, and various seasoning spices, based on cultural preferences. Some countries, such as India and China, have documented its historical herbal medicinal application. It is widely prescribed in China as part of some key ingredients in herbal formulations in clinical hospitals that provide traditional Chinese medicine. There are detailed records of its classification, properties, processing, and pharmacology in official reference materials. In addition, there is a work-related basis for consumption, as some professional drivers claim it keeps them awake. The psychoactive product's popularity ranks just below caffeine, alcohol, and nicotine, possessing a global user base of at least 600 million for betel nut–associated products.^[1] However, unlike tobacco and alcohol, most of its user base is pertained to the developing world, particularly the Asia-Pacific regions. According to official Food and Agriculture Statistics by the United Nations, 1.1 million hectares of areca nut were cultivated in 2021, yielding a production of 2.4 million tons valued at $5.5 billion USD.^[2] The betel nut industry in China alone was valued at 78.1 billion Yuan, covering agricultural and processing plants dedicated to product manufacturing according to the China Market Regulation News managed by the State Administration for Market Regulation.^[3] Like the issue with tobacco farming, many families rely on this work to support their livelihoods. Therefore, regulation for such products has always been a challenge in developing countries.

There were many studies carried out in past decades to address the public health concerns with consumption of betel nuts, as betel nut consumption became interest of public health agencies, e.g., the National Institutes of Health (NIH), the World Health Organization (WHO) and others. The main active ingredient, arecoline, was recently evaluated in 2021 and categorized as a Group 2B substance, denoting its possible carcinogenic property in humans.^[4] Some studies have now begun to focus on details regarding the processing of betel nut products and their relationship to the amount of active ingredients.^[5,6] Other research efforts have been made to the product’s effects, as its components have been implicated to alter the immune and inflammatory response in its users, while also affecting cell proliferation and inducing cell death in others.^[7] As such, further validation studies and evidence-based research are needed before comprehensive public health advice can be assigned and implemented.

Public health agencies and governments have initiated warnings and advice on betel nut usage to address issues associated with betel quid consumption, for example betel nut consumption is deemed illegal in many countries, such as Australia, United Arab Emirates and others. However, the effectiveness of these actions in reducing usage and addressing the public health issue remains largely inadequate, especially when applied in the context of developed countries. As it is still an economically significant crop for many developing countries, there should be more studies done for its economic significance and sustainability, particularly for understanding its revenue income, public health funds source, and its other public health priorities in these countries. Comparisons could be made regarding possible difficulties arising during the implementation of effective tobacco control measures, in which control efforts in developing countries may be largely hampered by issues related to sustainability, resource availability, and implementation troubles, despite a good systematic global framework.^[8]

To counteract the issue of poor implementation in intervention and control, we have recently started to see the digital intervention for tobacco control in China, such as the one managed by the Chinese Center for Disease Control and Prevention, targeting specific audiences.^[9] This type of digital intervention makes data collection more accessible and better able to obtain monitoring in a country heavily dependent on their mobile devices, while also enacting as a foundation for action, notice, and education in the future when necessary. Its success could provide a framework for future actions related to betel nut products, either for accurate data retrieval, or as a method of intervention. Additionally, such digitally-enabled interventions can be potentially combined with other public health messaging, reinforcing the message and educational components. For example, they can be combined with mobile-enabled public health messaging for tobacco smoking, alcohol and betel nut consumption ^[10], as these three behaviors often co-exist in the same individuals and population groups.

Several other digital interventions have been implemented at a community level in the last few years. As the message needed to reach to the consumer, such messaging was mostly mobile technology-based, so that it provides a perceived personalized connection as much as possible, and hopefully the precipitation of the public health messaging. Such examples include the platforms for telemedicine in India that can now accommodate online counselling for betel nut cessation ^[11]. A different approach has been championed in Odisha, India, where health-focused mobile apps have been developed to raise awareness about the dangers of betel nut chewing. These apps provide educational content, harm-reduction strategies, and testimonials from former users ^[12]. However, these apps remain largely extensions of existing designs, and there is a general lack of an innovative approach that would be tailored to betel nut cessation, e.g., health apps with educational content targeted to high-school populations of rural communities, or social media-enabled campaigns linked to public health messaging, usage screening and/or healthcare provision.

Betel nuts have been a staple of many Asia and Pacific regions and their demographics, consumed across genders and age groups, many being influenced at a young age, and initiated during youth to the product, functioning as a social activity. In the beginning, providing betel nuts was an etiquette and display of social status and wealth, available to guests during significant events such as births and weddings, as well as being gifts to important friends and people. The popularity of the crop eventually spread among all social classes, as it became more accessible. It has evolved to be a product with significance in terms of social and cultural perspectives. Furthermore, there are entire towns and villages designed around the cultivation and processing of such crops, providing an economic dependency of the products’ agricultural and manufacturing industry from the individuals who work there to support their families. Therefore, an outright ban on such a socially and culturally significant item would likely be ineffective without providing alternatives and subsidies to support individuals during transitional times and provide them with opportunities to transform their products toward an alternate sustainable industry.

Presently, governments, including those of India and China, do acknowledge the health concerns associated with betel nut products and potential substance abuse problems. They have taken steps to enact certain laws aimed at addressing the prevalence of these products, such as imposing media bans and tax impositions.^[13] Overall, there are limited resources directed to scientific research in many low- to middle-income countries and regions to make evidence-based decisions compared with the developed countries, and betel nuts are predominately consumed in regions with fewer resources for research. The issue is also not a priority compared with other public health concerns, given its generally lower prevalence than tobacco and alcohol. These latter issues can often take precedence in terms of attention and resources being dedicated to addressing the concerns of betel nut products, and possibly will hamper the facilitating a direction that the industry can take with limited effort through product bans.

A balance should be established between public health priorities and financial public interest, an idea underscored and discussed in Redman's paper.^[14] Both global and local authorities, as well as the affected industries, need to carefully consider both aspects of the issue. This involves addressing the treatment of a public health concern related to the product’s health impacts, while simultaneously ensuring the supply of a sustainable product that can economically support those dependent on the income it generates. However, the paper also critiques the possible overt conflict of interest imposed by industrial bodies on relevant research without transparent disclosure of their practices and data, which often is unacknowledged without access to common industrial agendas and systems.

To facilitate a sustainable product, for example in the existing traditional chinese medicine formulary, that would not interfere with health authorities’ goals of minimizing public risk from betel nut products, the industry will need to actively participate in research to address the health risk of betel nut usage. But to combat possible conflicts of interest, although not always purposeful other than not wanting research outcomes to place a negative perception on their products, an active track of its progress visible by health authorities should be implemented to rid of industrial bias and maintain research integrity. Incentives such as possible research partnerships with the government, or direct funding aids can help facilitate these activities. Release of an active research track and all associated research data will also provide public vestment in the issue, as they can be invested with the research, or the data can be used by governments to educate the public of the dangers of betel nut usage under problems of substance abuse. Digital platforms authorized by governments like those used for digital intervention of tobacco can also be used as tools in partnership with the industry to collect valuable and open data on individual, population, and subpopulation levels. These actions together can act as a trustworthy framework between the authorities and the industry, providing transparency and accountability for all parties toward the consumers of the product to the benefit of all.

All in all, if direct authoritative interventions like product bans are considered, there will also need to be considerations regarding how interventions can impact all of the different uses, from traditional medicine to recreational, as well as the region it has dependencies on, and providing a solution that considers such impacts. Having educational setups to acknowledge the usage of such products, while also needing to provide long-term economic plans for those who are majorly affected and economically dependent on such an industry, may ease those affected if bans are initiated as a public health policy, which is especially important for developing countries with limited resources. Perspectives from all affected parties should be considered, from the sustainability of the stakeholders, and the public health issues the demographics can face. For now, the digital health applications may provide a viable, impactful and sustainable solution forward, as they can be addressed at the individual level across large populations and remote geographies, yet providing consistent messaging.