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Year : 2019  |  Volume : 30  |  Issue : 4  |  Page : 612-621
Areca nut use disorder: A dynamic model map

Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, Affiliated to the Tamil Nadu Dr. MGR Medical University, Chennai, Tamil Nadu, India

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Date of Submission31-Dec-2018
Date of Decision05-Feb-2019
Date of Acceptance21-Mar-2019
Date of Web Publication18-Nov-2019


Problem: Areca nut (AN) chewing is common among Southeast Asian population. Use of AN products (with or without tobacco) have a multifaceted effect on physical health, especially on cardiovascular, nervous, gastrointestinal, metabolic, respiratory, and reproductive systems. AN is a known group 1 carcinogen and carries addictive potential. Varying degrees of AN-related substance use disorder (SUD) have been reported among AN chewers. There is a lacuna in awareness of the health risk of AN use, prevention, and cessation programs among AN users, particularly in those who have developed SUD. Existing Lacunae: The dynamic interaction of factors that promote AN use and later the risk of developing SUD at individual and community level has not been studied in depth. Understanding of the bio-psycho-socio-economic-cultural factors is necessary to identify the factors that prelude, promote, and reinforce AN usage. For managing AN-related conditions, including the several systemic disorders, there is a knowledge lacunae, among health care providers with respect to the pathophysiology of AN-related health issues, SUD, and nonavailability of structured, evidence-based cessation protocols. Solutions/Recommendations: This manuscript presents a model-map to study the dynamics of AN use and the impact of AN on health and health care system at individual as well as community level. The model proposed can help the health policymakers to create evidence-based awareness and cessation protocols for AN.

Keywords: Areca nut, cessation, deaddiction, oral submucous fibrosis, Substance use disorder

How to cite this article:
Thavarajah R, Ranganathan K, Joshua E, Rao UK. Areca nut use disorder: A dynamic model map. Indian J Dent Res 2019;30:612-21

How to cite this URL:
Thavarajah R, Ranganathan K, Joshua E, Rao UK. Areca nut use disorder: A dynamic model map. Indian J Dent Res [serial online] 2019 [cited 2023 Mar 30];30:612-21. Available from:

   Background Top

Globally around 600 million people use areca nut (AN), making it the fourth most common psychoactive substance used.[1] In India, about 10% of population regularly use AN (with or without tobacco) in some form.[2],[3],[4],[5],[6],[7] Habitual, long-term use of AN is associated with several health issues, the foremost of which is oral submucous fibrosis and oral cancer.[1] The carcinogenic potential of AN was recognized by the International Association of Cancer Research, Lyon, France in 2004.[8],[9],[10],[11],[12],[13] Long-term use of AN can also lead to diseases of brain, nervous system, heart, lungs, skeletal system, gastrointestinal tract, and reproductive organs [14],[15],[16],[17],[18] [Figure 1]. Pooled data analysis of 17 studies from South Asian countries, involving a cumulative sample size of 121,585 subjects, show that the adjusted relative risk of AN chewers as compared with nonchewers for obesity, metabolic syndrome, diabetes, hypertension, cardiovascular disease, and for all-cause mortality were 1.47, 1.51, 1.47, 1.45, 1.2, and 1.21, respectively.[16] Although AN has been associated with such health hazards it has not attracted as much medical attention as tobacco.[19],[20],[21]
Figure 1: Diseases, disorders, and medical conditions caused by habitual AN consumption . FEV1, Forced expiratory volume in 1 second; BP, Blood pressure; IL, Interleukin; IFN, Interferon; Th, T-helper cells; RBC, Red blood cells; T3, Triiodothyronine; T4, Thyroxine; TSH, Thyroid stimulating hormone

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AN is perceived in some cultures as a nonharmful product with medicinal values.[1],[7],[14] Consumption of AN is a socially established practice that finds a central place in traditional Indian Hindu worship offerings and religious and social functions.[1],[14],[22],[23],[24],[25] AN stimulates the mental alertness and gives the user a sense of well-being. The neurological effect and psychoactive perception of AN/AN product consumption is subtle and has been documented.[1] AN causes low intoxication manifestation without stigmatization and leads to continuous use of AN/AN products, to which other substances of abuse such as tobacco may be added.[1],[7],[26]

Habitual use of AN may lead to a substance use disorder (SUD), which we refer to here in this manuscript as the areca nut use disorder (ANUD). A recent study has shown that significant proportion of Southeast Asian population using AN alone or together with tobacco have features of ANUD.[27] Also, it has been shown that patients chewing AN with tobacco (as gutkha) failed to respond to regular, standard nicotine replacement therapy. The pattern of response could be attributed to the fact that the SUD mechanism of AN with tobacco (as gutkha) is NOT similar to that of use of tobacco or AN alone.[28],[29],[30],[31],[32],[33] ANUD is a dynamic phenomenon influenced by several factors. The development of habituation/SUD/addiction/dependence to AN is not fully deciphered and the biology of AN is complex.[1],[7],[28],[29],[30],[31],[32],[33]

We propose models to understand ANUD and its influence on the society in a dynamic fashion. The model-maps would facilitate study of the ANUD at multiple levels in an interactive pattern, as opposed to traditional approach of assessing single or multiple factors without dynamicity. This approach would be useful to frame policies and guidelines for combating ANUD.

   An-Related Macro-Environment Prevalent in Society Top

This model-map is based on similar system dynamic framework concept proposed for tobacco control [Figure 2].[34],[35] Society, being a dynamic entity, reacts to the burden of diseases caused by ANUD and AN use. Attempts to cut down morbidity are made by framing policies, imposing legislation, and taxes.[36],[37],[38],[39] This in turn affect the use of AN at the individual and societal level.
Figure 2: Scheme of the consideration of factors that influence AN and/or its products consumption in India

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The dynamic model of AN is based on three factors [Figure 3]: (1) The individual AN user as a part of the society has AN-associated morbidity; (2) the intervention strategies evolved by the society; and (3) the response of the AN lobby to such strategies.[34],[35],[36] Several individual characteristics dictate the regular use of AN. AN control interventions (at an individual and community level) could be through (1) media, (2) health care system, and (3) the academia/intellectuals. Such interventions, would have an impact on the individual AN users. The pro-AN lobby (cultivators, industry, and marketing chains) would resist the intervention measures. In this complex environment, the effects of any AN control initiatives could be initial/immediate, intermediate, or long-term. For example, as a result of price hike on AN: (1) immediate outcome would lead to decrease in use of AN or accumulation of AN stocks; (2) intermediate outcome would be reduction in tax collections, as demonstrated in Taiwan;[40] and (3) long-term outcome would be reduction in AN-related disease burden in society.[40]
Figure 3: Dynamic interactions in the existing model between individual, policies, AN industry, and the impact on change in disease pattern

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   Physical Health System's Response to an Consumption Top

Non-AN users (“healthy population”) and potential AN users (“experimenters”) together live in society. [Figure 4] depicts the factors that influence AN use (individual, societal, bio-social factors, government policies, media), morbidity/comorbidity, and prevention and treatment aspects of AN that are available.
Figure 4: Society's response to AN and/or its products use factors in the existing system. Rectangles with black letters represent the population characteristics; rectangles with red/green letters—characteristics of influences (red: negative influence; green: positive influence). Straight arrows represent flows of people. Curved arrows indicate causal influence

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The societal and environmental (bio-social) factors may precipitate the precarious use of AN. Succumbing to the adverse influences, “attempters” or “experimenters” use AN. If continued, they progress into regular users, become habituated, or develop ANUD. The individual influencing characteristics include: (i) age, (ii) gender, (iii) immediate socio-cultural environment, for example, occupation, (iv) type of AN used, (v) education levels, (vi) frequency, intensity, and duration of use. The discussion of these interactions has been reported earlier.[1],[7]

When several individuals develop ANUD, the prevalence of AN in the society increases. The increase in AN use is identifiable as a gross (i) increase in availability of AN products in society; (ii) increased AN-related commercial activities—production, transport, sales; (iii) increase in tax revenues; etc., When used for prolonged period, the users exhibit evidence of AN-related diseases. It could be a regional AN-related oral/esopharyngeal disease or systemic disease. There is a need to institute treatment for the ANUD. If untreated, ANUD results in oral submucous fibrosis that may progress to oral squamous cell carcinoma. The disease burden on the individual and society thus increases, which in turn affects the social, economic, and financial well-being domain.[1],[7],[13]

The left of [Figure 4], address issues such as (i) deprivation, (ii) poly-substance abuse, (iii) discrimination, (iv) inequalities, (v) environmental issues, (vi) stress, (vii) social/health insecurity, etc. For effective ANUD control, the above factors need to be addressed. Policies should address mutual accountability between society (individuals as a part of the society), and the policymakers, and while maintaining principles of democracy as well as freedom with an aim to preserve the health of the society. The right side of [Figure 4] highlights the steps involved in the management, which needs to focus on (i) health education, (ii) screening for diseases, (iii) management of AN policies, and (iv) physical and financial access to clinical services.

Primary prevention measures developed could help prevent morbidity among the “at risk population.” When the habit associated disease evolves, secondary intervention measures need to be implemented to minimize the mortality/morbidity, with the goal of controlling the disease and improving the quality of life. There is a need for large-scale primary and secondary intervention programs in a society with high number of ANUD or regular AN users. This underlines the need for ANUD cessation protocols or harm reduction measures, which do not exist unlike for tobacco.[1],[7]

For AN-associated comorbid conditions, disease control can be achieved only when AN consumption control is addressed. For diseases such as oral cancer, the morbidity and mortality continue to remain high. Measures for habit cessation should be emphasized, given the AN associated systemic effects such as obesity, metabolic syndrome, diabetes, hypertension, nervous disorders, and cardiovascular diseases.[16] Regional medical associations in India have responded to this growing problem by publishing position papers regarding AN with diabetic control.[41]

   Policies and an Consumption Top

Considering the impact of AN on human health, several Asian countries have attempted to regulate the production, advertisement, sale, and consumption of the AN. However, the increasing use of smokeless tobacco and/or AN use in India stands as a testimony to failures of such programs.[3],[4],[5],[6],[42],[43],[44],[45],[46],[47],[48],[49],[50] The regulation of chewing AN with or without tobacco has met with different outcomes in Southeast Asian countries. In Sri Lanka, it was deemed successful while in other countries, the outcomes were not so successful.[1],[7],[51],[52],[53],[54]

AN and ANUD habit burdens the Indian society not only due to diverse health issues but also the resulting economic and other outcomes.[1],[7],[55],[56]

Individuals may take up, owing to its use being symbolic of (1) individual freedom, (2) personal informed choice, and (3) cultural identity. Their arguments fail to account the burden of health issues associated with deleterious habit of chewing AN.[56] Besides the health cost, hidden costs involved are: (1) soil erosion; (2) use of water for cultivating intensive AN farms; (3) depletion of water table; (4) pollution from packaging materials that have a negative impact on the entire society.[56] India known to be successful in abolishing cultural practices, such as prevention of child marriage, female infanticide, and in combating illiteracy.[57],[58],[59] Given these successful stories, it is now necessary for its policymakers to take unanimous decision willingly to work toward the perception of AN in society.

   Economic Dimensions of an Consumption Top

AN brings in substantial revenue to government,[39],[40] and this explains the prevalence of AN cultivation in India, but in parallel, there is a relative vacuum (as compared to tobacco) in highlighting the burden of its use to the public.[39],[55] In post-colonial India (1961–2016), tobacco cultivation increased by 1.12 times while the average production increased (volume) 2.48 times. In the same period, the production of citrus fruits, vegetables, and cereals increased in terms of cultivation (10.12, 2.97, and 1.07 times, respectively) and production (9.94, 6.56, and 3.37 times, respectively). AN cultivation increased by 3.5 times since 1961 and the productivity increased by 5.86 times.[60],[61] The production of tobacco and AN in terms of cultivated area and tons of produce are nearly equal [Table 1]. Also, in the year 2016–2017, India exported 20.89 million USD worth of AN and 1.72 million worth of other AN products. In the same period, India imported 42.76 million USD worth of AN and 34.77 million USD worth of other AN products.[62] The Government of India, via the surcharge on tobacco and panmasala products is projected to earn a surcharge tax (additional tax besides mandatory taxes) of INR 3400 crores for the year 2017–2018.[63] These figures indicate that commercial AN production is as important as tobacco in India.
Table 1: Comparison of tobacco, areca nut and agricultural produce between 1961 and 2016

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   Cessation Biology and Modalities Top

Reports show that AN has a distinct neurobiological action on brain and shares some pathways with tobacco.[32],[33] Bayesian-meta cognitive concepts explain addictions and cravings, as a process involving two components (1) processing information of self-relevant physiological information gathered (use of AN) and (2) evaluation of such information at a meta-cognition level, including past experiences, which occurs in the human lateral prefrontal cortex area of the brain.[64] This part of the brain is also involved in drug addiction process and altered in chronic AN chewers,[65],[66],[67],[68] underlining the fact that ANUD is more severe than normally perceived and highlights the need for a customized AN cessation protocol. Concomitant use of tobacco with AN further facilitates habituation/SUD/dependence process. Understanding the mechanism of ANUD and AN craving is fundamental to plan pharmacotherapy.[33]

In the past, tobacco, a common addictive with AN, was considered to be the cause for the SUD/dependence/addiction.[27],[28],[29],[30],[31],[32],[33] There is increasing body of evidence to indicate AN causing ANUD.[69],[70],[71] Additionally there is a need for AN cessation at primary and secondary prevention levels. Such a program needs to focus on individual intervention by society. Because individual domains of tobacco addiction are different from ANUD, a tailor made protocol for ANUD may be needed.[1],[7],[27]

There are lessons for ANUD cessation from ongoing tobacco cessation programs. Tobacco intervention in India has a long history with varied outcomes.[72],[73],[74] India needs trained health professionals to deal with tobacco intervention. Till a decade back, in parts of India (1) 60–80% of doctors failed to take tobacco history during medical interview; (2) there were misconceptions on tobacco use.[75],[76],[77] Mass cessation programs are better than clinic-centered, intensive, individual approach.[78],[79],[80] Multi-intervention model is beneficial than using a single one.[72] Technology-driven cessation methods, such as (1) telephone counseling, (2) dedicated quit lines, (3) mobile- and web-based technologies, need to be adapted in the Indian context.[72]

Indian AN products contain many unknown additives, with their toxicological, mutagenic, neurobiological, and ANUD potential.[81],[82] There are certain scales for AN reported from Southeast Asian countries such as: (1) Substance use disorder scale,[69],[70] (2) Intention to Quit, (3) Reason for chewing AN, and (4) AN or betel quid dependency questionnaire.[83],[84],[85],[86],[87] These scales need modification to Indian ANUD. There is a need for a scale to assess the degree of craving for AN product. Such a scale should resemble the tobacco craving or alcohol use disorder questionnaire.[88],[89],[90] These scales have various related domains. Studying dynamic interactions of various scales (and domains) would help to understand ANUD better.[71] Also, this could aid in development of specific cessation protocols, addressing socio-cultural-religious factors.[27],[71]

Globally, there have been only a few attempts to address ANUD. There is an absence of evidence-based, universally accepted protocol to address ANUD. The available interventions are often modeled on tobacco cessation programs and subsequently refined by loco-regional experience.[1],[7],[90],[91],[92],[93],[94],[95],[96] These principles could be modified and adapted to develop region specific protocols.

   Overarching Model to Address Anud Top

The most common theories used to explain for addiction/dependence are: (1) Theories of social cognition (shared relationship between health behaviors, cognition/affect, and environmental factors); (2) triadic influences (human behaviors are often determined and shaped by broader socio-economic factors, immediate social contexts, and individual characteristics); and (3) resiliency theories (a positive behavior development perspective is dependent on internal and external factors that negate the effect of risk factors).[97],[98],[99],[100],[101] The authors found that these factors have not been studied in the ANUD context.

The proposed model-map [Figure 5] is developed accounting for ANUD, incorporating the factors in the above-mentioned theories. This dynamic model can address best individual and the society. This model is designed to consider the interactions among broadly defined states of (1) affliction (use disorder) prevalence; (2) adverse living conditions; and (3) community's capacity to act against AN. The model accomodates the socio-cultural-economic-geography of population as well as AN use. This model is robust enough to accommodate additional short- and long-term variables [Figure 5].
Figure 5: Interactions of the factors in the proposed dynamic system of interplay for AN or its products that leads to AN SUD. Rounded rectangles: factors and characteristics of AN in use—complex interactions; blue-dotted connectors: positive influence; red-dotted connectors: negative influence; purple connectors: mixed influence; block connectors: individual to community transformation via common factors

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In [Figure 5], the rounded rectangles indicate the various groups of factors and population characteristics of AN users. They are often complex within a biological range and vary widely. Inside every group, there are sub-factors that individually or in a combined fashion contribute to this system model. For example, frequency, intensity, and duration of AN use are interlinked and would influence the AN use pattern. The linear relationship between factors has been described previously.[1],[7] The connectors that are blue in color have a directly proportional relationship and those in red color indicate an inverse relationship [Figure 5]. The purple has a mixed, unpredictable relationship. For example, more the education, the lesser the chance of AN use, while the older individuals may prefer the older customary forms of AN. Demographic features may have a direct influence on the psychological constructs. The block connectors signify those factors that have a common quotient wherein the individual variations contribute to the overall collective community scores via common factors. The society factors also influence the individual characteristics. Collectively, they define ANUD of any individual or the society. Addressing all critical elements are necessary for successful control programs.

At an individual level, the domains of impaired control over AN chewing, social impairment due to AN, risky behavior of AN use, and pharmacological indicators (withdrawal and tolerance) differentiate habitual AN use from SUD.[69],[70] The individual degree of AN craving, individual preference of chewing AN (reinforcement, socio-cultural, and perceived AN-related stimulation), the betel quid dependency questionnaire (physical/physiological need, increasing dose, and maladaptive use) have been used to demonstrate the effect of AN among individuals.[83],[84],[85],[86],[87] These domains have not been reported from Indian population. The type and biology of AN product can vary widely in India due to the fact that AN products have tobacco as a vital additive.[1],[7]

The emotional, social, and cognitive quotients are based on individual characteristics.[98],[99],[100],[101] Individuals who are about to chew AN are often influenced by complex psychological processes and well designed biosocial constructs. Thus given the prevailing environment, continuous use of AN prevails in the society, since majority of individuals even with proper cognitive process, are not aware of the existing bias with respect to AN use.[56] To justify their actions, individuals would selectively perceive the positive outcomes of chewing AN while ignoring the negative effects.[1],[7],[56]

Individual constructs and biosocial factors analyzed at a community level can be used to estimate the cumulative effects of AN. The understanding of the AN-related domains at individual, community, and population level can help us design structured, focused prevention programs.

   Relevance of the Model Top

To properly utilize this model, identification of mathematical relationship between factors is needed. The concept of health (physical and mental) in ANUD users has to be widened beyond existing health definitions. This would require understanding of the holistic, bio-social connections of AN in Indian society and public health. AN-related diseases and other health conditions (such as nutritional status, anemia, diabetes, and stress) often interact synergistically in various and consequential ways.[14],[15],[16],[17],[18] The social conditions of people with AN-related illnesses are critical to understanding the impact of diseases, both at the individual and population level. ANUD scales would help to quantify and estimate the bio-psycho constructs and domains.

For combating ANUD, one needs to examine both AN-disease concentrations (multiple, comorbid diseases such as diabetes, hypertension, and disorders affecting individuals/society) and disease interactions. Indian social environment, including the prevailing structures of social relationships (such as social inequality, accessibility, affordability, and related factors) and also sociogenic environmental conditions (e.g., sales of toxic commodities, advertisement policies, packaging pollution), contribute enormously to disease clustering and interactions.[47],[48],[49],[50],[51],[52],[53],[54],[55]

Policies to regulate manufacturing, advertising and sale of AN and AN products are necessary. In India, rules have been framed to discourage public use of AN/AN products by various governmental agencies. They include: Indian Railways (penalties for activities affecting cleanliness at railway premises) Rules, 2012; The Goa Prohibition of Smoking and Spitting Act 1997; The Tamil Nadu Prohibition of Smoking and Spitting Act 2002; The West Bengal Prohibition of Smoking and Spitting and Protection of Health of non-Smokers and Minors Act 2001; The West Bengal Prohibition of Spitting in Public place 2003; The Karnataka Municipal Corporation Act 2013; The Bombay Police Act, 1951; The Bihar Municipal Act 2007. However, the enforcement and effect of these regulations as a deterrent of AN use is debatable. A study in Rajasthan, India, identified that one of the frequent reason for quitting tobacco containing AN products is the need for spitting often, which is perceived as an embarrassment.[102] Regulations may help the society to encourage individual citizens to follow the norms of the society.[103],[104],[105]

The proposed model-map address/dependence on AN in a bio-psycho-social construct. Theoretically, it can identify crucial drivers of the system. The model also facilitates prediction. Effect of AN interventions could be theoretically studied so as to estimate the outcome of intervention and predict the dynamic changes in the model. For example, tobacco-related legislations in India brought a significant change in the web search pattern for the alternative to electronic cigarettes.[106]

A similar model to the present proposal model-map is a system dynamics model of smokeless tobacco product use among Indian females living in Mumbai (then Bombay) slums.[107] However, the present model-map accounts for the bio-psycho-social constructs that can account for individual variations. The model-map proposed has several advantages, including being dynamic, accommodative, and high degree of adaptability when new factors are added. The limitation is that several factor's relationship have not been adequately documented. As existing studies on ANUD are often linear, either at individual, society, or population level more systematic work is needed to assess how these factors work simultaneously together within existing bio-social factors. Further studies need to include the mathematical relationship between the various parameters.

   Conclusions Top

India started its effort to limit tobacco use late, and even today smokeless form of tobacco use exists widely. If the harmful effects of AN or AN products are not properly addressed and the consumption is not limited, India may need to fight oral cancer from ANUD. With India increasingly being plagued by noncommunicable lifestyle diseases, AN could add to these already burdened health care system. Appropriate health care investment is needed to develop nonpharmacological and pharmacological management of AN habits, dependence, and ANUD. These should be evidence-based, catering to individual as well as mass cessation protocols accommodating socio-religious cultural ethos. Appropriate sensitization, targeted protection, and cessation programs for AN users are needed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Osborne PG, Ko Y, Wu M, Lee C. Intoxication and substance use disorder to areca catechu nut containing betel quid: A review of epidemiological evidence, pharmacological basis and social factors influencing quitting strategies. Drug Alcohol Depend 2017;179:187-97.  Back to cited text no. 1
Thakur JS, Prinja S, Bhatnagar N, Rana SK, Sinha DN, Singh PK. Widespread inequalities in smoking and smokeless tobacco consumption across wealth quintiles in states of India: Need for targeted interventions. Indian J Med Res 2015;141:789-98.  Back to cited text no. 2
[PUBMED]  [Full text]  
Rooban T, Elizabeth J, Umadevi KR, Ranganathan K. Sociodemographic correlates of male chewable smokeless tobacco users in India: A preliminary report of analysis of national family health survey, 2005–2006. Indian J Cancer 2010;47(Suppl S1):91-100.  Back to cited text no. 3
Rooban T, Joshua E, Rao UK, Ranganathan K. Prevalence of chewable smokeless tobacco in Indian women: Secondary data analysis from national family health survey 2005–06. J NTR Univ Health Sci 2013;2:29-35.  Back to cited text no. 4
  [Full text]  
Joseph I, Rooban T, Ranganathan K. Tobacco use, oral cancer screening, and oral disease burden in Indian women. Indian J Dent Res 2017;28:706-10.  Back to cited text no. 5
[PUBMED]  [Full text]  
Rooban T, Joshua E, Rao UK, Ranganathan K. Prevalence and correlates of tobacco use among urban adult men in India: A comparison of slum dwellers vs non-slum dwellers. Indian J Dent Res 2012;23:31-8.  Back to cited text no. 6
  [Full text]  
Mehrtash H, Duncan K, Parascandola M, David A, Gritz ER, Gupta PC, et al. Defining a global research and policy agenda for betel quid and areca nut. Lancet Oncol 2017;18:e767-75.  Back to cited text no. 7
Bentall WC. Cancer in Travancore – A resume of 1,700 cases. Ind Med Gaz 1908;43:452-8.  Back to cited text no. 8
Bentall WC. Cancer in Travancore, South India – A summary of 1,700 cases. Br Med J 1908;2:1428-31.  Back to cited text no. 9
Ram APB. The use of betel nut as a cause of cancer in Malabar. The Indian Med Gazette 1902;37:414.  Back to cited text no. 10
Orr LM. Oral cancer in betel nut chewers in Travancore – Its aetiology, pathology and treatment. Lancet 1933;1:575-80.  Back to cited text no. 11
Fells A. Remarks on cancer of the mouth in Southern India with an analysis of 209 operations – Read to a Meeting of the Bristol Division of the British Medical Association. Br Med J 1908;1:1357-8.  Back to cited text no. 12
Bhisey R.A., Boucher B.J., Chen T.H., Gajalakshmi V., Gupta P.C., Hecht S.S. (editors); IARC working group on the evaluation of carcinogenic risk to humans. Betel-quid and areca-nut chewing and some areca-nut-derived nitrosamines. Lyon: IARC Press; 2004.  Back to cited text no. 13
Boucher BJ, Mannan N. Metabolic effects of the consumption of areca catechu. Addict Biol 2002;7:103-10.  Back to cited text no. 14
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. 15
[PUBMED]  [Full text]  
Yamada T, Hara K, Kadowaki T. Chewing betel quid and the risk of metabolic disease, cardiovascular disease, and all-cause mortality: A meta-analysis. PLoS One 2013;8:e70679.  Back to cited text no. 16
Garg A, Chaturvedi P, Mishra A, Datta S. A review on harmful effects of pan masala. Indian J Cancer 2015;52:663-6.  Back to cited text no. 17
[PUBMED]  [Full text]  
Chen P, Mahmood Q, Mariottini GL, Chiang T, Lee K. Adverse health effects of betel quid and the risk of oral and pharyngeal cancers. Biomed Res Int 2017;3904098. Doi: 10.1155/2017/3904098.  Back to cited text no. 18
Sharma HK. Sociocultural perspective of substance use in India. Substance use misuse 1996;31:1689-1714.  Back to cited text no. 19
Strickland SS. Anthropological perspectives on use of the areca nut. Addict Biol 2002;7:85-97.  Back to cited text no. 20
Gutierrez A. Modes of betel consumption in early India. Scripta Instituti Donneriani Aboensis 2015;26:114–34.  Back to cited text no. 21
Rohel J. Empire and the reordering of edibility: Deconstructing betel quid through metropolitan discourses of intoxication. Global Food History 2017;3:150-70.  Back to cited text no. 22
Lan Y, Hser Y, Ho Y, Tsai W, Hsu J, Kang J. Patterns of adolescent chewing betel nut and later drug use in adults. Drug Alcohol Depend 2014;140:e114.  Back to cited text no. 23
Lee C, Ko A, Yang F. Association of DSM-5 betel-quid use disorder with oral potentially malignant disorder in 6 betel-quid endemic Asian populations. JAMA Psychiatry 2018;75:261-9.  Back to cited text no. 24
Joshi PS, Prashant MC, Nagpal N, Patil AA, Ahuja R, Mathur V. Gutkha addiction: Nicotine dependence or a conditioned reflex?. J Int Oral Health 2015;7(Suppl 2):45-7.  Back to cited text no. 25
Bhat SJS, Blank MD, Balster RL, Nichter M, Nichter M. Areca nut dependence among chewers in a South Indian community who do not also use tobacco. Addiction 2010;105: 1303-10.  Back to cited text no. 26
Benegal V, Rajkumar RP, Muralidharan K. Does areca nut use lead to dependence?. Drug Alcohol Depend 2008;97:114-21.  Back to cited text no. 27
Mirza SS, Shafique K, Vart P, Arain MI. Areca nut chewing and dependency syndrome: Is the dependence comparable to smoking? A cross sectional study. Subst Abuse Treat Prev Policy 2011;6:23.  Back to cited text no. 28
Farooq, A.D., Abbas, G. General aspects of areca nut addiction. In Neuropathology of drug addictions and substance misuse. Volume 3: General processes and mechanisms, prescription medications, caffeine and areca, polydrug misuse, emerging addictions and non-drug addictions. Preedy, V.R. (ed). Elsevier Inc., 1st edn; 2016, pp. 733-7.  Back to cited text no. 29
Papke RL, Horenstein NA, Stokes C. Nicotinic activity of arecoline, the psychoactive element of “betel nuts”, suggests a basis for habitual use and anti-inflammatory activity. PLoS One 2015;10:e0140907. Doi: 10.1371/journal.pone. 0140907.  Back to cited text no. 30
Stanisce L, Levin K, Ahmad N, Koshkareva Y. Reviewing smokeless tobacco epidemiology, carcinogenesis, and cessation strategy for otolaryngologists. Laryngoscope 2018. doi: 10.1002/lary. 27104.  Back to cited text no. 31
Siddiqi K, Shah S, Abbas SM, Vidyasagaran A, Jawad M, Dogar O, et al. Global burden of disease due to smokeless tobacco consumption in adults: Analysis of data from 113 countries. BMC Med 2015;13:194.  Back to cited text no. 32
Sinha DN, Suliankatchi RA, Gupta PC, Thamarangsi T, Agarwal N, Parascandola M, et al. Global burden of all-cause and cause-specific mortality due to smokeless tobacco use: Systematic review and meta-analysis. Tobacco Control 2018;27:35-42.  Back to cited text no. 33
Best, A., Clark, P.I., Leischow, S.J., Trochim, W.M.K. (eds) 1st edn, National Cancer Institute. Greater than the sum: Systems thinking in tobacco control. Tobacco Control Monograph No. 18. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. NIH Pub. No. 06-6085, April 2007.  Back to cited text no. 34
Evaluating comprehensive tobacco control interventions: Challenges and recommendations for future action. Report of a workshop convened by the Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health. Tob Control 2002;11:140-5 [Figure 3].  Back to cited text no. 35
Homer JB, Hirsch GB. System dynamics modeling for public health: Background and opportunities. Am J Public Health 2006;96:452-8 [Figure 4].  Back to cited text no. 36
Carey G, Malbon E, Carey N, Joyce A, Crammond B, Carey A. Systems science and systems thinking for public health: A systematic review of the field. BMJ Open 2015;5:e009002. Doi: 10.1136/bmjopen-2015-009002.  Back to cited text no. 37
van Olmen J, Criel B, Bhojani U, Marchal B, van Belle S, Chenge MF, et al. The health system dynamics framework: The introduction of an analytical model for health system analysis and its application to two case-studies. Health Culture Soc 2012;2:2-21.  Back to cited text no. 38
Pankaj C. Areca nut or betel nut control is mandatory if India wants to reduce the burden of cancer, especially cancer of oral cavity. Int J Head Neck Surg 2010;1:17-20.  Back to cited text no. 39
Chen S, Lee J, Liu H, Wang H, Ye C. The cross-effects of cigarette and betel nut consumption in Taiwan: Have tax increases made a difference?. Health Policy Planning 2011;26:266-73.  Back to cited text no. 40
Balhara YPS, Kalra S, Bajaj S, Kuppili PPK, Himanshu D, Atam V, et al. Uttar Pradesh Association of Physicians of India Position Statement: Betel quid (Paan) and diabetes. J Assoc Physicians India 2018;66:92-4.  Back to cited text no. 41
Sushma C, Sharang C. Pan masala advertisements are surrogate for tobacco products. Indian J Cancer 2005;42:94-8.  Back to cited text no. 42
[PUBMED]  [Full text]  
Vishwanath K, Ackerson LK, Sorensen G, Gupta PC. Movies and TV influence tobacco use in India: Findings from a national survey. PLoS One 2010;5:e11365. 0011365  Back to cited text no. 43
Goyal G, Bhagawathi BT. Knowledge, attitude and practice of chewing gutka, areca nut, snuff and tobacco smoking among the young population in the Northern India population. Asian Pac J Cancer Prev 2016;17:4813-8.  Back to cited text no. 44
Sinha DN, Palipudi KM, Oswal K, Gupta PC, Andes LJ, Asma S. Influence of tobacco industry advertisements and promotions on tobacco use in India: Findings from the Global Adult Tobacco Survey 2009–2010. Indian J Cancer 2014;51(Suppl S1):13-8.  Back to cited text no. 45
McKay AJ, Patel RKK, Majeed A. Strategies for tobacco control in India: A systematic review. PLoS One 2015;10:e0122610. 0122610.  Back to cited text no. 46
Gadiyar A, Ankola A, Rajpurohit L. Awareness of anti-tobacco advertisements and its influence on attitude toward tobacco use among 16 to 18-year-old students in Belgaum city: A cross-sectional study. J Edu Health Promot 2018;7:85.  Back to cited text no. 47
[PUBMED]  [Full text]  
Mohan P, Lando HA, Panneer S. Assessment of tobacco consumption and control in India. Indian J Clin Med 2018;9:1-8.  Back to cited text no. 48
Singh SK, Schensul JJ, Kashyap GC. The reach of media to smokers and smokeless tobacco users in India: Evidence from the Global Adult Tobacco Survey (GATS). J Popul Social Stud 2018;26:42-52.  Back to cited text no. 49
Rooban T, Madan Kumar P D, Ranganathan K. Reach of mass media among tobacco users in India: A preliminary report. Indian J Cancer 2010;47(Suppl S1):53-8.  Back to cited text no. 50
Nair S, Schensul JJ, Bilgi S, Kadam V, D'Mello S, Donta B. Local responses to the Maharashtra gutka and pan masala ban: A report from Mumbai. Indian J Cancer 2012;49:443-7.  Back to cited text no. 51
[PUBMED]  [Full text]  
Dhumal GG, Gupta PC. Assessment of gutka ban in Maharashtra: Findings from a focus group discussion. Int J Head Neck Surg 2013;4;115-8.  Back to cited text no. 52
Mishra GA, Gunjal SS, Pimple SA, Majmudar PV, Gupta SD, Shastri SS. Impact of 'gutkha and pan masala ban' in the state of Maharashtra on users and vendors. Indian J Cancer 2014;51:129-32.  Back to cited text no. 53
[PUBMED]  [Full text]  
Deepak K, Angeline M, Vidhubala E, Sundaramoorthy C, Basumallik B. Gutkha ban in Chennai, India: Is there any impact?. Int J Community Med Public Health. 2017;4:4595-9.  Back to cited text no. 54
Arora S, Squier C. Areca nut trade, globalisation and its health impact: Perspectives from India and South-east Asia. Perspect Public Health. 2018:1757913918785398. Doi: 10.1177/1757913918785398.  Back to cited text no. 55
Tham J, Sem G, Sit E. A scientific and socioeconomic review of betel nut use in Taiwan with bioethical reflections. Asian Bioethics Rev 2017;9:401-14.  Back to cited text no. 56
Srinivasan S. Daughters or dowries? The changing nature of dowry practices in South India. World Dev 2005;33:593-615.  Back to cited text no. 57
Kamat S. Postcolonial aporias, or what does fundamentalism have to do with globalization? The contradictory consequences of education reform in India. Comp Educ 2004;40:267-87.  Back to cited text no. 58
Anjanamma TC, Nagaraja TV. Female feticide/infanticide in India: A survey based study. Indian J Appl Res 2015;5:657-60.  Back to cited text no. 59
Source data from official website of The Food and Agriculture Organization, an agency of the United Nations, as accessed on June 5, 2018.  Back to cited text no. 60
Gupta PC, Arora M, Sinha D, Asma S, Parascondola M. Smokeless tobacco and public health in India. Ministry of Health and Family Welfare, Government of India, New Delhi, 2016, pp. 23-44.  Back to cited text no. 61
Source data from as on June 5, 2018.  Back to cited text no. 62
Source data from accessed on June 7, 2018.  Back to cited text no. 63
Gu X, Filbey F. A Bayesian observer model of drug craving. JAMA Psychiatry 2017;74:419-20.  Back to cited text no. 64
Zhu X, Zhu Q, Jian C, Shen H, Wang F, Liao W, et al. Disrupted resting-state default mode network in betel quid-dependent individuals. Front Psychol 2017;8:84.  Back to cited text no. 65
Liu T, Li J, Zhao Z, Zhong Y, Zhang Z, Xu Q, et al. Betel quid dependence is associated with functional connectivity changes of the anterior cingulate cortex: A resting-state fMRI study. J Transl Med 2016;14:33.  Back to cited text no. 66
Liu T, Li J, Zhao Z, Yang G, Pan M, Li C, et al. Altered spontaneous brain activity in betel quid dependence – A resting-state functional magnetic resonance imaging study. Medicine (Baltimore) 2016;95:e2638.  Back to cited text no. 67
Yen H, Chen P, Ko Y, Chiang S, Chang Y, Shiah Y. Betel quid chewing, personality and mood: Betel quid chewing associated with low extraversion and negative mood. J Substance Use Misuse 2018; Doi 10.1080/10826084.2018.1432652  Back to cited text no. 68
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th edn), 2013, 1st edition, APA, Washington, DC, pp. 483-4.  Back to cited text no. 69
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Substance-related and addictive disorders [Fact sheet]. Washington, DC: Author. Retrieved from  Back to cited text no. 70
Blanco C, Compton WM, Lopez M. What is a substance use disorder? JAMA Psychiatry 2018;75:229-30.  Back to cited text no. 71
Murthy P, Saddichha S. Tobacco cessation services in India: Recent developments and the need for expansion. Indian J Cancer 2010;47(Suppl S1):69-74.  Back to cited text no. 72
Murthy P, Manjunatha N, Subodh BN, Chand PK, Benegal V. Substance use and addiction research in India. Indian J Psychiatry 2010;52(Suppl S3):189-99.  Back to cited text no. 73
Murthy P, Subodh BN, Sinha D, Aghi M, Chaturvedi P. Smokeless tobacco (SLT) use and cessation in India: Lessons from user and health care provider perspectives. Asian J Psychiatr 2018;32:137-142.  Back to cited text no. 74
Sinha DN, Gupta PC. Tobacco control practices by medical doctors in developing world; a questionnaire study. Indian J Public Health 2004;48:144-6.  Back to cited text no. 75
[PUBMED]  [Full text]  
Mohan S, Pradeepkumar AS, Thresia CU, Thankappan KR, Poston WS, Haddock CK, et al. Tobacco use among medical professionals in Kerala, India: The need for enhanced tobacco cessation and control efforts. Addict Behav 2006;31:2313-8.  Back to cited text no. 76
Thankappan KR, Pradeepkumar AS, Nichter M. Doctors' behavior and skills for tobacco cessation in Kerala. Indian J Med Res 2009;129:249-55.  Back to cited text no. 77
[PUBMED]  [Full text]  
Sarkar BK, West R, Arora M, Ahluwalia JS, Reddy KS, Shahb L. Effectiveness of a brief community outreach tobacco cessation intervention in India: A cluster-randomised controlled trial (the BABEX trial). Thora×2017;72:167-73.  Back to cited text no. 78
Sidhu AK, Kumar S, Wipfli H, Arora M, Valente TW. International approaches to tobacco prevention and cessation programming and policy among adolescents in India. Curr Addict Rep 2018;5:10-21.  Back to cited text no. 79
Schensul JJ, Nair S, Bigli S, Cromley E, Kadam V, Mello SD, Donta B. Availability, accessibility and promotion of smokeless tobacco in a low-income area of Mumbai. Tob Control 2013;22:324-30.  Back to cited text no. 80
Bhartiya D, Kumar A, Kaur J, Kumari S, Sharma AK, Sinha DN, et al. In-silico study of toxicokinetics and disease association of chemicals present in smokeless tobacco products. Regul Toxicol Pharmacol 2018;95:8-16.  Back to cited text no. 81
Jain V, Garg A, Parascandola M, Chaturvedi P, Khariwala SS, Stepanov I. Analysis of alkaloids in areca nut-containing products by liquid chromatography-tandem mass-spectrometry. J Agric Food Chem 2017;65:1977-83.  Back to cited text no. 82
Lee C, Chiang S, Ko AM, Hua C, Tsai M, Warnakulasuriya S, et al. Betel-quid dependence domains and syndrome associated with betel-quid ingredients among chewers: An Asian multi-country evidence. Addiction 2014;109:1194-204.  Back to cited text no. 83
Little MA, Pokhrel P, Murphy KL, Kawamoto CT, Suguitan GS, Herzog TA. The reasons for betel-quid chewing scale: Assessment of factor structure, reliability, and validity. BMC Oral Health 2014;14:62.  Back to cited text no. 84
Herzog TA, Murphy KL, Little MA, Suguitan GS, Pokhrel P, Kawamoto CT. The betel quid dependence scale: Replication and extension in a Guamanian sample. Drug Alcohol Depend 2014; 138:154-60.  Back to cited text no. 85
Lee C, Chang C, Shieh T, Chang Y. Development and validation of a self-rating scale for betel quid chewers based on a male-prisoner population in Taiwan: The betel quid dependence scale. Drug Alcohol Depend 2012;121:18-22.  Back to cited text no. 86
Hsu KY, Tsai YF, Huang CC, Yeh WL, Chang KP, Lin CC, et al. Tobacco-smoking, alcohol-drinking, and betel-quid-chewing behaviors: Development and use of a web-based survey system. JMIR Mhealth Uhealth 2018;6:e142.  Back to cited text no. 87
Heishman SJ, Singleton EG, Pickworth WB. Reliability and validity of a Short Form of the tobacco craving questionnaire. Nicotine Tob Res 2008;10:643-51.  Back to cited text no. 88
Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström test for nicotine dependence: A revision of the Fagerström Tolerance Questionnaire. Br J Addict 1991;86:1119-27.  Back to cited text no. 89
Saunders JB, Aasland OG, Babor TF, de La Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption- II. Addiction 1993;88:791-84.  Back to cited text no. 90
Moss J, Kawamoto C, Pokhrel P, Paulino Y, Herzog T. Developing a betel quid cessation program on the Island of Guam. Pac Asia Inq 2015;6:144-50.  Back to cited text no. 91
Turk T, Chaturvedi P, Murukutla N, Mallik V, Sinha P, Mullin S. Raw and real: An innovative communication approach to smokeless tobacco control messaging in low and middle-income countries. Tob Control 2017;26:476-81.  Back to cited text no. 92
Yang TY, Lin HR. Taking actions to quit chewing betel nuts and starting a new life: Taxi drivers' successful experiences of quitting betel nut chewing. J Clin Nurs 2017;26:1031-41.  Back to cited text no. 93
Hussain A, Zaheer S, Shafique K. Individual, social and environmental determinants of smokeless tobacco and betel quid use amongst adolescents of Karachi: A school-based cross-sectional survey. BMC Public Health 2017;17:913. Doi 10.1186/s12889-017-4916-1.  Back to cited text no. 94
Little MA, Pokhrel P, Murphy KL, Kawamoto CT, Suguitan GS, Herzog TA. Intention to quit betel quid: A comparison of betel quid chewers and cigarette smokers. Oral Health Dent Manag 2014;13:512-8.  Back to cited text no. 95
Liu S, Pan F. Training on the ceasing intention of betel nut addiction. Int J Humanit Soc Sci 2011;5:1258-61.  Back to cited text no. 96
Mistry R, Pednekar MS, Gupta PC, Raghunathan TE, Appikatla S, Puntambekar N, et al. Longitudinal study of adolescent tobacco use and tobacco control policies in India. BMC Public Health 2018;18:815.  Back to cited text no. 97
Stokols D. Translating social ecological theory into guidelines for community health promotion. Am J Health Promot 1996;10:282-98.  Back to cited text no. 98
Bandura A. Human agency in social cognitive theory. Am Psychol 1989;44:1175-84.  Back to cited text no. 99
Flay, B., Petraitis, J. The theory of triadic influences: A new theory of health behavior with implication for preventive interventions. In: Albrecht, G.S. (editor). Advances in medical sociology. Vol. IV: A reconsideration of models of health behavior change. Greenwich: JAI Press; 1994.  Back to cited text no. 100
Compas BE, Hinden BR, Gerhardt CA. Adolescent development: Pathways and processes of risk and resilience. Annu Rev Psychol 1995;46:265-93.  Back to cited text no. 101
Chhabra C, Chhabra KG, Bishnoi S, Singh J, Sahu V, Lohra A, et al. Exploring the predictors of quitting tobacco usage among patients attending a private dental institution – a survey from Jodhpur, India. Oral Health Dent Manag 2014;13:815-20.  Back to cited text no. 102
Azar OH. Social norms evolve with asymmetric sanctions. Nat Hum Behav 2018;2:113-4.  Back to cited text no. 103
Strimling P, de Barra M, Eriksson K. Asymmetries in punishment propensity may drive the civilizing process. Nat Hum Behav 2018;2:148-55.  Back to cited text no. 104
Ruff CC. Brain stimulation studies of social norm compliance: Implications for personality disorders? Psychopathology 2018;51:105-09.  Back to cited text no. 105
Thavarajah R, Mohandoss AA, Ranganathan K, Kondalsamy-Chennakesavan S. Influence of legislations and news on Indian internet search query patterns of e-cigarettes. J Oral Maxillofac Pathol 2017;21:194-202.  Back to cited text no. 106
[PUBMED]  [Full text]  
Schensul J. Building a systems dynamic model of smokeless tobacco use in Mumbai. Pract Anthropol 2013;35:24-8  Back to cited text no. 107

Correspondence Address:
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DOI: 10.4103/ijdr.IJDR_947_18

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