Betel Leaves & Areca Nuts and Cancer Risk

OncoLink Team
The Abramson Cancer Center of the University of Pennsylvania
Last Modified: March 23, 2012

Parts of the Betel plant (leaves, vines, stems, flowers (inflorescence of Piper betel Linnaeus)) and Areca nuts may be used individually or together in the form of a betel quid. A betel quid is a combination of betel leaf, areca nut, and slaked lime. In many countries, tobacco is also added, and the product is known as gutka, ghutka, or gutkha. Other ingredients and flavorings (sweetners, spices) may be added according to local preferences and customs. The use of betel and areca nuts is very common in India and Asia.

Preparations of the betel plant, areca nut, and betel quid vary by country and region. An individual's risk for developing cancer can increase as a result of use of many such products, although precise risk varies with the preparation used. This risk may be magnified when combined with use of cigarettes or chewing tobacco. In Taiwan, researchers found that chewers using betel inflorescence in the quid are at highest risk for developing head and neck cancer, whereas those using betel leaves are at the lowest. A Taiwanese chewer commonly uses fresh, unripe betel fruit (areca nut) with slaked lime as an essential ingredient, unlike chewers from most countries in South-east Asia, who use mature fruit (areca nut). Whatever the composition of the quids, they are usually retained in the mouth for about 20 to 25 minutes but occasionally the mixture may be retained in the space between the teeth and cheek (mandibular groove) for many hours during sleep.

According to the CDC, betel plant, areca nut, and betel quid usage causes an increased risk of developing white or reddened lesions in the mouth that can progress to cancer. Use is also responsible for a condition called oral submucous fibrosis (OSF), in which inflammation and scarring (fibrosis) develop in the tissues lining the mouth, but can progress to affect the esophagus (swallowing tube). This is a debilitating and irreversible condition that, as it progresses, results in a stiff jaw and an inability to open the mouth. Treatment consists of cutting the fibrous bands in the mouth to allow the jaw to open. Furthermore, the users of betel products and areca nuts are at risk for oral cancers—predominantly those of the lip, mouth, tongue, and pharynx (throat) and cancer of the esophagus.

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Smokeless Tobacco Around the World

The types of cancer people are at risk for from smokeless tobacco use varies around the world due to the type of tobacco product most commonly used in that country and what is mixed with it. For example, in Middle Eastern countries (India and Sudan), many chewing tobaccos are prepared with betel quid or areca nut, which are both known to be carcinogens. As a result there is an increased risk for cancers of the mouth and throat in this area of the world. Studies in Asia and Africa have shown an increased risk of mouth, throat, and esophagus cancer in users of smokeless tobacco; in North America, cancers of the mouth are most common. Nordic and Northern European countries have an increased risk of esophagus and pancreas cancers due to the use of smokeless tobacco. In Sweden and Norway, snus, which a type of moist snuff made with air-cured tobacco, water, salt and flavorings, is the most common form of smokeless tobacco. Snus may have lower levels of carcinogens than other types of snuff, but is still linked to cancer.

Are You Ready to Quit Smokeless Tobacoo?

So you think you are ready to quit smokeless tobacco? Great- that is the first step to success! What are your personal motivations to quit? Write them down and refer to them when things get tough. Quitting is not easy, but you are not alone- many people want to quit and many are successful. Surveys show that most people who use snuff or chew would like to quit. Find a community (there are a few online specific for smokeless tobacco) or a buddy that has been successful to be your support person to call upon during tough times.

There are several reasons why quitting is important. First and most importantly, quitting will improve your health and lower your chances of developing a tobacco-related cancer or heart disease. Your risk of these diseases decreases the longer you stay off smokeless tobacco. A tobacco habit is costly, and by quitting you will have extra money to put towards other things. Mouth sores will heal soon after quitting, and you will be rid of the bad breath and stained teeth. The stains from tobacco juice on your clothes and in your car will be a thing of the past. Additionally, you will be setting a good example to those around you, especially if you have children in your life.

Quitting smokeless tobacco

Quitting smokeless tobacco is like quitting any addiction. Nicotine is a highly addictive substance and quitting involves dealing with the physical, mental and emotional components of this addiction. Talk with your healthcare provider for suggestions and support while you quit. Visit online support sites to learn ways to avoid or deal with common stumbling points. For smokeless tobacco users, there may be a greater need to find an oral substitute to take the place of the tobacco such as sugarless candy or gum.

Symptoms of withdrawal from smokeless tobacco

Stopping or cutting back on smokeless tobacco use causes symptoms of nicotine withdrawal that are much like those smokers get when they quit. Withdrawal from nicotine is both physical and mental. Physically, the body is reacting to the absence of nicotine. Mentally and emotionally, an individual is faced with giving up an addiction, which calls for a major change in behavior. Both the physical and mental factors must be dealt with to quit and stay quit.

Those who have used tobacco regularly for a few weeks or longer, and suddenly stop or greatly reduce the amount used will often have withdrawal symptoms. Symptoms usually start within a few hours of the last dip or chew and get worse about 2 to 3 days later when most of the nicotine and its by-products are out of the body. The following are withdrawal symptoms that you may experience: dizziness (which may last 1 or 2 days after quitting), depression, feelings of frustration, impatience, and anger, anxiety, irritability, trouble sleeping (including trouble falling asleep and staying asleep, and having bad dreams or even nightmares), trouble concentrating, restlessness, headaches, tiredness and increased appetite.

Withdrawal symptoms can last for a few days to up to several weeks. These uncomfortable feelings can lead you to start using tobacco, but remember: They will get better every day that you stay tobacco-free! Nicotine replacement products and other medications can help you get through the tough times. There are wonderful resources available online and in the community - learn more from the resources for quitting below.

Resources for Quitting

Quitting tobacco is not easy, but you can do it! Whether you're a smoker or someone who uses smokeless tobacco, to have the best chance of quitting and staying quit, you need to know what you're up against, what your options are, and where to go for help. Below are some resources that will help you.

Smoking cessation. Where do I start?
Start here for help in creating a quit plan, tips to coping with common obstacles and resources for support and smoking cessation programs.

There are several websites specifically for smokeless tobacco users. These include:

Smoking Cessation Aids
This article reviews the available treatments, both pharmacologic (drug) and non-pharmacologic, to aid in successful smoking and tobacco use cessation.

Life After Tobacco

Unfortunately, quitting tobacco cannot completely erase the damage done by months or years of use. You should always be honest with healthcare providers about your smoking history and be aware of the risks associated with this history.

As recommended by the American Cancer Society, you should tell your healthcare provider about any of the following symptoms:

  • Any change in a cough (for example, you cough up more phlegm or mucus than usual)
  • A new cough
  • Coughing up blood
  • Hoarseness
  • Trouble breathing
  • Wheezing
  • Chest pain
  • Loss of appetite
  • Weight loss
  • Feeling tired all the time (fatigue)
  • Frequent lung or respiratory infections (like pneumonia or bronchitis)
  • Development of sores, red areas, or white patches in your mouth.


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