Indian Journal of Dental Research

: 2019  |  Volume : 30  |  Issue : 4  |  Page : 612--621

Areca nut use disorder: A dynamic model map

Rooban Thavarajah, Kannan Ranganathan, Elizabeth Joshua, Umadevi Krishnamohan Rao 
 Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, Affiliated to the Tamil Nadu Dr. MGR Medical University, Chennai, Tamil Nadu, India

Correspondence Address:
Prof. Rooban Thavarajah
Marundeeshwara Oral Pathology Services and Analytics, B-1, Mistral Apartments, Wipro Street, Shollinganallur, Chennai - 600 119, Tamil Nadu


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.

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;30:612-621

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 2020 Nov 28 ];30:612-621
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Full Text


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}

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

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}

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}

 Physical Health System's Response to an Consumption

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}

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

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

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}

 Cessation Biology and Modalities

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

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}

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

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.


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.


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