Areca nut trade, globalisation and its health impact: perspectives from India and South-east Asia

Exploring the therapeutic mechanisms of resveratrol for treating arecoline-induced malignant transformation in oral epithelial cells: insights into hub targets

BACKGROUND

Betel nut chewing is a significant risk factor for oral cancer due to arecoline, its primary active component. Resveratrol, a non-flavonoid polyphenol, possesses anti-cancer properties. It has been shown to inhibit arecoline-induced oral malignant cells in preliminary experiments but the underlying mechanism remains unclear. This research therefore aimed to explore the potential therapeutic targets of resveratrol in treating arecoline-induced oral cancer.

METHODS

Data mining identified common targets and hub targets of resveratrol in arecoline-induced oral cancer. Gene set variation analysis (GSVA) was used to score and validate the expression and clinical significance of these hub targets in head and neck cancer (HNC) tissues. Molecular docking analysis was conducted on the hub targets. The effect of resveratrol intervention on hub targets was verified by experiments.

RESULTS

Sixty-one common targets and 15 hub targets were identified. Hub targets were highly expressed in HNC and were associated with unfavorable prognoses. They played a role in HNC metastasis, epithelial-mesenchymal transition, and invasion. Their expression also affected immune cell infiltration and correlated negatively with sensitivity to chemotherapeutic agents such as bleomycin and docetaxel. Experiments demonstrated that resveratrol down-regulated the expression of the hub targets, inhibited their proliferation and invasion, and induced apoptosis.

CONCLUSION

Resveratrol inhibits the arecoline-induced malignant phenotype of oral epithelial cells by regulating the expression of some target genes, suggesting that resveratrol may be used not only as an adjuvant treatment for oral cancer, but also as an adjuvant for oral cancer prevention due to its low toxicity and high efficacy. © 2024 Society of Chemical Industry.

Trends in smokeless tobacco use and attributable mortality and morbidity in the South-East Asia Region: implications for policy

OBJECTIVES

To describe the prevalence of smokeless tobacco (SLT) use and number of users by year, in addition to trends in mortality and attributable disease burden in countries of the WHO South-East Asia Region (SEAR), to inform policies for SLT control in the Region.

METHODS

For each SEAR country, we obtained data from Global Adult Tobacco Surveys, WHO STEPwise Approach to NCD Risk Factor Surveillance surveys and Demographic and Health Surveys conducted since 2010 to estimate prevalence of SLT use by country, sex and year. Using data from the World Population Prospects database we estimated the number of users by country. Next, using the results of previous meta-analyses and prevalence results, we estimated the population attributable fractions and attributable mortality and morbidity in terms of annual deaths and disability-adjusted life years lost. We then characterised trends in attributable deaths and disease burden for countries with comparable data.

RESULTS

There were wide differences in SLT use prevalence by country. We estimated that, during 2015-2019, there were 165 803 900 SLT users across SEAR, with 479 466 attributable deaths annually of which India accounted for 79.9% with 383 248. Attributable annual deaths increased in some countries during 2015-2019.

CONCLUSIONS

Annual deaths and disease burden attributable to SLT remain high across SEAR and have only declined modestly in recent years. Effective implementation of all WHO Framework Convention on Tobacco Control measures, addressing both supply-side and demand-side issues, in relation to SLT and areca nut products must be prioritised to ensure reductions in mortality and disease burden are sustained and accelerated.

Safety and efficacy evaluation of Simo decoction and Arecae semen in herbal medicine practice

Objective

The traditional Chinese patent medicine (TCPM), Simo decoction (Simo decoction oral solution), with its primary ingredient Arecae semen (Binglang, Areca catechu L.), known for its potential carcinogenic effects, is the subject of this study. The research aims to analyze the effectiveness and potential risks of Simo decoction, particularly as a carcinogen, and to suggest a framework for evaluating the risks and benefits of other herbal medicines.

Methods

The study is based on post-marketing research of Simo decoction and Arecae semen. It utilized a wide range of sources, including ancient and modern literature, focusing on the efficacy and safety of Simo decoction. The research includes retrospective data on the sources, varieties, and toxicological studies of Arecae semen from databases such as Pubmed, Clinical Trials, Chinese Clinical Trial Registry, China National Knowledge Infrastructure, WHO-UMC Vigibase, and China National Center for ADR Monitoring.

Results

Common adverse drug reactions (ADRs) associated with Simo decoction include skin rash, nausea, vomiting, abdominal pain, and diarrhea. However, no studies exist reporting the severe ADRs, such as carcinogenic effects. Arecae semen is distributed across approximately 60 varieties in tropical Asia and Australia. According to the WHO-UMC Vigibase and the National Adverse Drug Reaction Monitoring System databases, there are currently no reports of toxicity related to Arecae semen in the International System for Classification of ADRs (ISCR) or clinical studies.

Conclusion

Risk-benefit analysis in TCPM presents more challenges compared to conventional drugs. The development of a practical pharmacovigilance system and risk-benefit analysis framework is crucial for marketing authorization holders, researchers, and regulatory bodies. This approach is vital for scientific supervision and ensuring the safety and efficacy of drug applications, thus protecting public health.

Acute toxic effects of areca nut on central nervous system and liver: A case report

Areca nut (AN) is an addictive substance widely used in different world regions. There are several side effects associated with the use of AN, which have already been reported. However, the reports on hepatotoxicity of AN are sporadic and non-conclusive. In the present case report, we investigated the hepatotoxicity of AN in a four-year-old Iranian girl who was transferred to our medical center with abdominal pain, vomiting, diarrhea, fever, and other symptoms such as hematuria, decreased mental status, multiple seizure episodes. After a comprehensive evaluation, it was concluded that these signs and symptoms were all attributed to AN consumption, which was given by her mother to control diarrhea. Eventually, the patient medical conditions were managed successfully, and she survived by intense medical care. In conclusion, we suggest AN should be considered a potential hepatotoxic agent.

The antidiabetic drug pioglitazone ameliorates betel-nut-induced carcinogenesis in mice by restoring normal lipid metabolism, reducing oxidative stress, and inducing apoptosis

CONTEXT

Oral administration (2 mg mL-1) of aqueous extract of betel nut (AEBN) for 24 weeks induced oncogenic alterations in the liver of female Swiss Albino mice concomitant with aberrant lipid metabolism, overactivation of Akt/mTOR signaling, and loss of apoptosis.

AIM

This study was designed to investigate the potential of repurposing the antidiabetic drug pioglitazone for alleviating AEBN-induced carcinogenesis.

METHODS

Sera of animals were evaluated for lipid profile and free fatty acid levels. Liver tissues were investigated for oxidative stress, histopathology, and expression of proteins involved in lipid metabolism and oncogenesis by western blotting. Apoptosis was determined using TUNEL assay.

RESULTS

Coadministration of pioglitazone (10 mg kg-1 b.w) with AEBN for 8 weeks restored normal lipid profile and AMPK/ACC signaling, reduced FASN and HMGCR expressions and oxidative stress, and actively induced Akt/mTOR-mediated apoptosis in the liver.

CONCLUSIONS

Pioglitazone can effectively alleviate AEBN-induced carcinogenesis in mice.

Chemical Composition of Areca Nut and Its Adverse Effects on Human Health

Areca nut (AN) is one of the addictive substances consumed widely in the world. The composition of AN is very complex, and each component has variable properties. This study aims to review the composition of AN and its adverse effects on humans. For this review, the literature search was performed by an electronic search of the Pubmed/Medline, Scopus, and Google Scholar databases using proper MESH headings and retrieved the articles published from 1997 to 2022. The eligibility criteria included human studies, a form of AN, the composition of AN, harmful effects of AN, the effect of AN on the oral cavity, the effect of AN on vital organs, and articles published in English. Data were extracted regarding the composition of AN, forms of AN, and harmful effects of AN on the oral cavity and on other systems. A total of 449 articles were identified from various databases, and 36 studies were selected that met the inclusion criteria. The active components of AN, which produce harmful effects, are primarily alkaloids, polyphenols, tannins, and certain trace elements. AN is consumed in different forms, and based on the form, its composition also varies. AN is known to cause deleterious effects on the oral cavity as well as various body organs. The most dangerous and widely reported impacts of AN on the oral cavity are the development of oral submucous fibrosis, a premalignant condition, and oral malignancy. However, during the chewing process, excretory products of AN are released and circulate in the body of "chronic habitual" and affect the other body parts. Thus, AN consumption may contribute to cardiac, liver, endocrinal, metabolic, respiratory, and reproductive system disorders also. AN composition is complex, and its consumption is harmful to human health. In regard to controlling the issue of the harmful effects of this habit, preventive measures should be established.

Homo medicus: The transition to meat eating increased pathogen pressure and the use of pharmacological plants in Homo

The human lineage transitioned to a more carnivorous niche 2.6 mya and evolved a large body size and slower life history, which likely increased zoonotic pathogen pressure. Evidence for this increase includes increased zoonotic infections in modern hunter-gatherers and bushmeat hunters, exceptionally low stomach pH compared to other primates, and divergence in immune-related genes. These all point to change, and probably intensification, in the infectious disease environment of Homo compared to earlier hominins and other apes. At the same time, the brain, an organ in which immune responses are constrained, began to triple in size. We propose that the combination of increased zoonotic pathogen pressure and the challenges of defending a large brain and body from pathogens in a long-lived mammal, selected for intensification of the plant-based self-medication strategies already in place in apes and other primates. In support, there is evidence of medicinal plant use by hominins in the middle Paleolithic, and all cultures today have sophisticated, plant-based medical systems, add spices to food, and regularly consume psychoactive plant substances that are harmful to helminths and other pathogens. We propose that the computational challenges of discovering effective plant-based treatments, the consequent ability to consume more energy-rich animal foods, and the reduced reliance on energetically-costly immune responses helped select for increased cognitive abilities and unique exchange relationships in Homo. In the story of human evolution, which has long emphasized hunting skills, medical skills had an equal role to play.

A Review of Intervention Strategies for Areca Nut Use Cessation

Background

Areca nut (AN) is one of the world's most widely used drugs, especially in Asia-Pacific, causing dependence and multiple adverse health impacts. The International Agency for Research on Cancer (IARC) has classified it as a type-1 carcinogen. Despite evidence of harms, its use is culturally ingrained in many regions worldwide; harm perception is low; and the availability of intervention strategies is limited.

Methods

To identify the range and efficacy of interventional studies on AN use cessation, a narrative review of studies published between 1990 and 2021 was undertaken using selected electronic databases (PubMed, Embase, and Scopus).

Results

Three types of interventions were identified: educational, psychological, and pharmacological. Overall, educational interventions significantly enhanced knowledge regarding harms related to AN use. Some psychological interventions reported enhancement of motivation to quit as well as helped in reduction/cessation of AN use. Two pharmacological studies on psychiatric patients with depressive disorders and AN use found that antidepressants helped in reducing/cessation of AN use.

Conclusion

Overall, the number of interventional studies on AN cessation is limited, and most studies have measured the short-term effects of the intervention. The role of pharmacotherapeutic interventions needs to be evaluated for AN cessation, and evidence-based psychosocial interventions need to be developed for AN cessation. Furthermore, longitudinal research using adequate sample sizes and longer follow-up durations are needed to establish interventions in this important area.

Sociodemographic Factors, Attitudes, and Tobacco use among Adolescent Areca-Nut Users in Mumbai, India

Introduction

Areca nut, initiated in adolescence, is considered a gateway for tobacco use and an important cause of oral cancers in India. This study examined differences in sociodemographic factors, attitudes and beliefs, and tobacco use between current (last 30 days) areca nut users and past users, who have ever used areca but not in the last 30 days.

Material and Methods

A cross-sectional survey with school students attending grades 7, 8, 9 provided data to compare differences in age, gender, beliefs, attitudes, and concurrent tobacco use among self-reported areca users. Of 1909 participants surveyed, 641 (33.57%) reported use of areca nut; of which 355 (55.38%) current users had consumed it in the last 30 days.

Results

A logistic regression model revealed that male gender, using tobacco concurrently, inability to refuse a friend's request to use, and intention to use areca nuts in the next 12 months were significant predictors of current areca use.

Conclusion

More research is needed to understand adolescent areca-nut use, including different types of users such as experimenters and those with established habits. This will help design targeted areca-nut prevention and cessation programs.

Using the Theory of Planned Behavior to Explain and Predict Areca Nut Use Among Adolescents in India: An Exploratory Study

Context

Areca nut, used alone or in combination with tobacco, contributes to the high oral cancer burden in India. Used widely by adolescents, who perceive it as a harmless substance, areca nut is addictive and considered a precursor to tobacco use. Given its serious implications for addictiveness and physical health, urgent preventive interventions for areca nut use are required in India and South-East Asia. Studies examining the role of health behavior theory in explaining and predicting areca nut use and for development of its prevention among adolescents are scarce.

Aim

This study explored the role of the components of Theory of Planned Behavior (TPB) such as attitudes, subjective norms, perceived behavioral control, and intention in predicting areca nut use among adolescents.

Settings and Design

Observational study with cross-sectional design conducted with 1884 male and female adolescents attending low-income schools in Mumbai, India.

Methods and Material

Self-administered surveys were used to gather data on age, gender, behavioral factors and areca nut use.

Statistical Analysis Used

Chi-square and Mann Whitney test for bivariate and logistic regression for multivariate analysis.

Results

Around 27.2% of 1884 participants were areca nut users. The mean age of users was 13.75 years. Intention-to-use and perceived behavioral control were statistically significant predictors of actual areca nut use (p<0.001). The components of TPB such as attitude, perceived subjective social norms, and perceived behavioral control had a statistically significant effect on the intention-to-use areca nut (p<0.05).

Conclusion

This exploratory study indicates that constructs from TPB could help us understand and predict areca nut use. However, more rigorous future research is required to generate insights that help craft effective theory-based behavioral interventions for areca nut prevention and cessation in adolescents.

Arecoline induces heart injure via Fas/Fas ligand apoptotic pathway in heart of Sprague-Dawley rat

Habitual chewing of areca nut increases the risk of cardiovascular disease mortality, but less report demonstrate the toxic mechanism of areca nut on heart. To investigate toxicity of areca nut on cardiomyocytes, we induced the heart injury with arecoline to evaluate the acute damage of areca nut on heart. Different concentrations of are coline (lowdosage: 5 mg/kg/day and high dosage 50 mg/kg/day) were injected into Sprague-Dawley rat via intra-peritoneal method for 21 days to create negative effects of arecoline on cardiomyocyte. Themyocardial architecture of the rat heart was observed. The arecoline-induced apoptotic proteins were analysed via western blotting. The myocardialarchitecture of heart was injured with arecoline and TUNEL stain was also shown are coline-induced cardiac apoptosis. Arecoline promoted the protein expression of both Fas dependent snd mitochondrial dependent apoptosis. In summary, arecoline induces cardiac toxicity and apoptosis by inducing both death receptor and mitochondria-dependent apoptotic pathways on heart.

Overview of Oral Potentially Malignant Disorders: From Risk Factors to Specific Therapies

Oral squamous cell carcinoma (OSCC) is a very aggressive cancer, representing one of the most common malignancies worldwide. Oral potentially malignant disorders (OPMDs) regroup a variegate set of different histological lesions, characterized by the potential capacity to transform in OSCC. Most of the risk factors associated with OSCC are present also in OPMDs' development; however, the molecular mechanisms and steps of malignant transformation are still unknown. Treatment of OSCC, including surgery, systemic therapy and radiotherapy (alone or in combination), has suffered a dramatic change in last years, especially with the introduction of immunotherapy. However, most cases are diagnosed during the advanced stage of the disease, decreasing drastically the survival rate of the patients. Hence, early diagnosis of premalignant conditions (OPMDs) is a priority in oral cancer, as well as a massive education about risk factors, the understanding of mechanisms involved in malignant progression and the development of specific and more efficient therapies. The aim of this article is to review epidemiological, clinical, morphological and molecular features of OPMDs, with the purpose to lay the foundation for an exhaustive comprehension of these lesions and their ability of malignant transformation and for the development of more effective and personalized treatments.

A Qualitative Study of Perceptions and Practices Related to Areca Nut Use Among Adolescents in Mumbai, India

INTRODUCTION

Areca nut, commonly known as supari, is widely used in India. In addition to tobacco and alcohol, it has been identified as one of the contributory factors for high rates of oral cancer in the country.

METHODS

This qualitative study explored perceptions and practices around the use of areca nut by conducting in-depth interviews and focus group discussions with 61 school-going adolescents in the city of Mumbai, India.

RESULTS

Respondents used low-priced sachets of sweetened, flavored areca nut called supari. They perceived supari as harmless because it was sweet, it had a fresh after-taste as compared to bitter-tasting smokeless tobacco products. How can something sweet be harmful was a common argument offered by respondents. Respondents invariably compared and contrasted areca nut to more harmful and addictive tobacco products; perceiving supari to have milder or inconsequential health effects. Supari use was initiated with friends, a sibling, or a cousin. It was almost always used with friends. Respondents also reported difficulty in refusal to use when offered supari by friends. Parental response to finding out about the child's supari use was often muted in comparison to extreme reactions associated with the child's tobacco use.

CONCLUSIONS

Perceptions of low risk or relative harmlessness of the product, social influence, and the features of the product itself influence adolescents' use of areca nut. Although more research on perceptions of risk, with larger samples, is required, these findings are useful for school-based tobacco prevention and cessation programs and health policy-makers.

IMPLICATIONS

The study findings have implications for prevention and cessation programs, and policymakers. School-based health education programs should allocate special sessions on areca nut use. Focused mass media communication campaigns describing its harms and association with oral cancer are required for the larger community. As was done for tobacco, Indian policymakers will have to evaluate the marketing, commerce, and distribution of areca nut and create appropriate laws. More research, with larger nationwide samples, is required to examine perceptions of areca nut.

The Effectiveness of Betel Quid Cessation among Workers through the Adoption of the Five Action Areas of the Ottawa Charter

This study aimed to increase workers' awareness of betel quid cessation. Methods: Using community and workplace resources, a workplace health promotion program was developed in accordance with the five action areas of the Ottawa Charter. Questionnaires were administered to examine the changes in the knowledge and attitudes of 714 workers in different occupations before and three months after the intervention. Results: Regardless of subjects' pre-intervention chewing status, their knowledge and attitude scores relating to betel quid cessation increased significantly after the intervention. The effect of occupation was significant on the post-intervention knowledge and attitude scores among chewers. Furthermore, 16 (11.6%) of the 138 study subjects who chewed betel quid before the intervention and had no willingness to quit, did quit betel quid chewing following the intervention. The factors contributing to an unwillingness to quit among chewers with no intention to quit before the intervention were examined. Workers in the electronic material manufacturing industry had a greater willingness to quit compared to those in the metal, machinery, and related trades (odds ratio [OR] = 0.15; 95% confidence interval [CI] = 0.02-0.94). Travel attendants, tour guides, cleaners, and helpers were the least willing to quit (OR = 21.29; 95% CI = 2.51-180.81). Conclusions: This study promoted workers' awareness of betel quid cessation by adopting the five action areas of the Ottawa Charter framework, the effectiveness of the intervention varied in different occupations. Workers with a high-income and better education level had a higher awareness of betel quid cessation.

Vildagliptin, a dipeptidyl peptidase-4 inhibitor, reduces betel-nut induced carcinogenesis in female mice

AIM

Betel-nut, a popular masticatory among Southeast Asian populations is a class I carcinogen, previously associated with dyslipidemia and aberrant lipid metabolism, and is reported to be used more frequently by females, than males. This study investigates the potential of repurposing the anti-diabetic drug, vildagliptin, a dipeptidyl peptidase-4 inhibitor, for alleviating the oncogenic condition in female Swiss Albino mice administered an aqueous extract of betel-nut (AEBN) orally (2 mg ml^-1) for 24 weeks.

MAIN METHODS

Tissues were investigated by histopathological, immunohistochemical and apoptosis assays. Biochemical analyses of oxidative stress markers and lipid profile were performed using different tissues and sera. The expressions of different proteins involved in lipid metabolism and oncogenic pathways were evaluated by Western blotting.

KEY FINDINGS

AEBN induced carcinogenesis primarily in the liver by significantly impairing AMPK signaling, inducing oxidative stress, activating Akt/mTOR signaling, increasing Ki-67 immunoreactivity and cyclin D1 expression, and significantly diminishing apoptosis. Co-administration of AEBN with vildagliptin (10 mg kg^-1 body weight) for 8 weeks reduced liver dysplasia, and significantly decreased free palmitic acid, increased free oleic acid, normalized lipid profile, decreased oxidative stress, cyclin D1 expression, Ki-67 immunoreactivity, and Bcl2 expression, and increased the ratio of apoptotic/non-apoptotic cells. Mechanistically, vildagliptin elicited these physiological and molecular alterations by restoring normal AMPK signaling and reducing the cellular expressions of FASN and HMGCR, restoring AMPK-dependent phosphorylation of p53 at Ser-15 and reducing Akt/mTOR signaling.

SIGNIFICANCE

These results indicate that vildagliptin may alleviate betel-nut induced carcinogenesis in the liver of female mice.

Genetic toxicology and toxicokinetics of arecoline and related areca nut compounds: an updated review

Areca nut (AN) is consumed by more than 600 million of individuals, particularly in some regions of South Asia, East Africa, and tropical Pacific, being classified as carcinogenic to humans. The most popular way of exposure consists of chewing a mixture of AN with betel leaf, slaked lime, and other ingredients that may also contain tobacco named betel quid (BQ). Arecoline is the principal active compound of AN, and, therefore, has been systematically studied over the years in several in vitro and in vivo genotoxicity endpoints. However, much of this information is dispersed, justifying the interest of an updated and comprehensive review article on this topic. In this sense, it is thus pertinent to describe and integrate the genetic toxicology data available as well as to address key toxicokinetics aspects of arecoline. This review also provides information on the effects induced by arecoline metabolites and related compounds, including other major AN alkaloids and nitrosation derivatives. The complexity of the chemicals involved renders this issue a challenge in genetic toxicology. Overall, positive results in several endpoints have been reported, some of them suggesting a key role for arecoline metabolites. Nevertheless, some negative genotoxicity findings for this alkaloid in short-term assays have also been reported in the literature. Finally, this article also collates information on the potential mechanisms of arecoline-induced genotoxicity, and suggests further approaches to tackle this important toxicological issue.

Long non-coding RNA expression profiles and related regulatory networks in areca nut chewing-induced tongue squamous cell carcinoma

Areca nut chewing is an important risk factor for developing tongue squamous cell carcinoma (TSCC), although the underlying molecular mechanism is unknown. To determine the potential molecular mechanisms of areca nut chewing-induced TSCC, the present study performed whole-genome detection with five pairs of TSCC and adjacent normal tissues, via mRNA- and long non-coding (lnc)RNA-gene chip analysis. A total of 3,860 differentially expressed genes were identified, including 2,193 lncRNAs and 1,667 mRNAs. Gene set-enrichment analysis revealed that the differentially expressed mRNAs were enriched in chromosome 22q13, 8p21 and 3p21 regions, and were regulated by nuclear factor kappa B (NF-κB) and interferon regulatory factors (IRFs). The results of ingenuity pathway analysis revealed that these mRNAs were significantly enriched for inflammatory immune-related signaling pathways. A co-expression network of mRNAs and lncRNAs was constructed by performing weighted gene co-expression network analysis. The present study focused on NF-κB-, IRF- and Th cell-signaling pathway-related lncRNAs and the corresponding mRNA-lncRNA regulatory networks. To the best of our knowledge, the present study was the first to investigate differential mRNA- and lncRNA-expression profiles in TSCCs induced by areca nut chewing. Inflammation-related mRNA-lncRNA regulatory networks driven by IRFs and NF-κB were identified, as well as the Th cell-related signaling pathways that play important carcinogenic roles in areca nut chewing-induced TSCC. These differentially expressed mRNAs and lncRNAs, and their regulatory networks provide insight for further analysis on the molecular mechanism of areca nut chewing-induced TSCC, candidate molecular markers and targets for further clinical intervention.