The International Agency for Cancer Research (IARC) has classified areca nuts as human carcinogens, raising profound public health concerns globally.1 However, the lack of global consensus on how to manage its prevalence has left many countries grappling with ineffective intervention measures.2
In China, areca nuts are not only used as a traditional medicinal herb, as referenced in the Pharmacopoeia of the People's Republic of China but have also evolved into leisure products. These non-tobacco products, offered in various flavors and packaging options, are readily accessible through digital and physical retail channels, often without the need for age verification. However, the recognition of areca nuts as human carcinogens has necessitated a reassessment of their safety and classification in China.3 To understand the regulatory developments, we conducted a comprehensive review of Chinese policy documents concerning areca nuts. This letter revealed significant regulatory shifts over the past decades, outlined in several stages (Table 1). These changes, prompted by China's acceptance of IARC's carcinogen classification and national oral health campaigns, have halted attempts to promote areca nuts as medicinal and food products, while also underscored ongoing regulatory challenges.
Table 1.
National policies on areca nuts and intervention measures in China.
| Chinese areca nut policies in chronological order | |||
|---|---|---|---|
| Time | Authorities | Title | Key point(s) |
| Stage 1: Classification as food | |||
| June 30, 2003 | Trademark Office, State Administration for Industry and Commerce | Reply on Issues Related to ‘Areca Nut’ and Other Products | Areca nut is a type of fruit. According to the ‘International Classification of Goods and Services for the Purposes of the Registration of Marks,’ ‘fresh areca nuts’ are classified under Class 31, Group 5 as ‘unprocessed fruits and nuts’; ‘processed areca nuts’ fall under Class 29, Group 4 as ‘preserved, dried fruits and products.’ |
| Stage 2: Recognition as human carcinogen | |||
| August 21, 2017 | National Health and Family Planning Commission (Former) | Response to the Recommendation No. 5535 from the Fifth Session of the Twelfth National People's Congress | The Food Safety Law mandates that food be non-toxic and harmless, without causing any acute, subacute, or chronic harm to human health. Consequently, defining, quantifying, qualifying, and standard setting for areca nut must be rigorously researched and legally grounded. |
| October 30, 2017 | State Food and Drug Administration | World Health Organization International Agency for Research on Cancer List of Carcinogens | Preliminary compilation of the list of carcinogens published by the World Health Organization International Agency for Research on Cancer on October 27, 2017, includes betel nut as a Group 1 carcinogen. |
| February, 2019 | National Health Commission | Oral Health Action Plan (2019–2025) | Targeted interventions for oral diseases in regions where habitual areca nut chewing is prevalent, focusing on long-term harms and promoting early diagnosis and treatment of oral diseases. |
| Stage 3: Exclusion from food category | |||
| February 30, 2020 | State Administration for Market Regulation | Latest Revision of the Food Production Permit Classification Catalogue | Edible areca nut is excluded from the updated Food Production Permit Classification Catalogue. Thus, areca nuts are no longer regulated as a food item, and food production permits cannot be issued accordingly. |
| August 20, 2020 | National Health Commission | Response to the Recommendation No. 1427 from the Third Session of the Thirteenth National People's Congress | NHC has not approved areca nuts as a new food ingredient, nor included in the food and drug materials directory, and it is deemed inappropriate to set food safety standards for areca nuts. |
| September 17, 2021 | Office of the National Radio and Television Administration | Announcement on Stopping the Promotion of Areca Nut and Its Products through Broadcasting, Television, and Online Audio-Visual Programs | National Radio and Television Administration prohibits the promotion of areca nut and its products through broadcasting, television, and online audio-visual programs. |
| September 26, 2021 | Office of the State Administration for Market Regulation | Notification on the Supervision of Areca Nut Products | Areca nuts shall no longer be regulated as a food item. Food business operators are prohibited from mixing areca nut products with other foods for sale, and from displaying or selling areca nut products in food business areas. |
|
Chinese intervention measures of areca nuts | |
|---|---|
| Intervention measures | Provisions |
| Ban on mixing areca nut products with other foods for sale, and ban on displaying or selling areca nut products in food business areas | Food business operators shall not mix areca nut products with other foods for sale, and shall not display or sell areca nut products in food business areas (see Notification on the Supervision of Areca Nut Products). |
| Bans on advertisement in broadcasting, television and online audio-visual program | It is prohibited to promote areca nut and its products through broadcasting, television, and online audio-visual programs (see Announcement on Stopping the Promotion of Areca Nut and Its Products through Broadcasting, Television, and Online Audio-Visual Programs). |
| Intervention education | Local health authorities offer targeted interventions for oral diseases in regions where chewing areca nut is common, including public education and oral health screenings to promote early diagnosis and treatment of periodontal diseases and oral mucosal lesions (see Oral Health Action Plan (2019–2025). |
The existing regulatory framework of areca nuts in China is inadequate for curbing their prevalence and promoting public health initiatives. Despite the well-documented health risks, only one local regulation in Xiamen City prohibits the production, sale, and consumption of areca nuts, exempting their pharmaceutical use, and imposes fines for violations. Furthermore, the enforcement of existing intervention measures has proven ineffective. When areca nuts were removed from the food category, no alternative classification was provided, leaving them in a regulatory vacuum that contrasts with the stringent regulations governing tobacco and alcohol. Areca nut products are now displayed more prominently on specialized retail shelves, distinctly separated from other items, ironically increases their visibility and accessibility to consumers.4 Their physical advertisements continue to capture public's attention in public spaces such as highways bulletins and bus stops.
A significant barrier to effective regulation is industry interference and its impact on local governments.5 The industry plays an important role in the local economy, generating profits and creating jobs, especially in regions like Hunan and Hainan Provinces, where the areca nut consumption is notably high.4 Following the abolition of provincial standards for edible areca nuts in Hainan (DB46/T 75-2007) and Hunan (DB43/132-2004), the absence of compulsory national standards has left the regulation authority to local producer associations. For instance, the Hunan Province Areca Nut Industry Association has established its own Community Standards of Refined Areca Nut (T/HNBFIA 01-2023), Good Manufacturing Practice for Refined Areca Nut and the Standardized Production Evaluation Rules for Refined Areca Nut. Moreover, collaborations between local enterprises and authorities have promoted areca nuts as “local specialty products.”6 In provinces such as Hunan and Hainan, where the cultivation and consumption of areca nut hold cultural significance, initiatives have been undertaken to acknowledge areca nut chewing traditions and production techniques as intangible cultural heritage. This strategic positioning further complicates public health interventions by intertwining economic interests with cultural identity, thereby impeding the development of a well-framed regulatory framework.
To protect public health, it is crucial for China to realize the health risks associated with areca nuts and to strengthen regulations that govern the industry's commercial practices while prioritizing health-centric policies. Insights from China's experiences may assist global health governance in managing similar public health challenges, ensuring that cultural and economic factors do not undermine effective interventions.
Declaration of interests
We declare no competing interests.
Acknowledgements
Funding: None.
References
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