Betel Nut Chewing in Hawai‘i: Is it Becoming a Public Health Problem? Historical and Socio-Cultural Considerations

Abstract

This article examines the socio-cultural significance of betel nut use among Micronesians, in light of the recent migration of Micronesians to Hawai‘i. The different ways of chewing betel nut are the result of historical changes within Micronesia over time due to Spanish and US colonialism as well as the introduction of tobacco. These divergent ways of chewing may have different risks or impacts on health and it remains to be seen whether or not betel nut will become a significant public health problem in Hawai‘i.

Introduction and Background

The purpose of this article is to describe the socio-cultural significance of betel nut among some of the peoples of Micronesia and the island of Guam and to explicate the differential betel nut chewing practices, in light of recent migration of Micronesians to Hawai‘i. These differential betel nut chewing practices are divergent because of historical changes due to both Spanish and US colonialism, as well as the introduction of tobacco, among United States current and former colonial possessions in the Pacific. These divergent practices may have different risks or impacts on oral health, and especially oral cancer.

Betel nut/Areca nut (Areca cathecu) chewing is prevalent in South Asia (eg, India, Pakistan and Nepal), Southeast Asia (eg, Cambodia, Vietnam, Taiwan, Malaysia, Indonesia, Papua New Guinea, and the Philippines) and the Western Pacific islands.¹ Betel nut is used in parts of Melanesia (including the Solomon Islands and New Ireland) and in Micronesia (eg, Guam, Yap, Belau, and Pohnpei).² The traditional way to chew betel nut in the Pacific islands is by betel nut chewing alone, or in combination with pepper leaf (Piper betle) and/or slaked lime,³ and/or various forms of tobacco (originally introduced by the Spaniards). Recently, the practice of betel nut chewing has been spreading in some Asian and Pacific areas (such as coastal Papua New Guinea), while declining in other areas (fast-growing cities in mainland South and South East Asia).⁴ In Indonesia, Strickland states there is “…persuasive historical evidence that tobacco smoking by men displaced areca use almost completely in Sulawesi in the half century following 1900, while in Java, Bali and Sumatra the process was less rapid.” Strickland also cites evidence from Thailand where legislation prohibiting area betel nut use in 1942 led to a decline in urban use.

There has been recent interest in Hawai‘i and other Pacific public health circles about the link to oral cancers by betel nut chewing alone, or in combination with pepper leaf (Piper betle) and/or slaked lime, and/or various forms of tobacco, because of the large influx of Micronesian migrants in Hawai‘i over the past decade. Micronesians are considered to be Hawai‘i's fastest growing population, yet they are dwarfed by the sheer numbers of other immigrants from Asia, especially the Philippines. If the number of migrants from Micronesia is up to 25,000 people (double the US Census estimates from the 2008 Compact of Free Association (COFA) census and close to the 2006-2008 American Community Survey's (ACS) estimates of 22,192), they still would constitute only 1.5% of the state's population. Micronesians, mainly Marshallese and Chuukese, have been migrating in large numbers to Hawai‘i for employment, health, and educational opportunities.^5–7 Many of the recent Micronesian migrants have adopted “Yapese style” or traditional betel nut chewing and a small market niche has developed so that betel nuts, pepper leaf, and lime are available for purchase at certain stores on O‘ahu.⁸

In light of this recent interest, it is important to understand both the important cultural role of betel nut chewing in Guam and Micronesia as well as the way it is chewed or consumed (which may impact potential oral cancer or other risk). Knowing the importance of betel nut chewing in both of its main forms (modern “Chamorro” style and traditional “Yapese” style) (1) provides information to determine if any interventions are necessary and (2) could also be a key to understanding urbanization and modernization patterns, along with out-migration trends in Micronesia.

Betel Nut Chewing Practices in Micronesia

Betel nut is called bu in Yap, bua in Belau and poc in Pohnpei and pu in Chuuk.¹ In Micronesia betel nut is chewed in the traditional way with young, immature nuts with slaked lime, and Piper betle (pepper leaf). When the green, immature betel nut is chewed, it is chewed (depending on the size) either whole or sliced in half. The young immature nuts include the husk and when the leaf, lime (or tobacco) is added and chewed, this forms a so-called “quid” or “betel quid.” It is the husk that forms the structure of the large “quid.” The husk is not swallowed, only chewed. When chewing the immature, green nut with leaf and lime, this resulting mixture turns red and the juice is usually spit out in various quantities during the chew. For an added effect, after chewing for awhile, one can take out the quid and add a few more sprinkles of lime and keep chewing (learned from Yapese acquaintances).⁹

In the Marshall Islands, Bhandry and Bhandry report increasing use of betel nut and chewing tobacco among Marshallese for whom this is not a traditional practice¹⁰ but rather a recently adopted one.¹¹ There is also increasing evidence that other Micronesian groups from the Federated States of Micronesia have taken up chewing betel nut (eg, Chuukese or other Marshallese migrants) in Hawai‘i (personal observation). This recent adoption of “Yapese style” betel-nut chewing by Micronesians and Micronesian migrants as a form of ethnic regional identity as Micronesians may pose additional obstacles to “stamping out” the practice regardless of potential adverse health effects (ie, possible oral or other cancer in the far distant future).

Betel Nut Chewing Practices on Guam and the Philippines

On Guam, betel nut is called pugua, the leaf pupulu and the lime afok. If one chews betel nut mixed with lime, pepper leaf and tobacco, this is called mama' or mama'on. Mama' in Chamorro can refer to something becoming or turning liquid. This is the same in the Visayan islands in the Philippines, where chewing betel nut is called maman: to chew it is mama'. Also in the Visayan islands, betel nut is called bunga, the leaf buyo and the lime apog.¹² The Chamorros of Guam and the Mariana Islands previously chewed betel nut in the traditional way, with immature nuts, leaf, and lime.¹³ After centuries of Spanish colonialism and especially after another century of American military colonialism, the Chamorro people of Guam altered their betel nut habit to chew mainly mature nuts so that it is an acceptable part of modern, urban life and continues as a cultural practice. Betel nut chewing is an integral part of socializing on Guam and in Micronesia. Chamorros on Guam will offer the hard, mature nut usually by itself (and occasionally with leaf) at work, at fiestas, and when socializing. In the Philippines, another Spanish colony (and where Guam was administered via Manila under Spanish rule), traditional betel nut use (also like “Yapese” style) is now prevalent only among Muslims in rural areas.

Betel Nut Chewing Practices in Hawai‘i

In Hawai‘i, since Micronesian migrants are a small proportion of the total population,¹⁴ their numbers are similarly small in national and state health surveillance surveys. However, in 2009 questions about betel nut use with tobacco were added on the Hawai‘i Youth Tobacco Survey (YTS), a survey administered to Hawai‘i middle and high school students to determine tobacco use. The results show that “ever use” of betel nut among high school students was very low at 3.1%, while “current use” of betel nut with tobacco (within the past 30 days) was even lower at 1.3% for middle school students and 2% for high school students.

Since there was a scarcity of data about betel nut use among adults in Hawai‘i, the Tobacco Prevention and Education Program (TPEP) and Bilingual Health Services Program (BHS) at the Department of Health gathered data among Asian and Pacific immigrants and migrants to Hawai‘i, using a survey. Clients utilize BHS translators to access needed services. The survey was administered with the usual intake forms and included questions on existing chronic diseases, smoking, betel nut use and possible tobacco cessation intervention strategies to clients in 2008–2009, with a total sample of N=2,350. The smoking data showed that limited and non-English speaking Filipinos and Vietnamese comprised the largest part of this client sample and they also reported the highest current smoking at around 30%. However, Micronesians also reported current smoking in this sample at 16%. BHS clients were also asked about betel nut use. The total number reporting current betel nut use in this sample was very low at less than 1% (n=103 out of 2,350). However, among Micronesians, it was 1 in 5 adults in this sample (20.6%). Overall, those reporting using betel nut alone were more likely to also report smoking than those chewing betel nut with leaf, lime, and plug or other chewing tobacco.¹⁵ Although the numbers are small, this pattern illustrates the divergent patterns that have occurred in Micronesia, with plug or other tobacco being used along with traditional or “Yapese” style betel nut chewing and use of betel nut alone with cigarette smoking.

Chewing betel nut on O‘ahu can be an expensive habit, particularly if cigarettes are used for tobacco. The cheapest generic cigarettes are $6.50 per pack. Fresh young immature betel nut is $5.00 for eight pieces, with leaf included, but slightly cheaper are frozen nuts at $6.00 for 15 pieces.⁸ Micronesians may harvest betel nut in areas throughout the state where there is enough rainfall for betel palms to grow, but, betel nut is not very commonly grown in Hawai‘i.

Betel Nut Use and Oral Cancer

The habitual, long term (chronic) chewing of betel nut is known to have health effects, including oral lesions and oral cancer,^16–17 and recent research suggests it may be an independent risk factor for oral cancer when used without tobacco.^18,19 However, few studies differentiate the use of lime as the possible culprit.¹⁴ The question of whether it is the tobacco that is the problem or the added caustic effect of the lime has not been adequately answered. The addition of lime aggravates the gums and oral cavity, and tobacco is a known carcinogen, so it could be a synergistic effect.²⁰ Research in the Solomon Islands showed that the prevalence of oral cancer was highest for those who smoked tobacco and chewed betel nut and for those who chewed the highest numbers of betel nut quid per day.²¹

Betel Nut, Smoking and Cancer

Since tobacco was introduced in the Pacific, it has been smoked and or chewed with betel nut. Smoking rates are high in both Guam and Micronesia; people on Guam report the highest smoking rates in the nation on the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance Survey (2008) at 27.5% for adults²² and 23.1% for youth on the Youth Risk Behavior Survey. Lung cancer and oral cancers follow these patterns in smoking and betel nut use. The oral and lung cancer incidence rates for Hawai‘i (2000–2005) and Guam (2003–2007) by gender are presented in Table 1. Guam's men and women have lower oral cancer rates than Hawai‘i's men and women, but Guam's lung cancer incidence rates are higher; men's rates are higher than women's. The current practice of chewing mature betel nut with leaf only among Chamorros on Guam does not seem to have as harmful oral health consequences as “Yapese style” chewing. However, betel nut chewing is addictive and there is evidence of an independent risk for deleterious oral health results even by betel nut chewing alone.¹⁷ Unfortunately smoking risk has replaced traditional betel nut chewing risk in Guam. In Guam, it is also not uncommon for Chamorros to smoke and chew mature betel nut at the same time, just as Yapese will add tobacco to their betel quid. In Taiwan, chewing betel nut and smoking when combined led to multiple-site cancers.²⁰

Table 1.

Oral and lung cancer incidence rates per 100,000 population (age-adjusted to the US population) in Hawai‘i and Guam.

	Hawai‘i (2000–2005)	Guam (2003–2007)
Oral cancer rate	Men 15.9 Women 6.7	Men 11.1 Women 2.4
Lung cancer rate	Men 67.7 Women 38.8	Men 85.4 Women 40.6

Data Sources: Hawai‘i Cancer Facts & Figures 2010; Guam Cancer Facts and Figures, 2003–2007.

The annualized oral and lung cancer prevalence for the Micronesian jurisdictions from 1985–1998 are presented in Table 2, although data are not available by sex. It is important to note that these data are annualized cancer period prevalence estimates, which the authors noted is a less than optimal way to ascertain cancer. However, even though the numbers/cases are small, the pattern of high oral cancer among the Yapese is apparent when age adjusted to the US standard population or the WHO world standard population (Table 2). On the island of Yap, which has the most traditional and persistent betel nut practices, the oral cancer rate is quite high at 31.8 per 100,000, followed by the Republic of the Marshall Islands and the Republic of Belau. Lung cancer rates are also highest in Yap, followed by the Republic of the Marshall Islands, the Republic of Belau, Chuuk and Pohnpei. Kosrae had the lowest rates of lung cancer and Chuuk had the lowest rate of oral cancer. On Guam, oral cancer rates from 1997–2003 were found to be highest among Micronesians and lowest among Filipinos.²³

Table 2.

Annualized oral and lung cancer prevalence (number of cases per 100,000 population).

	Federated States of Micronesia:				Republic of the Marshall Islands	Republic of Belau
	Yap	Kosrae	Pohnpei	Chuuk
Oral cancer (age-adjusted to the US population)	31.8	13.1	7.7	4.2	16.2	16.1
Oral cancer (age-adjusted to the WHO world standard population)	22.1	7.9	6.2	3.8	12.6	12.4
Lung cancer (age-adjusted to the US population)	53.7	8.6	28.4	32.5	52.7	46.5
Lung cancer (age-adjusted to the WHO world standard population)	39.6	8.7	21.3	3.8	41.1	34.6

Data Sources: Katz, Palafox, Johnson et al.²⁶

Betel Nut Use and Social Change

Betel nut chewing in the Pacific is still more of a rural habit than an urban one. It is much easier to chew the immature nuts with pepper leaf and lime and be able to spit with impunity in sparsely populated rural areas. With urbanization, in places such as Pakistan and India, the mature nuts are sliced, sugared and packaged like candy and the candied nut is chewed and swallowed. There is recent historical evidence in Indonesia that tobacco smoking displaces betel nut use and that use may decline with urbanization.³ However, Strickland provides examples of where betel nut use has been spreading in places like Papua New Guinea and that there is regional variation even within countries in South Asia and Southeast Asia. Strickland notes that social pressures due to migrant status may contribute to betel nut use, but no research has examined this phenomenon in detail.⁴

The important questions that need to be pursued regarding betel nut chewing in Hawai‘i are: (1) are current practices of betel nut chewing a public health threat? or (2) are they just a new interesting phenomenon to explore because of the influx of Micronesian migrants who have recently adopted “Yapese style” betel nut chewing (eg, the Chuukese and Marshallese)?

The Yapese have the highest rate of oral cancer in Micronesia,²⁴ linked to their long standing practice of chronic betel nut chewing (see Table 2). This is a health risk and this should be communicated to people who make it a habit throughout Micronesia. However, given the small total numbers of people reporting chewing betel nut, and the small number of Micronesians in Hawai‘i, it does not seem that betel nut chewing is a huge public health threat at this time.

There is no evidence that betel nut use is growing rapidly among young Micronesian immigrants to Hawai‘i. It is much more likely that young people are influenced by their peers at school and their present situation NOT to chew betel nut. This is one of the main contentions of this paper, that betel nut chewing will decrease as Micronesians adapt to Hawai‘i where the practice may be initially tolerated, but later banished, since local people do not chew betel nut. And, while betel nut chewing is also initially part of the repertoire of Micronesian migrants to Hawai‘i as an identifier, it is our contention that betel nut chewing will wane as Micronesians assimilate. It is much more likely that the Micronesians will drop the habits that make them “peculiar” to others, especially at workplaces and schools. One of the authors has observed two different Belauans' chewing betel nut in secret in Hawai‘i, whereby people they work with do not know they even chew betel nut anymore! At the present time, it remains to be seen whether Micronesians will gradually phase out betel nut chewing as they assimilate in Hawai‘i, or whether they will continue to use it.

Conclusions

More research is clearly needed on this topic and to clearly differentiate the practices associated with betel nut chewing in the Pacific.²⁵ How widespread is betel nut chewing or smoking among Micronesian migrants in Hawai‘i? Are younger people not picking up the habit as a result of assimilation and urbanization? Have the Chuukese and other Micronesians in Hawai‘i become addicted with a chronic habit for “Yapese style” betel chewing with all its risks, or is this more of a regional identity marker involving sporadic chewing for social reasons to identify themselves and others as Micronesians? Are the practices changing in different jurisdictions of Micronesia or in Guam or the CNMI-Commonwealth of the Northern Mariana Islands? More information also needs to be gathered from the people in the Micronesian jurisdictions about betel nut practices and the use of cigarette or plug tobacco, as well as smoking habits. Has smoking displaced betel nut chewing? Who is chewing? Is it mainly men or women? Do people begin the habit as children, youths, or adults? There is a need to document practices and conduct more research on how—not only whether—betel nut is chewed.

Conflict of Interest

None of the authors identify any conflict of interest.