Betel Nut: Culture & Carcinogenicity

Taiwan has the highest incidence of betel nut linked oral cancer globally, and Xiangtan, China, the lowest. Varying cultural practices of betel nut preparation influence the carcinogenicity of the betel nut. This study aims to characterize preparation practices and their effects on toxicity in Taiwan and China through film, community interviews, surveys, and quantification of carcinogenic compounds via mass spectrometry in search of novel, culturally miscible strategies for oral cancer mitigation in Taiwan.

Personal Experiences + Conceptualizing the Project

In 2016, I attended a Bangladeshi family friend's wedding with my family. After dinner, I found small golden packages at our table that appeared to be some sort of candy or breath freshener.

“Be careful Anika, don’t eat too many or you may feel dizzy,” my father gently warned me in Bengali, with the excited chatter of wedding guests and festive music blaring in the background. My fingers paused in the midst of unwrapping a small package encased with golden foil. “Dizzy? Why would this paan make me dizzy?” I wondered aloud. My parents shrugged in response, so I promptly consulted a Wikipedia entry on paan. A cursory read caused me to double take, as I discovered that paan, another name for the betel nut, is a highly carcinogenic psychoactive stimulant consumed throughout the world. I stared at the screen in disbelief—I had grown up seeing my grandmother eat paan, her teeth stained red, and was familiar with paan as an innocent snack eaten during Bangladeshi festivities.

I spent the next year fervently researching the betel nut. My initial horror quickly evolved into fascination as I discovered the diversity of cultural practices and phenomena surrounding betel nut consumption in different countries. A hallmark of entering womanhood, hunger suppression, a social lubricant, a pick me up for long hours of manual labor—these were just a few reasons for consumption I read about from country to country. Having spent four years in high school learning Chinese language and culture and growing up in a predominantly Taiwanese town, discovering that Taiwan has the highest rate of betel nut linked oral cancer globally and China the lowest piqued my curiosity in investigating a contemporary phenomenon where digestive health and cultural practice intersect. A whirlwind of events—getting connected to the Taiwanese Vice President’s research team at an international gastroenterology conference, serendipitously meeting a UCSD plant biochemist from Xiangtan, China, and learning how to perform liquid chromatography mass spectrometry (LCMS) experiments for my senior honors research thesis on natural remedies for urinary tract infection (UTI)— galvanized my realization that there was a way in which I could synthesize my experiences and passions to investigate this phenomenon further in a way that could benefit the health of others.



Approximately 10% to 20% of the world’s population consumes the betel quid—a palm-sized concoction prepared by wrapping a betel nut with an assortment of culturally variant additives such as slaked lime paste, spices, and tobacco, in a piper betel leaf. Commonly found in markets and roadside stalls throughout Southeast Asia for the past 2500 years, preparation of betel nut varies by culture, as does the reason for its consumption. In 2004, the World Health Organization (WHO) declared the chewing of betel nut to be a Group 1 carcinogen. With its consumption causing a 28.2 times increase in oral cancer risk, the betel nut is a major contributor to global oral and esophageal cancer incidence. Varying cultural practices of preparing the betel quid are directly linked with the carcinogenicity of betel quid consumption.


Taiwan is the second largest producer of betel nut globally and has the highest incidence of oral cancer in the world. The Taiwanese government has faced significant difficulty in curbing domestic betel nut consumption since1997, considering that betel nut consumption is intricately intertwined with cultural practice and the nation's economy. 


A possible culturally appropriate solution may lie in a nearby region: Xiangtan, China. A handful of studies report Xiangtan, China as the only documented region in the world where betel nut is widely consumed, yet the area exhibits a surprisingly low prevalence rate of oral cancer. Considering that the method of betel quid preparation directly affects its toxicity, it is pertinent to investigate if differing cultural preparation practices are a contributing factor to the discrepancy in Chinese and Taiwanese oral cancer burden. Knowledge from this study has potential to offer new avenues for a globally relevant public health issue.






Multifaceted research questions need multifaceted approaches. To undertake this project, I will combine methods such as community engaged filmmaking, person centered interviews, opinion surveys, and mass spectrometry to research the following key questions:

                       What are the cultural preparation methods and histories of the betel quid

                       in Taiwan and China?

                       Is Chinese betel quid less carcinogenic than Taiwanese betel quid? 

                       What do betel nut consumers think of alternative betel quid preparation methods?

I am currently analyzing the toxicity of U.S betel nut through the Global Food-Omics Project in Rob Knight's lab and Pieter Dorrestein's lab at the University of California, San Diego to optimize some of the experimental methods required of this project.