Oral Cancer as a Result of Betel Quid Use: An Interventional Analysis of Betel Quid Prevention and Cessation in Papua New Guinea Adolescents and the Role of Dentists as Global Citizens

Ared-stained smile, often observed in Asia-Pacific populations, is the hallmark of betel quid (BQ), a carcinogenic seed chewed by an estimated 600 million people globally (Ping-Ho et al., 2017). This practice is deeply rooted in Asia-Pacific culture; however, BQ is widely recognized to cause multisystem adverse health effects and oral cancer (Chu, 2001; Moe et al., 2016; Ping-Ho et al., 2017). Despite BQ’s classification of a group one carcinogen and the urgent public health threat announced in 2012 by the World Health Organization (WHO), it is still perceived and advertised by many as harmless and health enhancing (International Agency for Research on Cancer [IARC], 2018). For this reason, there is an urgent need for global awareness of BQ’s harmful effects and the development and implementation of effective strategies to mitigate global morbidity and mortality. This paper will describe the global health issue of oral cancer as a result of BQ use. An intervention by Chen et al. (2018) aimed at BQ prevention and cessation in Papua New Guinea (PNG) adolescents will be presented and analyzed to recognize its successes and barriers to help inform future BQ prevention and cessation strategies. Global health, global citizenship, and the role of dentists in BQ prevention and cessation on a global, national, and local level will also be discussed.

Description of Global Health Issue: Oral Cancer as a Result of Betel Quid Use
BQ is the fourth most common psychoactive substance used after tobacco, alcohol, and caffeine (Sullivan & Hagen, 2002). Although it is technically the areca nut that is chewed, the terms betel and areca nut are often used interchangeably (IARC, 2018). The term quid denotes a mixture of substances that is placed in the oral cavity, chewed, and swallowed (IARC, 2018). BQ may contain a variety of ingredients depending on individual and cultural preference, such as tobacco, condiments, and sweeteners; however, it is most commonly draped in slaked lime and folded in a Piper Betel leaf for use (IARC, 2018). In this paper, the term BQ will be used to refer to any preparation of chewed areca nut, including the nut alone and all admixtures involved.

Oral Cancer and Global Burden of Disease
Oral cancer is one of the most common cancers globally and is estimated to have an annual incidence of 300,000 cases (Bray et al., 2018). Over the last decade, the global incidence, mortality, and disability‐adjusted life years (DALYs) for oral cancer have increased, predominantly in Asia-Pacific countries (Ren et al., 2020). Oral cancer is a multifaceted noncommunicable disease (NCD) linked with myriad risk factors and causative agents such as alcohol, tobacco, diet, oral hygiene, human papilloma virus, and BQ chewing (Warnakulasuriya, 2009). Reports have attributed the increasing incidence of oral cancer in Asia to the use of tobacco products and the growing BQ industry (Ren et al., 2020). It is estimated that half of oral cancers in the Asia-Pacific could be prevented with BQ cessation, with a population attributable fraction of 53.7% in Taiwan and China, and 49.5% in India (Guha et al., 2014). BQ is chewed by at least 10-20% of the world’s population, with most use concentrated in Asia-Pacific countries (Little et al., 2015). BQ is often compared to tobacco with both its associated stimulant and anxiolytic effects, leading to habituation, addiction, and withdrawal (Benegal et al., 2008; Bhat et al., 2010). Despite its common association with tobacco, BQ use has been linked in isolation to oral cancer (IARC, 2018; Trivedy et al., 2002).

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Social and Cultural Influences
BQ usage in the Asia-Pacific has a longstanding sociocultural role dating back to the eleventh century among the royal courts (Singh et al., 2020). Historically, BQ was prominent in societal language, poetry, and sexual relations as cited in the Kama Sutra and is still deeply rooted today in social acceptance and social relations between families, friends, and businesses (Rooney, 1993; Singh et al., 2020). Culturally, BQ has assimilated into many Hindu and Buddhist customs and is served as a traditional offering at many religious ceremonies such as births, deaths, and marriages (Wangdi & Jamtsho, 2020). Because of BQ’s longstanding social and cultural influence, BQ is used in traditional ayurvedic medicine for indigestion, impotence, parasitic infections, and prevention of morning sickness in pregnancy, resulting in a widespread view that BQ use has myriad health benefits (Auluck et al., 2009; Strickland, 2002).

Sex and Gender Influences
Culturally ingrained socially constructed gender ideologies among societies result in different BQ chewing prevalence rates and behavior among men and women (Yap et al., 2008). A multi-national population-based cross-sectional study found that BQ abuse prevalence rates in men (4.9%-13.0%) were higher than in women (0.8%-1.7%) in Taiwan and China; however, prevalence rates in women (22.7%-46.3%) were higher than in men (8.9%-11.6%) in Malaysia and Indonesia (Lee et al., 2012). Similarly, smaller countries such as Bhutan have reported conflicting intranational studies on sex and gender prevalence (Dorji et al., 2012; Wangdi & Jamtsho, 2020). Although the variation amongst nations is likely multi-factorial involving social and cultural differences, researchers have attributed the difference in sex and gender prevalence to the underrepresentation of women in study samples (Wangdi & Jamtsho, 2020). Such underrepresentation in research could result in poorer outcomes for women due to increased oral cancer rates. In terms of gendered BQ behavioral patterns, a study in Myanmar revealed that males used BQ more frequently to display power, risk-taking, and manliness, while working-class men used BQ to maintain energy and stamina (Moe et al., 2016). Other studies found woman used BQ with smokeless tobacco at increased rates because it is not culturally appropriate for women to smoke tobacco and that males were more attracted to women with red stained teeth from BQ use (Constance et al., 2019; Murphy & Herzog, 2015). Overall, limited research has been conducted on why BQ prevalence and behaviors differ among sex and gender. More research on this topic can generate useful information when constructing BQ cessation and prevention programs.

Economic and Political Influences
In most Asia-Pacific countries, economics are based on BQ trade representing an important source of income for people (Singh et al., 2020; Wangdi & Jamtsho, 2020). Since BQ production and processing creates thousands of jobs, it is a common misconception that mitigating BQ in Asia-Pacific economies would not be advantageous, due to the unemployment it would create (International Labour Organization [ILO], 2018). Research on revenue generated from BQ in the Asia-Pacific is limited because more than 68% of these countries operate on informal economies, defined by unregulated workers from the government (ILO, 2018). Unregulated workers result in unregulated BQ production, distribution, and trade – resulting in easily available BQ products and lack of source control contributing to the global popularity, morbidity, and mortality (Singh et al., 2020). There needs to be a comprehensive and integrated strategy including a range of policy sectors and important institutional and societal stakeholders to control for the negative aspects of informal economy products, such as BQ, that preserves its significant job creation (ILO, 2018).

Population of Interest: Papua New Guinea (PNG) Adolescents
PNG is a lower to middle income country, that has struggled for decades to provide quality health care services due to lack of infrastructure and financial resources (United Nations Development Programme, 2021). With a profound shortage of dentists, oral health is particularly poor resulting in high levels of dental caries, periodontal disease, facial trauma, and oral cancer (Crocombe et al., 2017). The PNG National Health Plan (2011-2020) highlights the need to improve health care, but oral health is not identified as a priority (Kelwaip et al., 2020).

BQ is currently gaining popularity in Asia-Pacific adolescents in the form of processed BQ products (Wangdi & Jamtsho, 2020). Research suggests that the majority of BQ initiation occurs in Asia-Pacific adolescents starting from ages 11.7 to 13 years old (Chen et al., 2011). The WHO STEPS survey found BQ rates of 79% among PNG adolescents with the majority reporting daily use (WHO, 2012). Younger daily BQ users in PNG already show signs of oral premalignancies, rendering them higher risk (Oakley et al., 2005). PNG has both the highest global incidence of oral cancer (20.4) followed by Pakistan (12.2) per 100,000 people and the highest prevalence of BQ use as cited by a recent literature review (IARC, 2018; Gunjal et al., 2020). These statistics suggest that PNG adolescents could be the driver of disproportionately high oral cancer rates in PNG as a result of BQ use.

The research on motivations for BQ use among PNG adolescents is limited; however, studies have shown four common domains in similar Asia-Pacific adolescent populations as to why BQ use is high in this age group. The four common domains are: personal, social, cultural, and political-economic factors (Dalisay et al., 2019). The personal domain includes intrinsic risk factors such as higher risk-taking behavior and perceived positive outcomes associated with BQ use (Dalisay et al., 2019). The social domain includes a lack of social maturity to resist peer and family pressure (Dalisay et al., 2019). The cultural and political-economic domains include reinforcing cultural norms and easy access (Dalisay et al., 2019). These four domains suggest that the motivations for BQ chewing in PNG adolescents is unique to adults in various ways. Adolescence is an impressionable age group in which BQ use initiation occurs, progressing into regular use; thereby, increasing oral cancer rates. Therefore, comprehensive education is critical at this impressionable age that targets all four domains.

Intervention of Interest: An Educational Program on BQ Chewing in PNG Adolescents
A recent systematic review revealed 21 global interventions targeting BQ use between 1990 and 2018 (Das et al., 2020). Published strategies included product bans, media campaigns, education, cessation, and taxation at micro, meso, and macro levels (Das et al., 2020). While these interventions yielded promising findings, there have been few successful interventions specific to BQ use in adolescents, an age group that lacks knowledge of BQ’s harmful effects and motivation for cessation (Chen et al., 2018). Taiwanese researchers Chen et al. (2018) implemented an educational program among primary and secondary school students to study the effectiveness of health education on BQ prevention and cessation. This section will outline the details of this intervention with a focus on the latter group – PNG secondary school students of adolescent age.

The Department of Overseas Medical Centre and Changhua Christian Hospital in Taiwan initiated this program as a PNG oral cancer prevention strategy (Chen et al., 2018). The program was also supported by the Ministry of Health and Welfare and the Republic of China on Taiwan (Chen et al., 2018). Two classes of secondary school students aged 16 years old from Lae city – the second largest city in PNG – received a 30-minute lecture on topics within oral cancer, including epidemiology, etiology, clinical appearance, clinical management, and treatment. The classes were provided by the school in English as this is the primary regional language of instruction. Sixty-five participants were selected at random out of 447 to complete pre and post questionnaires on oral cancer, BQ, and tobacco knowledge; however, only 55 participants completed both questionnaires making them eligible for the study.

The results of the intervention found that only 76% of PNG adolescents knew that BQ causes oral cancer. Adolescents termed BQ as green gold with many positive health effects; however, the intervention showed significant improvement in the knowledge of harmful effects of BQ use in adolescents. Despite improvement in knowledge, the lectures were not successful at motivating behavioral change in BQ cessation. The researchers believed that by providing the short 30-minute lecture, they were successful at teaching adolescents the potential harmful effects of BQ and thus, preventing the BQ habit.

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Interventional Analysis: An Educational Program on BQ Chewing in PNG Adolescents
Chen et al.’s (2018) intervention was successful in providing knowledge to PNG adolescents about BQ’s harmful effects and role in oral cancer; however, it was not an effective intervention for BQ prevention and cessation for various reasons. This intervention did not address BQ’s deeply rooted nature in social, cultural, gender, and political-economic domains in PNG society. Strategies on how to support BQ cessation were not present and the program failed to change attitudes towards BQ cessation.

Social, Cultural, Sex, and Gender Successes and Barriers
This intervention was not successful at changing adolescent attitudes towards BQ cessation as it lacked an individualized approach amongst the adolescent group and between both age groups studied. A recent study demonstrated that traditional school-based interventions have not yet been effective for middle-aged adolescents due to the inability to address adolescent sensitivity to status and respect, despite such interventions being beneficial in younger children (Yeager et al., 2018). Adolescents are ready for change at different times due to individual differences (Haleem et al., 2015). Therefore, continuous and personalized education can ensure individuals will receive the support they need when ready for change. Moreover, making education more comprehensive in terms of content and delivery, including videos and peer discussion, has also proven successful in other Asia-Pacific regions (Singh et al., 2020). Additionally, a more long-term program could have been more beneficial as researchers in Pakistan found that long-term education programs on oral health that provide repetition and reinforcement are more effective in changing knowledge, attitudes, and behavior in adolescents (Haleem et al., 2015).

This intervention was provided through a colonial lens by not using the native language of PNG to deliver its education (Farmer et al., 2009). Using English was found to be a barrier for adolescents and instructors whose primary language is Tok Pisin as they lacked certain understandings (Chen et al., 2011). An educational intervention based in Guam had similar barriers and highly recommended developing program materials in native languages for better uptake (Moss et al., 2015). If delivering this intervention to PNG rural areas – where BQ rates are higher and English is sparse – a community-based grass roots design involving participatory planning of the PNG community may have more success than a colonial framework.

One success of this intervention was the use of local instructors to deliver its content. Using local community members is successful as they are more trusted by Asia-Pacific youth (Chudgar & Shafiq, 2010). However, BQ sociocultural barriers were not addressed in the lectures which could have contributed to a lack of attitudinal change on BQ cessation. A large sociocultural barrier in PNG is the involvement of BQ in family culture (Singh et al., 2020). BQ is widely available in the home and adolescents from families who chew BQ are 14 times more likely to chew than those from BQ abstinent families (Dorji et al., 2012). Family engagement in youth education is one of the main determinants of effective education (Chudgar & Shafiq, 2010). Although there are no known family-centered approach to BQ cessation in adolescents, Moss et al. (2016) found that a family-centered approach in Guam adults was successful. Changing BQ use in PNG culture can be difficult; however, changing perspectives through education needs to be family-centered and in collaboration with local community members and leaders to avoid negating PNG culture and tradition in the process.

The lack of transparency between sex and gender adolescent outcomes in this intervention was also a barrier. Because research on BQ use patterns among genders in PNG adolescents is limited, researchers could have compared the differences in educational beliefs, knowledge, and attitudes amongst boys and girls. If similar BQ masculine ideologies were seen in PNG male adolescents as in Myanmar men, this information could be useful to guide future gender-sensitive behaviour modification approaches in BQ cessation.

Political and Economic Successes and Barriers
Another success of this intervention was early education on the harmful effects of BQ as early intervention is known to be effective in BQ prevention and cessation strategies (Haleem et al., 2015).
However, educational strategies for adolescents would be better utilized if made mandatory under PNG policy. This is difficult given BQ consumption is closely linked with authority, politics, and economy in PNG (Singh et al., 2020). Developing countries such as PNG often lack manpower and the financial means to implement such mandatory programming in schools (WHO, 2003); however, Asia-Pacific economic burdens due to BQ associated oral cancer is much greater than the revenue generated by the industry (Singh et al., 2020). Large amounts of resources and productivity are lost due to BQ related NCD morbidity and mortality in the Asia-Pacific, putting a significant financial strain on governments as NCDs continue to be grossly underfunded (Reubi et al., 2016). Additional lack of financial support in developing countries such as PNG leads to a lack of knowledge and epidemiological study on BQ health consequence and inability to implement universal health care (Ghani et al., 2011; Sachs, 2012; Wang et al., 2018). More of a focus needs to be placed on funding NCD prevention strategies for oral cancer and government policy on BQ prevention and cessation strategies.

Although not a direct barrier of the intervention, providing education on why BQ use is harmful while simultaneously witnessing widespread use among PNG residents could be confusing to adolescents. PNG policies should include stricter BQ regulation on source control since 80% of PNG residents participate in the informal economy (ILO, 2018). For example, India has banned BQ products due to widespread adolescent use which has proven effective (Garg et al., 2014). In addition to traditional education in schools, the Indian government created an awareness campaign which led to has shown better knowledge, negative attitudes towards BQ, and greater cessation intentions and behaviours among BQ users (Murukutla et al., 2012). PNG government officials need to create BQ bans to send clearer messages to adolescents.

Global Health, Global Citizenship, and The Dentistry Role
The definition of global health is often thought to have specific focus on addressing health inequities in low- and middle-income countries (Turcotte-Tremblay et al., 2020); however, global health is much more inclusive referring to every health challenge as a transnational determinant, including global and local environments (Holst, 2020). For example, the Asia-Pacific community is one of the largest and fastest developing minorities in Western countries (Singh et al., 2020). The effect of globalization and increased movement of Asia-Pacific populations across borders is resulting in changes in the patterns of disease in Canada, such as oral cancer due to wider dissemination of BQ (Singh et al., 2020) – thereby, establishing oral cancer as both a global and local issue. No formal definition of global health has been established; however, Holst (2020) defines this term as promoting human rights and a universal right to health, and encompassing social, economic, and political perspectives. This definition can be useful when trying to mitigate deeply rooted ill habits such as BQ use since it encompasses the myriad perspectives that accompany BQ use. Global health should also include the understanding of how we can work collectively on a global scale to improve resources of disadvantaged populations and how different disciplines, can work together to solve health problems that no country or party can solve on their own. This was evidenced by external Taiwanese resources used in the early educational program implemented in PNG adolescents to help decrease PNG’s oral cancer rates via BQ knowledge and cessation.

The concept of global citizenship and education has become a recent focus in global health, positing that one’s responsibilities are not limited to a specific area but extended to a universal one, transcending borders created by each country to augment universal rights, global interconnectedness, and global ethical responsibility (Pais & Costa, 2020). Global health education requires multidisciplinary strategies to navigate complex global issues such as the role of BQ in NCD in Asia-Pacific regions (Holst, 2020). To fulfill the global citizen role and grow successfully, practitioners need to become more politically aware, consider multiple perspectives, advocate to improve local and global access to resources, and critically self-reflect on their position in the politicized field of global health (Bozorgmehr, 2010). Moreover, understanding global interconnectedness and valuing diversity provides a foundation that enables us to take action and meaningfully challenge global injustice.

In order to bring global citizenship to the forefront on the issue of oral cancer, dental professionals must consider social, cultural, gender, and political-economic factors that shape global, national, and local policy (Bozorgmehr, 2010). Globally, dentists can advocate for more research on more effective BQ cessation programs and lobby for strong, early efforts in establishing community education programs in Asia-Pacific children and adolescents. Nationally, Canada has already banned BQ use; however, previous use can still predispose individuals to oral cancer (IARC, 2018). Advocating for national BQ screening and cessation programs due to the growing diversity of Canadian populations as seen in global travel, immigration, and increased accessibility to commercially manufactured BQ products should be a focus to provide proper care for high-risk populations (Cesario, 2017). From a local standpoint, Canadian dentists can partner with local health care providers and community organizations to teach local educational initiatives on the harmful effects of BQ and how to recognize signs of BQ use in order to provide appropriate patient education and early intervention. BQ cessation interventions need to be culturally appropriate and explained in native language (Public Health Law Center, 2017). While collective efforts are needed to make a global impact, dentists are uniquely positioned to provide BQ education during oral cancer screenings and advocate at the local and global level for increased efforts towards oral health and BQ cessation to decrease the trajectory of oral cancer.

Conclusion
Oral cancer rates due to BQ usage are increasing worldwide with a focus on Asia-Pacific regions. BQ use is deeply rooted in social, cultural, gender, and political-economic domains which needs to be taken into consideration when creating BQ prevention and cessation strategies. An educational intervention to prevent BQ usage in PNG adolescents was analyzed. Successes, barriers, and recommendations were discussed to better inform future interventions. Dental practitioners need to be aware of BQ use and oral cancer rates at global, national, and local levels. As health care providers, being aware of global trends and issues can better define our position as global citizens, to provide the ultimate shared goal of better health outcomes for all and decreasing the global burden of oral cancer.

Oral Health welcomes this original article.

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About the Author

Meagan Noble recently completed a Master of Nursing, Nurse Practitioner (NP) degree with a Collaborative Specialization in Resuscitation Science from the University of Toronto. As an RN, she has worked in emergency departments across Canada and the Dr. Peter Fritz Periodontal Wellness & Implant Surgery clinic. As a new graduate, Meagan is excited to start her career in Northern Ontario for Indigenous Health Care Services Canada.

Jordan Mackenzie is a fourth-year Doctor of Dental Surgery student at the University of Toronto. He graduated summa cum laude from Saint Mary’s University in Halifax with a major in biology. Jordan hopes to return to Nova Scotia to provide dental care to underserviced populations.