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Cancer risks from betel quid chewing beyond oral cancer: a multiple-site carcinogen when acting with smoking

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Abstract

Objectives

This cohort study is to assess the extent of cancer risks of betel quid chewing (without tobacco added) beyond oral cancer, as such information was limited from case–control studies.

Methods

The cohort, selected from participants in a medical screening program since 1994, consisted of 177,271 adult men with 19.2% chewers of betel quid. As of 2006, out of 4,840 deaths, 1,901 cancer deaths were identified. Mortality hazard ratios (HR) were estimated by Cox proportional hazard model. Life expectancy was calculated by life table method.

Results

One-third of smokers chewed (33%) but most of chewers smoked (90%). Risk for all cancer doubled among chewers (HR = 2.00). Risks of at least six cancer sites were increased among chewers: oral cavity (HR = 12.52), esophagus (HR = 5.64), liver (HR = 2.27), pancreas (HR = 2.67), larynx (HR = 6.24), and lung (HR = 2.43) with risks increased with increasing betel quid amount consumed. All-cancer age-adjusted mortality rates in Taiwan increased 25%, including 223% increase in oral cancer, during the last 20 years when chewing rate increased five- to tenfolds. Chewing on top of smoking increased the risks synergistically, and these two were responsible for at least half (50%) of all cancer deaths among 2 million chewers in Taiwan. Life expectancy of chewers was shorter than non-chewers by 5.93 years at age 20 and 5.55 years at age 40.

Conclusion

In addition to oral cancer, significant increases were seen among chewers for cancer of the esophagus, liver, pancreas, larynx, lung, and all cancer. Chewing and smoking, as combined by most chewers, interacted synergistically and was responsible for half of all cancer deaths in this group. They were responsible for the recent increases in oral, esophageal, pancreatic, and liver cancer in Taiwan. Chewing and smoking shortened their life span by nearly 6 years.

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References

  1. Mack T (2001) The new pan-asian paan problem. Lancet 357:1638

    Article  PubMed  CAS  Google Scholar 

  2. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans (2004) Betel-quid and areca-nut chewing and some areca-nut-derived nitrosamines. IARC Monogr Eval Carcinog Risks Hum 85:1

    Google Scholar 

  3. Gupta P, Warnakulasuriya S (2002) Global epidemiology of areca nut usage. Addict Biol 7:77

    Article  PubMed  CAS  Google Scholar 

  4. Warnakulasuriya S, Trivedy C, Peters T (2002) Areca nut use: an independent risk factor for oral cancer: the health problem is under-recognised. BMJ 324:799

    Article  PubMed  Google Scholar 

  5. Winstock A (2002) Areca nut symposium: areca nut-abuse liability, dependence and public health. Addict Biol 7:77

    Article  Google Scholar 

  6. IARC Working Group on the Evaluation of Carcinogenic Risks of Chemicals to Humans (1985) Betel-quid and areca-nut chewing, and some related nitrosamines. IARC Monogr Eval Carcinog Risks Hum 37:141

    Google Scholar 

  7. Wen CP, Tsai SP, Cheng TYD, Chen CJ, Levy DT, Yang HJ, Eriksen MP (2005) Uncovering the relation between betel quid chewing and cigarette smoking in Taiwan. Tob Control 14:i16

    Article  PubMed  Google Scholar 

  8. Sharma DC (2003) Betel quid and areca nut are carcinogenic without tobacco. Lancet Oncol 4:587

    Article  PubMed  Google Scholar 

  9. Wen CP, Levy DT, Cheng TY, Hsu CC, Tsai SP (2005) Smoking behavior in Taiwan, 2001. Tob Control 14(Suppl 1):i51

    Article  PubMed  Google Scholar 

  10. Ko YC, Huang YL, Lee CH, Chen MJ, Lin LM, Tsai CC (1995) Betel quid chewing, cigarette smoking and alcohol consumption related to oral cancer in Taiwan. J Oral Pathol Med 24:450

    Article  PubMed  CAS  Google Scholar 

  11. Thomas SJ, Bain CJ, Battistutta D, Ness AR, Paissat D, Maclennan R (2007) Betel quid not containing tobacco and oral cancer: a report on a case–control study in Papua New Guinea and a meta-analysis of current evidence. Int J Cancer 120:1318

    Article  PubMed  CAS  Google Scholar 

  12. Wen CP, Cheng TYD, Tsai MK, Chang YC, Chan HT, Tsai SP, Chiang PH, Hsu CC, Sung PK, Hsu YH, Wen SF (2008) All-cause mortality attributable to chronic kidney disease: a prospective cohort study based on 462, 293 adults in Taiwan. Lancet 371:2173

    Article  PubMed  Google Scholar 

  13. Wang LY, You SL, Lu SN, Ho HC, Wu MH, Sun CA, Yang HI, Chen CJ (2003) Risk of hepatocellular carcinoma and habits of alcohol drinking, betel quid chewing and cigarette smoking: a cohort of 2416 HBsAg-seropositive and 9421 HBsAg-seronegative male residents in Taiwan. Cancer Causes Control 14:241

    Article  PubMed  Google Scholar 

  14. Wu GHM, Boucher BJ, Chiu YH, Liao CS, Chen THH (2008) Impact of chewing betel-nut (Areca catechu) on liver cirrhosis and hepatocellular carcinoma-: a population-based study from an area with a high prevalence of hepatitis B and C infections. Public Health Nutr 12:129

    Article  PubMed  CAS  Google Scholar 

  15. Cheng TY, Wen CP, Tai SP, Chung WSI, Hsu CC (2005) Reducing health disparity in Taiwan: quantifying the role of smoking. Tob Control 14:i23

    Article  PubMed  Google Scholar 

  16. Chiang CL (1984) The life tables and its applications. Florida, Florida

    Google Scholar 

  17. Wen CP, Tsai SP, Chung WSI (2008) A 10-year experience with universal health insurance in Taiwan: measuring changes in health and health disparity. Ann Intern Med 148:258

    PubMed  Google Scholar 

  18. Bureau of Health Promotion, Department of Health, ROC (2007) Prevention strategies of oral cancer in Taiwan. Available from http://www.bhp.doh.gov.tw/bhpnet/portal/Them_Show.aspx?Subject=200712250032&Class=2&No=200712250186

  19. Wen CP, Cheng TY, Eriksen MP (2005) How opening the cigarette market led to an increase in betel quid use in Taiwan. Public Health 119:940

    Article  PubMed  CAS  Google Scholar 

  20. Wen CP, Cheng TY, Eriksen MP, Tsai SP, Hsu CC (2005) The impact of the cigarette market opening in Taiwan. Tob Control 14:i4

    Article  PubMed  Google Scholar 

  21. Wen CP, Cheng CW, Cheng TY, Tsai MK, Chiang PH, Tsai SP, Chan HT, Chang YC, Chang HY (2009) Trends in betel quid chewing behavior in Taiwan- exploring the relationship between betel quid chewing and smoking, (In Chinese). Taiwan J Public Health 28:407

    Google Scholar 

  22. Department of Health Executive Yuan T (1986–2006) Age adjusted mortality from leading cancer causes of death by gender. Vital Statistics in Taiwan (In Chinese). Health Statistics in Taiwan, Taipei

  23. Directorate-General of Budget Accounting and Statistics (2007) Consumption of Tobacco, wine and betel nuts. Statistical yearbook of the Republic of China. Directorate-General of Budget Accounting and Statistics, Taipei

    Google Scholar 

  24. Uter W (2001) The application of methods to quantify attributable risk in medical practice. Stat Methods Med Res 10:231

    Article  PubMed  CAS  Google Scholar 

  25. Bosetti C, Levi F, Ferlay J, Garavello W, Lucchini F, Bertuccio P, Negri E, Vecchia CL (2008) Trends in oesophageal cancer incidence and mortality in Europe. Int J Cancer 122:1118

    Article  PubMed  CAS  Google Scholar 

  26. Vizcaino AP, Moreno V, Lambert R, RParkin DM (2002) Time trends incidence of both major histologic types of esophageal carcinomas in selected countries, 1973–1995. Int J Cancer 99:860

    Article  PubMed  CAS  Google Scholar 

  27. Lee C-H, Wu D-C, Lee J-M, Wu I-C, Goan Y-G, Kao E-L, Huang H-L, Chan T-F, Chou S-H, Chou Y-P, Ho C-K, Wu M-T (2007) Anatomical subsite discrepancy in relation to the impact of the consumption of alcohol, tobacco and betel quid on esophageal cancer. Int J Cancer 120:1755

    Article  PubMed  CAS  Google Scholar 

  28. Wu IC, Lu CY, Kuo FC, Tsai SM, Lee KW, Kuo WR, Cheng EL, Kao EL, Yang MS, Ko YC (2006) Interaction between cigarette, alcohol and betel nut use on esophageal cancer risk in Taiwan. Eur J Clin Invest 36:236

    Article  PubMed  CAS  Google Scholar 

  29. Taiwan Bureau of Health Promotion Department of Health, ROC. Cancer Registration System. Available from http://www.bhp.doh.gov.tw/BHPnet/Portal/StatisticsShow.aspx?No=200911300001

  30. Morse DE, Psoter WJ, Cleveland D, Cohen D, Mohit-Tabatabai M, Kosis DL, Eisenberg E (2007) Smoking and drinking in relation to oral cancer and oral epithelial dysplasia. Cancer Causes Control 18:919

    Article  PubMed  Google Scholar 

  31. Lee CH, Lee JM, Wu DC, Hsu HK, Kao EL, Huang HL, Wang TN, Huang MC, Wu MT (2005) Independent and combined effects of alcohol intake, tobacco smoking and betel quid chewing on the risk of esophageal cancer in Taiwan. Int J Cancer 113:475

    Article  PubMed  CAS  Google Scholar 

  32. Chen C-C, Yin S-J (2008) Alcohol abuse and related factors in Asia. Int Rev Psychiatry 20:425

    Article  PubMed  Google Scholar 

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Conflict of interest statement

We declare that we have no conflict of interest.

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Authors and Affiliations

  1. Division of Health Policy Research and Development, Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County 350, Taiwan

    Chi Pang Wen, Min Kuang Tsai, Wen Shen Isabella Chung, Hui Ling Hsu, Yen Chen Chang, Hui Ting Chan & Po Huang Chiang

  2. Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA

    Ting-Yuan David Cheng

  3. University of Texas School of Public Health, Houston, TX, USA

    Shan Pou Tsai

  4. China Medical University Hospital, Taichung, Taiwan

    Chi Pang Wen

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  1. Chi Pang Wen
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Correspondence to Chi Pang Wen.

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Wen, C.P., Tsai, M.K., Chung, W.S.I. et al. Cancer risks from betel quid chewing beyond oral cancer: a multiple-site carcinogen when acting with smoking. Cancer Causes Control 21, 1427–1435 (2010). https://doi.org/10.1007/s10552-010-9570-1

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  • DOI: https://doi.org/10.1007/s10552-010-9570-1

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