Cancer Causes & Control

, Volume 21, Issue 9, pp 1427–1435 | Cite as

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

  • Chi Pang Wen
  • Min Kuang Tsai
  • Wen Shen Isabella Chung
  • Hui Ling Hsu
  • Yen Chen Chang
  • Hui Ting Chan
  • Po Huang Chiang
  • Ting-Yuan David Cheng
  • Shan Pou Tsai
Original paper



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.


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.


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.


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.


Betel quid Smoking Cancer Mortality Taiwan 


Conflict of interest statement

We declare that we have no conflict of interest.


  1. 1.
    Mack T (2001) The new pan-asian paan problem. Lancet 357:1638CrossRefPubMedGoogle Scholar
  2. 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 85:1Google Scholar
  3. 3.
    Gupta P, Warnakulasuriya S (2002) Global epidemiology of areca nut usage. Addict Biol 7:77CrossRefPubMedGoogle Scholar
  4. 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 324:799CrossRefPubMedGoogle Scholar
  5. 5.
    Winstock A (2002) Areca nut symposium: areca nut-abuse liability, dependence and public health. Addict Biol 7:77CrossRefGoogle Scholar
  6. 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 37:141Google Scholar
  7. 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:i16CrossRefPubMedGoogle Scholar
  8. 8.
    Sharma DC (2003) Betel quid and areca nut are carcinogenic without tobacco. Lancet Oncol 4:587CrossRefPubMedGoogle Scholar
  9. 9.
    Wen CP, Levy DT, Cheng TY, Hsu CC, Tsai SP (2005) Smoking behavior in Taiwan, 2001. Tob Control 14(Suppl 1):i51CrossRefPubMedGoogle Scholar
  10. 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 24:450CrossRefPubMedGoogle Scholar
  11. 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 120:1318CrossRefPubMedGoogle Scholar
  12. 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 371:2173CrossRefPubMedGoogle Scholar
  13. 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 14:241CrossRefPubMedGoogle Scholar
  14. 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 12:129CrossRefPubMedGoogle Scholar
  15. 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:i23CrossRefPubMedGoogle Scholar
  16. 16.
    Chiang CL (1984) The life tables and its applications. Florida, FloridaGoogle Scholar
  17. 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 148:258PubMedGoogle Scholar
  18. 18.
    Bureau of Health Promotion, Department of Health, ROC (2007) Prevention strategies of oral cancer in Taiwan. Available from
  19. 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 119:940CrossRefPubMedGoogle Scholar
  20. 20.
    Wen CP, Cheng TY, Eriksen MP, Tsai SP, Hsu CC (2005) The impact of the cigarette market opening in Taiwan. Tob Control 14:i4CrossRefPubMedGoogle Scholar
  21. 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 28:407Google Scholar
  22. 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, TaipeiGoogle Scholar
  23. 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, TaipeiGoogle Scholar
  24. 24.
    Uter W (2001) The application of methods to quantify attributable risk in medical practice. Stat Methods Med Res 10:231CrossRefPubMedGoogle Scholar
  25. 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 122:1118CrossRefPubMedGoogle Scholar
  26. 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 99:860CrossRefPubMedGoogle Scholar
  27. 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 120:1755CrossRefPubMedGoogle Scholar
  28. 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 36:236CrossRefPubMedGoogle Scholar
  29. 29.
    Taiwan Bureau of Health Promotion Department of Health, ROC. Cancer Registration System. Available from
  30. 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 18:919CrossRefPubMedGoogle Scholar
  31. 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 113:475CrossRefPubMedGoogle Scholar
  32. 32.
    Chen C-C, Yin S-J (2008) Alcohol abuse and related factors in Asia. Int Rev Psychiatry 20:425CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2010

Authors and Affiliations

  • Chi Pang Wen
    • 1
    • 4
  • Min Kuang Tsai
    • 1
  • Wen Shen Isabella Chung
    • 1
  • Hui Ling Hsu
    • 1
  • Yen Chen Chang
    • 1
  • Hui Ting Chan
    • 1
  • Po Huang Chiang
    • 1
  • Ting-Yuan David Cheng
    • 2
  • Shan Pou Tsai
    • 3
  1. 1.Division of Health Policy Research and Development, Institute of Population Health SciencesNational Health Research InstitutesZhunan, Miaoli County 350Taiwan
  2. 2.Department of Epidemiology, School of Public HealthUniversity of WashingtonSeattleUSA
  3. 3.University of Texas School of Public HealthHoustonUSA
  4. 4.China Medical University HospitalTaichungTaiwan

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