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== References ==
== References ==

Revision as of 14:54, 28 May 2016

For the practice of chewing the areca nut, see Paan and Betel.
"Supari" redirects here. For the 2003 film, see Supari (film).
Areca nut
Areca nuts hanging from the palm
A ripe areca nut.
File:Betelnuttw.jpg
Areca nuts wrapped in betel leaves, appearing as they are commonly prepared and sold in Taiwan

The areca nut (/ˈær[invalid input: 'ɨ']kə/ or /əˈriːkə/) is the seed of the areca palm (Areca catechu), which grows in much of the tropical Pacific, Asia, and parts of east Africa. It is commonly referred to as betel nut, as it is often chewed wrapped in betel leaves (paan). The term areca originated from a South Asian word[1] during the 16th century, when Dutch and Portuguese sailors took the nut to Europe. The habit has many harmful effects on health. The International Agency for Research on Cancer concluded after reviewing the published medical research that chewing areca nut is carcinogenic to humans.[2][3] Various compounds present in the nut, most importantly arecoline (the primary psychoactive ingredient), contribute to histologic changes in the oral mucosa. As with chewing tobacco, its use is discouraged by preventive efforts, such as awareness of the risks of chewing buai.

Description

The areca nut is not a true nut, but rather a fruit categorized as a berry. It is commercially available in dried, cured and fresh forms. When the husk of the fresh fruit is green, the nut inside is soft enough to be cut with a typical knife. In the ripe fruit, the husk becomes yellow or orange and, as it dries, the fruit inside hardens to a wood-like consistency. At that stage, the areca nut can only be sliced using a special scissors-like cutter (known as aḍakattera in Telugu, adake kattari in Kannada,bajjeai in Tulu, adakitta [अडकित्ता] in Marathi, puwak [පුවක්] in Sinhala, sôrta [চৰ্তা] in Assamese, shupari [সুপারি] or jaanti in Bengali, adakka അടക്കാ in Malayalam, pakku (பாக்கு) in Tamil, sarautaa in Hindi, Khilikaati in Odia, sudi in Gujarati), Su'aro سوئڙو in Sindhi and Gue in Garo.

Usually for chewing, a few slices of the nut are wrapped in a betel leaf along with calcium hydroxide (slaked lime) and may include clove, cardamom, catechu (kattha) and/or other spices for extra flavouring. Betel leaf has a fresh, peppery taste, but it can also be bitter to varying degrees depending on the variety. The combination of areca nut with betel leaf is called "buai" in Tok Pisin (with the spit being known as buai pekpek), goi in (Bodo), tamul-pan/tamûl-pan (তামূল-পান/তামোল-পান, tamûl means areca nut and pan means betel leaf) in Assamese , kavala in Kannada, tambulam in Sanskrit, bajjai in Tulu, and paan in Bengali, Hindi, Marathi, Punjabi, and Urdu.

Areca nuts are chewed with betel leaf for their effects as a mild stimulant,[4] causing a warming sensation in the body and slightly heightened alertness, although the effects vary from person to person. The effect of chewing betel leaf and areca nut together is relatively mild, and could be compared to that of drinking a cup of coffee.[citation needed]

The areca nut contains the tannins arecatannin and gallic acid; a fixed oil gum; a little terpineol; lignin; various saline substances; and three main alkaloids — arecoline, arecaidine and guvacine — all of which have vasoconstricting properties.[5] The betel leaf chewed along with the nut contains eugenol, another vasoconstrictor. Tobacco leaf is often added to the mixture, thereby adding the effect of nicotine.[2]

In parts of India, Sri Lanka and southern China, areca nuts are not only chewed along with betel leaf, but are also used in the preparation of Ayurvedic and traditional Chinese medicines. Powdered areca nut is used as a constituent in some dentifrices.[6] Other traditional uses include the removal of tapeworms and other intestinal parasites by swallowing a few teaspoons of powdered areca nut, drunk as a decoction, or by taking tablets containing the extracted alkaloids.[6] According to traditional Ayurvedic medicine, chewing areca nut and betel leaf is a good remedy against bad breath.[7][unreliable source?] Diplomat Edmund Roberts noted that Chinese people would mix areca nut with Uncaria gambir during his visit to China in the 1830s.[8] After chewing a betelnut, the red residue from chewing the betelnut, buai pekpek, is generally spit out and is considered an eyesore. This has led many places to ban chewing buai as many people spit the pekpek on the ground rather than in a spit cup or waste receptacle.[citation needed]

Tradition

Main article: Paan
Areca nut and betel leaf consumption in the world

Chewing the mixture of areca nut and betel leaf is a tradition, custom or ritual which dates back thousands of years in much of the geographical areas from South Asia eastward to the Pacific. It constitutes an important and popular cultural activity in many Asian and Oceanic countries, including Pakistan, the Maldives, India, Nepal, Sri Lanka, Bhutan, Bangladesh, Burma (Myanmar), China, Laos, Thailand, Malaysia, Indonesia, Cambodia, Vietnam, Taiwan, the Philippines, Palau, Yap, Guam, Papua New Guinea, the Solomon Islands, and Vanuatu. It is not known how or when the areca nut and the betel leaf were first combined into one psychoactive drug. Archaeological evidence from Thailand, Indonesia and the Philippines suggests they have been used in tandem for at least 4000 years.[9]

In Vietnam, the areca nut and the betel leaf are such important symbols of love and marriage that in Vietnamese the phrase "matters of betel and areca" (chuyện trầu cau) is synonymous with marriage. The tradition of chewing areca nuts starts the talk between the groom's parents and the bride's parents about the young couple's marriage. Therefore, the leaves and juices are used ceremonially in Vietnamese weddings. The folk tale explaining the origin of this Vietnamese tradition is a good illustration of the belief that the combination of areca nut and the betel leaf is ideal to the point they are practically inseparable, like an idealized married couple.[10]

Display of the items usually included in a chewing session: The betel leaves are folded in different ways according to the country and most have a little calcium hydroxide daubed inside. Slices of the dry areca nut are on the upper left hand and slices of the tender areca nut on the upper right. The pouch on the lower right contains tobacco, a relatively recent introduction.
Areca nut cutter from Bali/Indonesia

Malay culture and tradition hold betel nut and leaves in high esteem. Traditionally, guests who visit a Malay house are presented with a tray of areca nuts and betel leaves, in much the same way as drinks are offered to guests in many cultures around the world. There is even a Malay proverb about the betel nut, "bagaikan pinang dibelah dua", loosely translated, like a betel nut divided in half. It usually refers to newlyweds, who are compatible to each other, just like a betel nut when divided in half. The proverb is analogous to the English "two peas in a pod".[citation needed]

Areca Nut in small packs, usually labelled as betel nut in South India.

In the Indian subcontinent, the chewing of betel and areca nut dates back to the pre-Vedic period Harappan empire.[11] Formerly, in both India and Sri Lanka, it was a custom of the royalty to chew areca nut with betel leaf. Kings had special attendants whose duty it was to carry a box with all the necessary ingredients for a good chewing session. There was also a custom for lovers to chew areca nut and betel leaf together, because of its breath-freshening and relaxant properties. A sexual symbolism thus became attached to the chewing of the nut and the leaf. The areca nut represented the male principle, and the betel leaf the female principle. Considered an auspicious ingredient in Hinduism and some schools of Buddhism, the areca nut is still used along with betel leaf in religious ceremonies, and also while honoring individuals in much of southern Asia.[citation needed]

In Assam, it is a tradition to offer pan-tamul (betel leaves and raw areca nut) to guests, after tea or meals, served in a brass plate with stands called bota. Among the Assamese, the areca nut also has a variety of uses during religious and marriage ceremonies, where it has the role of a fertility symbol.[citation needed] A tradition from Upper Assam is to invite guests to wedding receptions by offering a few areca nuts with betel leaves. During Bihu, the husori players are offered areca nuts and betel leaves by each household while their blessings are solicited.

Spanish mariner Álvaro de Mendaña reported observing Solomon Islanders chewing the nut and the leaf with caustic lime, and the manner in which the habit stained their mouths red. He noted the friendly and genial chief Malope, on Santa Isabel Island, would offer him the combination as a token of friendship every time they met.[12]

In Bhutan the areca nut is called doma. The raw areca nut, which is soft and moist is very potent and when chewed can cause palpitation and vasoconstricting. This form is eaten in the lower regions of Bhutan and in North Bengal, where the nut is cut into half and put into a local paan leaf with a generous amount of lime. In the rest of Bhutan the raw nut, with the husk on, is fermented such that the husk rots and is easy to extract. The fermented doma has a putrid odour, which can be smelled from miles. Traditionally, this fragrant nut is cut in half and placed on top of a cone made of local betel leaf, which has a dash of lime put into it. "Myth has it that the inhabitants of Bhutan traditionally known as Monyul, the land of Monpas where Buddhism did not reach lived on raw flesh, drank blood and chewed bones. After the arrival of Guru Rinpoche in the 8th century, he stopped the people from eating flesh and drinking blood and created a substitute which is betel leaf, lime and areca nut. Today, chewing doma has become a custom. Doma is served after meals, during rituals and ceremonies. It is offered to friends and is chewed at work places by all sections of the society and has become an essential part of Bhutanese life and culture."[13]

The addition of tobacco leaf to the chewing mixture is a relatively recent innovation, as tobacco was not introduced from the American continent until the colonial era.

Effects on health

Systemic effects of areca nut

Areca nut affects almost all organs of the human body, including the brain, heart, lungs, gastrointestinal tract and reproductive organs. It causes or aggravates pre-existing conditions such as neuronal injury, myocardial infarction, cardiac arrhythmias, hepatotoxicity, asthma, central obesity, type II diabetes, hyperlipidemia, metabolic syndrome, etc. Areca nut affects the endocrine system, leading to hypothyroidism, prostate hyperplasia and infertility. It affects the immune system leading to suppression of T-cell activity and decreased release of cytokines. It has harmful effects on the fetus when used during pregnancy.

Garg et al. (2014)[14]

Areca nut vendor with red mouth from areca consumption preparing betel leaves

Habitual chewers of betel leaf and areca nut have a greatly increased risk of developing a range of serious diseases, including cancers of the mouth and esophagus.[14][15] It has many systemic effects (see box).[14]

Chewing areca nut alone has been linked to oral submucosal fibrosis.[16] According to Medline Plus, "Long-term use [of betel-areca preparations] has been associated with oral submucosal fibrosis (OSF), pre-cancerous oral lesions and squamous cell carcinoma. Acute effects of betel chewing include asthma exacerbation, hypertension, and tachycardia. There may additionally be a higher risk of cancers of the liver, mouth, esophagus, stomach, prostate, cervix, and lung with regular betel use. Other effects can include a possible effect on blood sugar levels, which may in turn increase the risk of developing type 2 diabetes."[17]

Use of areca nut has been associated with deterioration of psychosis in patients with preexisting psychiatric disorders.[18] Areca nut consumption is also tied to chronic kidney disease in men.[19]

In 2003 the International Agency for Research on Cancer (IARC), a World Health Organization sponsored group, reached the conclusion that there is sufficient evidence that the habit of chewing betel quid, with or without tobacco, is carcinogenic to humans.[20] Support for this conclusion is provided by a recent study which found that paan, even without concurrent tobacco use, is a risk factor for oral cancer. In October, 2009, 30 scientists from 10 countries met at IARC to reassess the carcinogenicity of various agents including areca nut, and mechanisms of carcinogenesis. They confirmed there is sufficient evidence that areca nut, with or without tobacco, can cause cancer.[21]

Use during pregnancy

Chewing paan (and/or other areca nut and betel leaf formulations) during pregnancy significantly increases adverse outcomes for the baby.[22] The habit is associated with higher incidences of preterm birth and low birth weight and height.[14] Biologically, these effects may be a consequence of the arecoline that is found in areca nuts.[15] The habit also exposes the unborn baby to various other toxic components linked to cancer.[14]

Modern-day consumption

Sign in Indonesia saying that chewing betelnut is prohibited. Because of the mess from buai pekpek, many places ban chewing betelnuts. Notably, Port Moresby, the capital of Papua New Guinea, has a ban on buai. This buai ban is from Sentani Airport, Jayapura, Papua Province, Indonesia.
Chewing betelnut produces a red residue which is spat out. This spit, known as buai pekpek, is often considered an eyesore.

In India (the largest consumer of areca nut) and Pakistan, the preparation of nut with or without betel leaf is commonly referred to as paan. It is available practically everywhere and is sold in ready-to-chew pouches called pan masala or supari, as a mixture of many flavours whose primary base is areca nut crushed into small pieces. Poor people, who may eat only every other day, use it to stave off hunger pangs.[15][23] Pan masala with a small quantity of tobacco is called gutka. The easily discarded, small plastic supari or gutka pouches are a ubiquitous pollutant of the South Asian environment. Some of the liquid in the mouth is usually disposed of by spitting, producing bright red spots wherever the expectorate lands.

Shopkeeper making paan in an Indian store

In the Maldives, areca nut chewing is very popular, but spitting is frowned upon and regarded as an unrefined, repulsive way of chewing. Usually, people prefer to chew thin slices of the dry nut, which is sometimes roasted. Kili, a mixture of areca nut, betel, cloves, cardamom and sugar is sold in small home-made paper pouches. Old people who have lost their teeth keep "chewing" by pounding the mixture of areca nut and betel with a small mortar and pestle.

In Papua New Guinea and the Solomon Islands, fresh areca nut, betel leaf or 'fruit leaf' (daka in PNG) and lime are sold on street corners. In these countries, dried or flavoured areca nut is not popular. Betelnuts there are referred to in Tok Pisin as buai, and the red spit from them, as well as their shells and rubbish thrown out along with the spit, is called buai pekpek. There has recently been a controversial ban on selling and chewing betelnuts and spitting buai pekpek in Port Moresby. Because of this, many people have tried to smuggle betelnuts into Pom Town. Notably, there was a raid in Hanuabada in May 2015 where several bags of betelnut were confiscated, the total value of the confiscated nut sacks exceeding $180,000 USD. Areca nut chewing has recently been introduced into Vanuatu, where it is growing in popularity, especially in the northern islands of the country. In Guam and the neighboring Northern Mariana Islands, betel and areca nut chewing is a social pastime as a means to extend friendship, and can be found in many, if not most, large gatherings as part of the food display.

In Palau, betel nut is chewed with lime, piper leaf and nowadays, with the addition of tobacco. Older and younger generations alike enjoy the use of betel nut, which is readily available at stores and markets. Unlike in Papua New Guinea and the Solomon Islands, where the inner areca nut is used, in Palau, the areca nut's skin is chewed along with lime, leaf and tobacco and the juice is not swallowed but spat out.

In Taiwan, bags of 20 to 40 areca nuts are purchased fresh daily by a large number of consumers. To meet the steady year-round demand, two kinds of betel-nut shops sell betel and nuts, as well as cigarettes and drinks, including beer: Small mom and pop shops, often poorly maintained and with unassuming façades, and shops which will often consist of nothing more than a single, free-standing room, or booth. The latter is usually elevated one meter above the street, and measures less than 3 by 2 m. Large picture windows comprise two or more of the walls, allowing those who pass by a complete view of the interior. The interior is often painted brightly. Within such a shop, a sexily dressed young woman, a "betel nut beauty", can be seen preparing betel and areca nuts. Shops are often identified by multicoloured (commonly green) fluorescent tubes or neon lights that frame the windows or that are arranged radially above a store. Customers stop on the side of the road and wait for the girls to bring their betel and areca nut to their vehicles. The habit of chewing betel nut is often associated with blue-collar labor industries such a long-haul transportation, construction, or fishing. Workers in these labor-intensive industries use betel nut for its stimulating effect, but it also becomes a tool for socializing with coworkers. For example, studies have shown chewing betel nut is prevalent among taxi, bus and truck drivers, who rely on the stimulating effect of betel nut to cope with long work hours.[24][25][26] For these reasons, oral cancer has been identified as a leading cause of death in professions with high betel nut-chewing rates.[27]

In Hainan and Hunan Province, China, where Xiangtan is a center of use and processing,[28] a wide range of old and young people consume areca nut daily. Most, though, consume the dried variety of the nut by itself, without the betel leaves. Some people also consume the areca nut in its raw, fresh form with or without the betel leaves. Betel nuts are sold mostly by old women walking around trying to sell it, but the dried version can be found in most shops which sell tea, alcohol and cigarettes.

In Thailand, the consumption of areca nut has declined gradually in the last decades. The younger generation rarely chews the substance, especially in the cities. Most of the present-day consumption is confined to older generations, mostly people above 50. Even so, small trays of betel leaves and sliced tender areca nut are sold in markets and used as offerings in Buddhist shrines.

In the Philippines, chewing the areca nut and betel leaf was a very widespread tradition in the past. Now, though, this tradition is almost dead among the urban people in the cities and big towns, and has largely been replaced by chewing gum and cigarettes. Nowadays, older people are the only ones chewing betel nuts. But in rural areas, betel nut-chewing is very much alive.

Areca nuts as sold in Hainan, China

In the United States, areca nut is not a controlled or specially taxed substance and may be found in some Asian grocery stores. However, importation of areca nut in a form other than whole or carved kernels of nuts can be stopped at the discretion of US Customs officers on the grounds of food, agricultural, or medicinal drug violations. Such actions by Customs are very rare. In the United Kingdom, areca nut is readily available in Asian grocery stores and even in shredded forms from the World Food aisles of larger Tesco supermarkets.

Possession of betel nut or leaf is banned in the UAE and is a punishable offense.

Recently it has been reported that areca nut powder extract is capable of reducing silver ions to create silver nanoparticles,[6] which may be useful as antimicrobial agents.

Vernacular names

19th century drawing of the Areca palm and its nut.
An Areca nut sapling from the Indian state of Kerala. Dwarf variety.
  • Bodo:Goi
  • Sanskrit: Poogi phalam
  • Sindhi:Sopari
  • 'Are'are: Ota.
  • Nepali: (सुपारी), "Supari"
  • Assamese: Guwa (গুৱা) or Tamûl (তামোল) or Sûfari (চোফাৰী, sliced areca nut).
  • Template:Lang-bn.
  • Template:Lang-my, pronounced [kʊ́ɴ ðí] (areca nut) or ‹See Tfd›ကွမ်းယာ, pronounced [kʊ́ɴ jà] (betel nut)
  • Dzongkha: Doma.
  • Chamorro (Guam): Pugua (areca nut), pupulu (betel), åfok (lime), måmå'on (the chewing or the preparation).
  • Chinese: 槟榔 (pinyin: Bīnláng) .
  • Dhivehi (Maldives): Fōh (Foah) or Fuvah (areca nut), bileiy (betel), huni (lime), dhu'fuň (the chewing or the preparation).
  • Guadalcanal: Bua.
  • Gujarati: Sopari (સોપારી).
  • Template:Lang-pa (ਸੁਪਾਰੀ).
  • Template:Lang-hi (सुपारी), "Kasaili"
  • Ilocano: Bua.
  • Template:Lang-id. (Sirih is basically the betel leaf).
  • Javanese: Jambe.
  • Khasi: Kwai.
  • Kannada: Adike(ಅಡಿಕೆ), Kangu(ಕಂಗು)
  • Kapampangan: Lúyus (areca nut), Samat (betel leaf), Ápî (lime), Mamâ-n (the chewing)
  • Template:Lang-km
  • Konkani: सुपारी (suppari)
  • Template:Lang-lo or Mark (ໝາກ)
  • Template:Lang-ms
  • Malayalam: Adakka (അടക്ക)
  • Marathi: Supari (सुपारी).
  • Meiteilon - Manipuri: Kwa
  • Memoni: Sopari
  • Mizo: Kuhva
  • Mon: Sōd (‹See Tfd›သတ်)
  • Motu: Buatau.
  • Mranao: Bamaan.
  • Odia: Gua.
  • Nanggu: Kertu (areca nut), pwe (betel), ndo (lime).
  • Raga (North Pentecost): Niniu.
  • Palau (Micronesia): Buuch.
  • Pohnpei (Micronesia): Pwuh.
  • Sindhi: Sopari سوپاري .
  • Template:Lang-si (පුවක්) and Karunka (කරුංකා) (dried and peeled).
  • Tagalog: Bunga, Tempak Siri or Nga Nga.
  • Hokkien: Chinese: 檳榔, pronounced pin-nn̂g in Hokkien.
  • Template:Lang-ta (பாக்கு)
  • Telugu: Poka, vakka, వక్క , పోచోక్క
  • Tetum: Bua (areca nut), malus (betel), ahu (lime), mama (the chewing or the preparation).
  • Template:Lang-th,หมาก, (areca nut), plue,พลู (betel).
  • Tokodede: Buo (areca nut), malu (betel), rapo (lime), mam (the chewing or the preparation).
  • Tok Pisin: Buai (betelnut), Buai pekpek (The red spit from chewing buai, as well as the shell of the betelnut, sometimes also refers to rubbish thrown out next to the spit from the buai, which alone ks referred to as pipia), Kaikai buai (chewing betelnut).
  • Tulu:Bajjaialso phoolu .
  • Urdu : Chalia Supari
  • Yap (Micronesia): Buw (areca nut), waech (lime), gabuy (betel leaf), langad (preparation).
  • Template:Lang-vi.
  • Sylheti : Gua/supari.
  • Philippines (Cordillera Administrative Region) : buwa/ prepared for chewing is "momma"

Places such as Guwahati (গুৱাহটী) in Assam (অসম), Penang in Malaysia, Ko Mak (เกาะหมาก) in Thailand and Fua Mulaku in Maldives have been named after the areca nut.

See also

References

  1. ^ Merriam-Webster, Merriam-Webster's Collegiate Dictionary, Merriam-Webster. Additional information: Cognates include Kannada adike/ಅಡಿಕೆ, Malayalam adakka/ataykka, and Tamil adakkai.
  2. ^ a b "IARC Monographs Programme finds betel-quid and areca-nut chewing carcinogenic to humans". World Health Organization. 2003.
  3. ^ International Agency for Research on Cancer (2005). Betel-quid and areca-nut chewing. IARC Monograph 85-6 (PDF). IARC. ISBN 978-92-832-1285-0.
  4. ^ Gupta Prakash Chandra; Ray Cecily S (July 2004). "Epidemiology of betel quid usage" (PDF). Ann. Acad. Med. Singap. 33 (4 Suppl): 31–6. PMID 15389304.
  5. ^ "Modern herbal". Botanical.com. Retrieved 2014-06-10.
  6. ^ a b c Bhat, R.; Ganachari, S.; Deshpande, R.; Ravindra, G.; Venkataraman, A. (2012). "Rapid Biosynthesis of Silver Nanoparticles Using Areca Nut (Areca catechu) Extract Under Microwave-Assistance". Journal of Cluster Science. 24: 107. doi:10.1007/s10876-012-0519-2.
  7. ^ Naveen Pattnaik, The Tree of Life
  8. ^ Roberts, Edmund (1837). Embassy to the Eastern Courts of Cochin-China, Siam, and Muscat. New York: Harper & Brothers. p. 138.
  9. ^ "Archaeological evidence from Thailand, Indonesia and the Philippines". Epistola.com. Retrieved 2014-06-10.
  10. ^ "Vietnamese Legend". Vietspring.org. Retrieved 2014-06-10.
  11. ^ "Betel chewing". Singapore Infopedia. National Library Singapore. May 5, 1999.
  12. ^ Graves, Robert (1984), Las islas de la imprudencia, Barcelona: Edhasa. ISBN 84-350-0430-9
  13. ^ [1]
  14. ^ a b c d e Garg A, Chaturvedi P, Gupta PC (January 2014). "A review of the systemic adverse effects of areca nut or betel nut". Indian Journal of Medical and Paediatric Oncology. 35 (1): 3–9. doi:10.4103/0971-5851.133702. PMC 4080659. PMID 25006276.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  15. ^ a b c Javed F, Bello Correra FO, Chotai M, Tappuni AR, Almas K (December 2010). "Systemic conditions associated with areca nut usage: a literature review" (PDF). Scandinavian Journal of Public Health. 38 (8): 838–44. doi:10.1177/1403494810379291. PMID 20688790.
  16. ^ Maher, R.; Maher R; Lee AJ; Warnakulasuriya KA; Lewis JA; Johnson NW. (1994-02-23). "Role of areca nut in the causation of oral submucosal fibrosis: a case-control study in Pakistan". Journal of oral pathology and medicine. 23 (2): 65–9. doi:10.1111/j.1600-0714.1994.tb00258.x. PMID 8164155. Retrieved 2008-10-23.
  17. ^ [2] Archived 2010-07-06 at the Wayback Machine
  18. ^ Ernst, E. (1998). "Harmless Herbs? A Review of the Recent Literature". American Journal of Medicine. 104 (2): 170–178. doi:10.1016/S0002-9343(97)00397-5. PMID 9528737.
  19. ^ Chou, Che-Yi; Cheng, Shi-Yann; Liu, Jiung-Hsiun; Cheng, Wen-Chun; Kang, I.-Min; Tseng, Yu-Hsiang; Shih, Chuen-Ming; Chen, Walter (2009-05-01). "Association between betel-nut chewing and chronic kidney disease in men". Public Health Nutrition. 12 (5): 723–727. doi:10.1017/S1368980008003339. ISSN 1368-9800. PMID 18647430.
  20. ^ "WHO | IARC Monographs Programme finds betel-quid and areca-nut chewing carcinogenic to humans". Who.int. 2003-08-07. Retrieved 2014-06-10.
  21. ^ Beatrice Secretan; et al. (2009). "A review of human carcinogens". The Lancet Oncology, see table for Group 1 carcinogen agents. 10 (11): 1033–1034. doi:10.1016/S1470-2045(09)70326-2. PMID 19891056.
  22. ^ Kumar, S (April 2013). "Tobacco and areca nut chewing—reproductive impairments: an overview". Reproductive Toxicology (Elmsford, N.Y.). 36: 12–7. doi:10.1016/j.reprotox.2012.11.007. PMID 23207167.
  23. ^ Collingham, Lizzie (2006). Curry: A Tale of Cooks and Conquerors. Oxford: Oxford University Press. p. 7. ISBN 978-0-19-988381-3.
  24. ^ Chuang CY, Chang CH, Chang CC. The workplace relevant factors of betel quid chewing among transportation workers in Central Taiwan (in Chinese). Taiwan Journal of Public Health 2007; 26: 433-42.
  25. ^ Republic of China (Taiwan), Institute of Occupational Safety and Health, Council of Labor Affairs, The Executive Yuan. Health survey for the long-distance bus drivers (in Chinese). Taipei: Republic of China (Taiwan), Institute of Occupational Safety and Health, Council of Labor Affairs, The Executive Yuan, 2003. http://www.iosh.gov.tw/book/Report_Publish.aspx?PID=826&UID=F1165
  26. ^ Kuo SC, Lew-Ting CY. The health lifestyles of areca quid-chewing taxi drivers – an exploratory study from the viewpoint of social context (in Chinese). Taiwan Journal of Oral Medical Science 2008; 27: 67-80.
  27. ^ Republic of China (Taiwan), Institute of Occupational Safety and Health, Council of Labor Affairs, The Executive Yuan. Analysis of the major causes of death of laborers in Taiwan (in Chinese). Taipei: Institute of Occupational Safety and Health, Council of Labor Affairs, The Executive Yuan, 2010. http://www.iosh.gov.tw/Print.aspx?cnid=16&p=1773
  28. ^ "Despite Risks, an Addictive Treat Fuels a Chinese City" article by Dan Levin in The New York Times August 19, 2010, accessed August 20, 2010
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