In our study, 17·1% of the participants who self-identified as Asian immigrants or descendants living in Houston reported being ever-users of AN products. This prevalence is even higher (31·2%) among individuals with Indian Subcontinent ancestry. This alarming prevalence denotes a public health concern considering that among all the Harris County Asians (6·9% of the county’s inhabitants) participating in the 2010 US Census, Indians and Pakistanis represented the second-largest Asian community (20·0%) in the county . Even more, between 2010 to 2017, these groups grew exponentially (Indians by 59%, and Pakistanis by 49%), resulting in India being ranked first in 2017 among the Asian origin countries of the Houston Metropolitan Area foreign-born population [4, 19].
Surprisingly, 6·7% of the respondents reported being diagnosed with cancer. This finding could be explained by the fact that our sampling strategy was supported by the outreach program of a major cancer center in Houston and/or by the concurrent use tobacco products, frequently reported by AN users . While only 5·3% of the respondents using AN products reported being current smokers, our pilot study did not collect information about other cancer-risk factors.
Based on sample size and study designs, our findings can only be comparable to two reports about AN consumption in the US. These reports by Changrani et al.13 and Shi et al.15may have shown higher AN prevalence because the targeted populations were first-generation Asians migrating to the US, while our study included not only Asian immigrants but also their descendants. A research effort conducted in the Mariana Islands , one of the US Affiliated Pacific Islands, reported a 5-year (2011–2015) AN use prevalence of 11·3% among 300 surveyed adults residing in Guam and Saipan. This result is comparable to the 17·1% AN use prevalence reported in our study. AN chewing has also been reported among Asian groups residing in other industrialized countries. Findings from a study conducted in a large concentration of Bangladeshis living in the London boroughs of Tower Hamlet and Camden in the United Kingdom (UK) have shown an AN use prevalence ranging between 25–75% and 14–43% among adults and children, respectively . Another research effort conducted among 143 first- and second-generation Bangladeshi women residing in London, UK, found that the AN use prevalence ranged between 25 and 33% without significant difference between generations . Areca nut chewing was also reported in two dental patients in Australia who migrated from Myanmar and Sri Lanka .
Among our survey respondents, the mean age of AN initiation was 15·4 years (SD ± 7·44). This finding should be considered while designing educational programs and cessation interventions, as AN initiation during early adolescence has been shown to be associated with greater AN consumption, high levels of dependence, and a lower cumulative probability of quitting [25, 26].
Data from this population-based pilot study suggest that Indian Subcontinent immigrants or descendants (ISID) were almost 4-times more likely to be AN ever-users than Non-ISID, highlighting the need of prioritizing the AN prevention and control interventions to this particular group in Houston. Additionally, study participants who had friends and/or family members using AN products were 6 times more likely to be AN ever-users themselves. This is consistent with the results from studies conducted in the Mariana Islands, where witnessing regular AN consumption by family members and friends was among the cited reasons contributing to AN consumption among study participants [21, 27]. These findings resonate with the fact that for some Asian groups, AN consumption has a strong social connotation and cultural roots, as it is offered to guests at celebrations, weddings, and gatherings or as part of traditional beliefs . Therefore, developing culturally relevant programs that serve the targeted population should be guaranteed, in addition to considering social network interventions in all efforts aiming to prevent and control AN consumption.
Although the Food and Drug Administration (FDA) banned the import of AN products into the US owing to its adulterated, unsafe nature, and carcinogenic properties; and that the US Department of Agriculture has reinforced a prohibition against the introduction of AN in raw or unprocessed forms into the US [8, 29], these products continue to be easily available across the country, mainly at Asian stores . As of 2020, the US is the largest importer (59·39%) and India is the largest exporter (46·29%) of AN. The top export flow of AN in 2020 was from India to the US, with an export value of USD 2.16 million . A study conducted in 5 stores selling AN products in Richmond, Virginia, revealed that the AN products were from either India or Pakistan . Some importers also use misleading names for these products, such as “fragrant wood slice,” to avoid Customs scrutiny . AN is also widely sold online  with many AN retailers utilizing the Internet and social media platforms to increase their products’ visibility, which has long been a tobacco industry strategy . This was also a purchase avenue pursued by some of our survey respondents. Unfortunately, there are no federal or state laws that explicitly restrict, monitor, and/or regulate AN products’ online marketing in the US. As it already happens with tobacco products, particularly among youth , Internet AN sales may pose an attractive route for many consumers seeking cheaper, tax-free products. Therefore, such easy accessibility to AN products may be responsible for the prevalence of AN use in the US. Regulatory agencies in the US could develop and implement similar regulations to those recently imposed by the Food Safety and Standards Authority of India (FSSAI), where all imported consignments of AN entering to this country undergo 100% sampling and testing, as opposed to merely random checks . However, this will require implementing tailored training programs aiming at building capacity of FDA officials and Custom agents. India has also raised AN minimum import price (MIP: rate below which no imports are allowed) by almost three times in recent years to deter AN imports into the country . In the US, either banning the sales of AN products (action already taken by Canada)  or implementing effective national control laws similar to those imposed on tobacco products (e.g., pictorial health warning on AN products, banning AN sales to minors, AN-free policies on public spaces, among others) should be considered towards preventing AN addiction and decrease the risk of oral cancer and other detrimental conditions related to AN use. Regarding implementing effective national AN control laws, the WHO Framework Convention on Tobacco Control (FCTC)  has established a package of standardized and validated measures for eliminating illicit trade of tobacco products that could be adapted to AN products.
Even though prolonged AN consumption is associated with a myriad of adverse health effects such as tooth decay; periodontitis; OPMDs; oral/pharyngeal, esophageal and hepatocellular cancers; liver cirrhosis; metabolic syndromes likely contributing to type 2 diabetes mellitus; hypertension; cardiovascular disease; anemia; pregnancy-related disorders; asthma; and chronic kidney disease [15, 36, 37], a large proportion of individuals in our study sample (42·6%) were unaware of the adverse health effects of AN use. This result contrasts with what was reported by a study conducted in Karachi, Pakistan, among 370 subjects where more than 70% of these individuals acknowledged that AN chewing might contribute to oral/oropharyngeal cancers . Similarly, there was a high awareness (80%) of cancer risk among 200 AN users recruited in a study conducted in Yangon, Myanmar . The lower awareness of the harmful effects of AN consumption among our study sample underscores the need for health promotion programs in the Houston Metropolitan Area focusing on the broad spectrum of short-term and long-term deleterious health effects caused by AN use.
Healthcare providers (HCPs), especially dental professionals, can play a crucial role in identifying the oral clinical signs of AN use . Chronic AN use can have potentially deleterious effects on both hard and soft tissues of the oral cavity. The hard, fibrous nature of the AN may cause tooth fracture and extensive attrition of the teeth . Also, the copious red saliva produced on AN chewing gets embedded into and stains the teeth, gingiva, and oral mucosa . In chronic chewers, a condition called betel chewers mucosa is often found where the quid is placed, characterized by oral mucosa desquamation and underlying pseudomembranous or wrinkled areas . AN consumption can also lead to several OPMDs, such as oral submucous fibrosis (OSMF), leukoplakia, and lichenoid lesion. AN is the primary etiological factor in the development of OSMF. This condition is usually preceded by the formation of vesicles, followed by increased fibrosis that leads to stiffness and diffuse blanching of the oral mucosa, trismus, and reduced tongue protrusion . AN chewing can also lead to leukoplakia—a predominantly white patch or plaque on the oral mucosa, which has an increased risk of malignant transformation . Betel quid‑induced lichenoid oral lesions have been reported exclusively among AN users at the quid placement sites and have the potential to progress to oral cancer. This oral condition is characterized by fine, white, wavy, non-overlapping, parallel lines that in some instances radiate from a central erythematous area . Hence, educational programs can strengthen the capacity of HCPs to screen for AN use and early diagnosis and treatment of conditions associated with AN consumption in the ISID population. Unfortunately, specialized AN cessation services and resources are lacking, which negatively impact healthcare providers’ motivation in assisting AN users with their quitting efforts. Perhaps the critical step for promoting AN prevention and control strategies should be to develop the curriculum of a training program based on stages of change , motivational interviewing techniques  and the 5As intervention (Ask, Advise, Assess, Assist, and Arrange) . These approaches, developed initially for smoking cessation, can be adapted to provide practitioners with a framework for AN counseling, as this model has proved to be successful in achieving long-term abstinence with other additions (.e.g., smoking cessation) and developing strategies for early diagnosis of conditions associated with AN consumption.
The recent COVID-19 pandemic has raised concerns that AN consumption, like smokeless tobacco use, may increase risk of virus transmission. Since AN users spit frequently, droplets from COVID-19 infected chewers can settle on objects and surfaces that can be touched by non-infected individuals (Figs. 1 and 2). The transmission risk of several viral and some non-viral diseases through saliva is well documented . So, in the same way, that covering one’s cough or sneeze is recommended to prevent disease transmission, avoiding spitting, especially in public venues, would seem a logical extension of these recommendations . This becomes even more relevant during the ongoing COVID-19 pandemic.
Although our study is among the five research efforts focusing on AN use in the US mainland in the past 25 years, several limitations must be considered. The main caveat is that this study was based on cross-sectional data. Therefore, we cannot assume any causal relationships between AN use and oral lesions or systemic conditions. Due to the nature of our pilot study and limited resources available, we did not validate the questionnaire items. Despite that, our findings set the foundation for future mixed-methods approaches with content experts and AN users to measure the validity and reliability of the proposed data collection instrument and use it to assess AN consumption in a larger sample of Asian groups residing in Houston and other large cities in Texas. Also, our findings are not truly representative of the entire Asian population in Houston. Surveyed participants were selected using non-probability sampling methods, reaching out to attendees of health fairs and cultural events in the area (selection bias). Nevertheless, our study population included a balanced proportion of the main Asian groups residing in Houston. In addition, missing data could result from study participants’ perceiving sensitivity towards some of the research questions in our data collection instrument, particularly those related to AN consumption. Also, the study design used self-reporting, which makes the research findings prone to subjectivity (information bias). Finally, social desirability bias could be expected, as some of the responses may not reflect the true thoughts of our study participants.