The Lifetime Health and Economic Burden of Smokeless Tobacco use in Bangladesh, India, and Pakistan: Results From ASTRAMOD.

INTRODUCTION: Under the current policy landscapes, the lifetime health and economic burden of smokeless tobacco (ST) products, consumed by over 297 million ST users in South Asia, is unknown. The aim of this study was to estimate the lifetime health effects and costs attributable to current and future ST use in Bangladesh, India, and Pakistan where the majority of ST users live. AIMS AND METHODS: We developed a Markov-based state-transition model (ASTRAMOD) to predict the lifetime costs of treatment of four diseases (oral, pharyngeal, esophageal cancers, and stroke) and disability-adjusted life years (DALYs), attributable to the current and future use of ST under existing ST policy scenario. Country-specific Global Adult Tobacco Surveys, life tables, and meta-analyses of South Asian and South East Asian studies were used to populate the model. A probabilistic sensitivity analysis evaluated the uncertainty in model predictions. RESULTS: If there were no change in the current ST policies, the lifetime ST-attributable treatment costs would be over US$19 billion in India, over US$1.5 billion in Bangladesh, and over US$3 billion in Pakistan. For all countries, the attributable costs are higher for younger cohorts with costs declining with increasing age for those over 50. The model predicted that a typical 15-year-old male adoloscent would gain 0.07-0.18 life years, avert 0.07-0.19 DALYs, and generate a cost-savings of US$7-21 on healthcare spending if ST policies were changed to eliminate ST use. CONCLUSIONS: Policy interventions aimed at decreasing the uptake of ST and increasing quitting success have the potential to substantially decrease the economic and health burden of ST. IMPLICATIONS: This study provides the most comprehensive estimates of the lifetime health and economic burden of ST by 5-year age and sex cohorts. This is also the first study that highlights the scale of health and economic burden of ST in Bangladesh, India, and Pakistan if there were no changes in the current ST policies. Policymakers and practitioners can use the reported data to justify their decisions to improve current ST policies and practices in their country. Researchers can use the ASTRAMOD methodology to estimate the impact of future ST policy changes.

From cultivation to cancer: formation of N-nitrosamines and other carcinogens in smokeless tobacco and their mutagenic implications.

Tobacco use is a major cause of preventable morbidity and mortality globally. Tobacco products, including smokeless tobacco (ST), generally contain tobacco-specific N-nitrosamines (TSNAs), such as N'-nitrosonornicotine (NNN) and 4-(methylnitrosamino)-1-(3-pyridyl)-butanone (NNK), which are potent carcinogens that cause mutations in critical genes in human DNA. This review covers the series of biochemical and chemical transformations, related to TSNAs, leading from tobacco cultivation to cancer initiation. A key aim of this review is to provide a greater understanding of TSNAs: their precursors, the microbial and chemical mechanisms that contribute to their formation in ST, their mutagenicity leading to cancer due to ST use, and potential means of lowering TSNA levels in tobacco products. TSNAs are not present in harvested tobacco but can form due to nitrosating agents reacting with tobacco alkaloids present in tobacco during certain types of curing. TSNAs can also form during or following ST production when certain microorganisms perform nitrate metabolism, with dissimilatory nitrate reductases converting nitrate to nitrite that is then released into tobacco and reacts chemically with tobacco alkaloids. When ST usage occurs, TSNAs are absorbed and metabolized to reactive compounds that form DNA adducts leading to mutations in critical target genes, including the RAS oncogenes and the p53 tumor suppressor gene. DNA repair mechanisms remove most adducts induced by carcinogens, thus preventing many but not all mutations. Lastly, because TSNAs and other agents cause cancer, previously documented strategies for lowering their levels in ST products are discussed, including using tobacco with lower nornicotine levels, pasteurization and other means of eliminating microorganisms, omitting fermentation and fire-curing, refrigerating ST products, and including nitrite scavenging chemicals as ST ingredients.

Non-compliant packaging and illicit smokeless tobacco in Bangladesh, India and Pakistan: findings of a pack analysis.

INTRODUCTION: Illicit smokeless tobacco (ST) trade has seldom been documented despite ST use in at least 127 countries across the world. Based on non-compliance with packaging regulations, we report the proportion of illicit ST products from samples on sale in Bangladesh, India and Pakistan where 85% of global ST users reside. METHODS: We purchased unique ST products from tobacco sellers in two purposively selected administrative areas (division/district) in each of the three countries. The criteria to determine illicit ST products were based on country-specific legal requirements for ST packaging and labelling. These requirements included: 'market retail price disclosure', 'sale statement disclosure', 'pictorial health warning (PHW) pertinence', 'appropriate textual health warning' and 'using misleading descriptors (MDs)'. Non-compliance with even one of the legal requirements was considered to render the ST product illicit. RESULTS: Almost all ST products bought in Bangladesh and India were non-compliant with the local packaging requirements and hence potentially illicit, all products in Pakistan lacked desirable features. The most common feature missing was health warnings: 84% packs in Bangladesh, 93% in India, and 100% in Pakistan either did not have PHW or their sizes were too small. In Bangladesh, 61% packs carried MDs. In India and Pakistan, the proportions of such packs were 32% and 42%, respectively. CONCLUSIONS: Weak and poorly enforced ST control policies may be slowing the progress of tobacco control in South Asia. Standardised regulations are required for packaging and labelling ST. Improving compliance and reducing sale of cheap illicit products may require business licensing and market surveillance.

Cancer awareness & its association with demographic variables & mobile phone usage among the rural population of a district in north India.

Background & objectives: Lack of awareness is one of the major reasons for the high morbidity and mortality associated with cancers. The present study was aimed to evaluate the awareness of prevalent cancers among the rural population in a district of north India and its association specifically with mobile phone usage. Methods: Using a stratified random sampling technique, households in three villages of Gautam Buddh Nagar district of India were selected. A house-to-house survey on cancer awareness was conducted among adults in selected households and data were analyzed to check for the association of such an awareness with sociodemographic factors and internet usage. Results: The study included 59 males and 145 females, with majority (115) being in the age group of 18-30 yr. Although most (96.5%) of the participants were aware of cancer, the common risk factors and warning signs of cancer were known to only a few. Specific risk factors for cervical and breast cancers were, however, not known to a majority (79.9% and 72.2%). A significant association between the awareness of general risk factors and warning signs as well as specific aspects including risk factors for breast, cervical and oral cancer, HPV vaccine and the education level of the participants (P<0.05 for all). Knowledge of risk factors, warning signs and cancer prevention modalities was higher among mobile phone users who accessed internet for health information. There was no significant association between age group and cancer risk factor awareness, though females were more aware of the risk factors for breast cancer (P=0.002). Interpretation & conclusions: The findings of this study highlight the existing low level of awareness of cervical and breast cancers among the rural population. The association of cancer awareness with education level and mobile phone-based internet usage suggests the potential utility of internet-based platforms such as m-health programmes for cancer prevention activities.

Evidence of areca nut consumption in the United States mainland: a cross-sectional study.

BACKGROUND: Areca nut (AN) is an addictive substance consumed in the Southeast region and is highly associated with oral premalignant lesions and oral cancer. The impact of AN use in the United States (US) is largely unknown, but the products are readily available and probably used by a significant fraction of Asian immigrants or descendants living in the US. We aimed at assessing AN use prevalence among the Asian community in Houston, Texas. METHODS: A cross-sectional questionnaire was used to interview adult individuals (≥ 18 years of age) who self-identified as Asian immigrants or descendants residing in Houston. Means, frequencies, and proportions were reported. Factors associated with AN use were evaluated using logistic regression. RESULTS: We surveyed 275 individuals (58% women, 43% between 35-54 years old, 67% born outside of the US, and 6% concurrent smokers). Among respondents, 91% were familiar with AN products, 17% self-reported ever use of AN products in the US, and 31% had friends/family members who were AN ever users. AN use was significantly associated with being Indian Subcontinent immigrants or descendants (ISID) (OR = 3·9; CI: 1·10,13·81; p = 0·035) and having friends/family members using AN products (OR = 6·2; CI: 1·69, 22·69; p = 0·006). CONCLUSIONS: Our findings provide quantitative data on the prevalence of AN ever use and context for future AN prevention and cessation interventions specific to the Southeast Asian groups living in the US mainland. This is crucial for the prevention and control of oral cancer and other detrimental conditions related to AN consumption.

Microbiomes, Epigenomics, Immune Response, and Splicing Signatures Interplay: Potential Use of Combination of Regulatory Pathways as Targets for Malignant Mesothelioma.

Malignant mesotheliomas (MM) are hard to treat malignancies with poor prognosis and high mortality rates. This cancer is highly misdiagnosed in Sub-Saharan African countries. According to literature, the incidence of MM is likely to increase particularly in low-middle-income countries (LMICs). The burden of asbestos-induced diseases was estimated to be about 231,000 per annum. Lack of awareness and implementation of regulatory frameworks to control exposure to asbestos fibers contributes to the expected increase. Exposure to asbestos fibers can lead to cancer initiation by several mechanisms. Asbestos-induced epigenetic modifications of gene expression machinery and non-coding RNAs promote cancer initiation and progression. Furthermore, microbiome-epigenetic interactions control the innate and adaptive immunity causing exacerbation of cancer progression and therapeutic resistance. This review discusses epigenetic mechanisms with more focus on miRNAs and their interaction with the microbiome. The potential use of epigenetic alterations and microbiota as specific biomarkers to aid in the early detection and/or development of therapeutic targets is explored. The advancement of combinatorial therapies to prolong overall patient survival or possible eradication of MM especially if it is detected early is discussed.

Perspectives of Healthcare Providers and the General Population on a Cancer Awareness Portal: a Qualitative Study.

This study was aimed at a qualitative assessment of a cancer informational website, "India Against Cancer," developed by the ICMR-National Institute of Cancer Prevention and Research with the dual purpose of promoting cancer awareness among the general population and providing comprehensive information to healthcare providers. We used the narrative qualitative approach (data collection using in-depth interviews (IDIs) and focused group discussions (FGDs)) and content analysis. Purposive sampling was undertaken for both IDIs and FGDs. Thematic analysis was done on four themes: general cancer awareness, ease of comprehension of the Web portal, the relevance of the website content, and general comments and suggestions. Readability assessment of content of the website was conducted using Flesch-Kincaid Readability methodology. The general cancer awareness was enhanced among the participants after visiting the website. Ease of comprehension of the Web portal content was reported to fare well. The sections on "risk factors," "warning signs," and "diet and cancer" were mentioned as most relevant by the general population, whereas "myths and facts" and "screening guidelines" were most relevant for the healthcare workers. Similarly, references and epidemiology sections were most useful for healthcare researchers/professionals. Readability scores of content in English were appropriate for high school pass audience. The content on "India Against Cancer" website was found to serve its intended purpose of promoting cancer awareness among the general population and providing authentic cancer-related information to the healthcare providers. The suggestions received would enable us to enhance the utility of our website by tailoring it to the needs of the target audience.

Role of integrative medicine in the continuum of care of breast cancer patients in the Indian context.

Breast cancer is the most frequently diagnosed cancer among women in both transitioned and transitioning countries and has become a major women's health problem. Although recent advances in our understanding of the biological nature of cancer, improved awareness coupled with better early detection facilities, use of chemotherapy, hormone therapy, and targeted therapy have significantly improved survival from cancer, there are many gaps in providing individual-centric, holistic care. Integrative medicine refers to the use of traditional medicine alongside conventional preventive or therapeutic interventions (allopathic medicine) as a comprehensive, individual-centered, evidence-based care. The three pillars of complementary medicine (lifestyle modifications, mind-body practices, and use of natural products) have the potential for cancer prevention and improving quality-of-life and even treatment response in cancer patients when combined with conventional oncology care. Therefore, continued research into integrative therapies is required to extend the benefits to a broader patient population and improve outcomes in breast and other common cancers. In the present review article, the possible role of integrative medicine across the breast cancer care continuum has been discussed along with the concept of integrating complementary practices into mainstream health delivery. We have focused on breast cancer as a model cancer that is well amenable to prevention, early detection and stage appropriate treatment. However, our observations are pertinent for other common cancers, for which there are several opportunities for improving the continuum of care, especially in developing countries like India.

Symposium report: breast cancer in India-trends, environmental exposures and clinical implications.

PURPOSE: Incidence of breast cancer (BC), particularly in young women, are rising in India. Without population-based mammography screening, rising rates cannot be attributed to screening. Investigations are needed to understand the potential drivers of this trend. METHODS: An international team of experts convened to discuss the trends, environmental exposures, and clinical implications associated with BC in India and outlined recommendations for its management. RESULTS: Panels were structured across three major BC themes (n = 10 presentations). The symposium concluded with a semi-structured Think Tank designed to elicit short-term and long-term goals that could address the challenges of BC in India. CONCLUSION: There was consensus that the prevalence of late-stage BC and the high BC mortality rates are associated with the practice of detection, which is primarily through clinical and self-breast exams, as opposed to mammography. Triple-Negative BC (TNBC) was extensively discussed, including TNBC etiology and potential risk factors, the limited treatment options, and if reported TNBC rates are supported by rigorous scientific evidence. The Think Tank session yielded long-term and short-term goals to further BC reduction in India and included more regional etiological studies on environmental exposures using existing India-based cohorts and case-control studies, standardization for molecular subtyping of BC cases, and improving the public's awareness of breast health.

Leveraging Technology for Nation-Wide Training of Healthcare Professionals in Cancer Screening in India: a Methods Article.

The Indian Council of Medical Research-National Institute of Cancer Prevention and Research (ICMR-NICPR) has been conducting online cancer screening training certificate courses since 2017. Thereafter, multiple cohorts have been trained successfully in cancer screening using the Extensions for Community Healthcare Outcomes (ECHO) platform. A 14-week course was designed for various cadres of healthcare professionals (HCP), through which they were trained in cancer screening and their roles and responsibilities in implementing the population-based cancer screening, as per the operational framework released by the Ministry of Health and Family Welfare. Then, a contact program was held to upskill the participants in cancer screening techniques. Eight cohorts have been successfully trained using the hybrid model of online training and hands-on training. Cancer screening conducted utilizing the hybrid model, consisting of the online ECHO model, followed by hands-on training is a suitable training model to train large cohorts, such as the one in populous countries like India.

Breast cancer early detection: A phased approach to implementation.

When breast cancer is detected and treated early, the chances of survival are very high. However, women in many settings face complex barriers to early detection, including social, economic, geographic, and other interrelated factors, which can limit their access to timely, affordable, and effective breast health care services. Previously, the Breast Health Global Initiative (BHGI) developed resource-stratified guidelines for the early detection and diagnosis of breast cancer. In this consensus article from the sixth BHGI Global Summit held in October 2018, the authors describe phases of early detection program development, beginning with management strategies required for the diagnosis of clinically detectable disease based on awareness education and technical training, history and physical examination, and accurate tissue diagnosis. The core issues address include finance and governance, which pertain to successful planning, implementation, and the iterative process of program improvement and are needed for a breast cancer early detection program to succeed in any resource setting. Examples are presented of implementation, process, and clinical outcome metrics that assist in program implementation monitoring. Country case examples are presented to highlight the challenges and opportunities of implementing successful breast cancer early detection programs, and the complex interplay of barriers and facilitators to achieving early detection for breast cancer in real-world settings are considered.

Why smokeless tobacco control needs to be strengthened?

Tobacco menace is responsible for significant mortality and morbidity worldwide. Smokeless tobacco (SLT) is consumed in more than 140 countries, thus is emerging as a global problem. Several adverse health outcomes like oropharyngeal, oesophageal, and pancreatic cancers; oral potentially malignant lesions; diabetes mellitus; cardiovascular diseases; mental illness; osteopenia; low birth weight; preterm births; small for gestation age babies; and stillbirths are attributed to SLT usage. Smokeless tobacco products vary greatly in types, constituents, packaging, forms, addiction, and harm potential, and thus are challenging to study and control. Involvement of both formal and informal sector in SLT production and sales further add to the complexities. The problem of SLT is usually understated and less researched upon. This paper summarizes the existing knowledge and provides evidence to strengthen the case against the SLT, stressing on the need to enhance the SLT control across the globe.

Is India's public health care system prepared for cervical cancer screening?: Evaluating facility readiness from the fourth round of the District Level Household and Facility Survey (DLHS-4).

India's cervical cancer screening program was launched in 2016. We evaluated baseline facility readiness using nationally representative data from the 2012-13 District Level Household and Facility Survey on 4 tiers of the public health care system - 18,367 sub-health centres (SHCs), 8540 primary health centres (PHCs), 4810 community health centres and 1540 district/sub-divisional hospitals. To evaluate facility readiness we used the Improving Data for Decision Making in Global Cervical Cancer Programmes toolkit on six domains - potential staffing, infrastructure, equipment and supplies, infection prevention, medicines and laboratory testing, and data management. Composite scores were created by summing responses within domains, standardizing scores across domains at each facility level, and averaging across districts/states. Overall, readiness scores were low for cervical cancer screening. At SHCs, the lowest scores were observed in 'infrastructure' (0.55) and 'infection prevention' (0.44), while PHCs had low 'potential staffing' scores (0.50) due to limited manpower to diagnose and treat (cryotherapy) potential cases. Scores were higher for tiers conducting diagnostic work-up and treatment/referral. The highest scores were in 'potential staffing' except for PHCs, while the lowest scores were in 'infection & prevention' and 'medicines and laboratory'. Goa and Maharashtra were consistently among the top 5 ranking states for readiness. Substantial heterogeneity in facility readiness for cervical cancer screening spans states and tiers of India's public healthcare system. Infrastructure and staffing are large barriers to screening at PHCs, which are crucial for referral of high-risk patients. Our results suggest focus areas in cervical cancer screening at the district level for policy makers.

Behavioral Interventions for Smokeless Tobacco Cessation.

INTRODUCTION: Consumption of smokeless tobacco (SLT) is on the rise (especially in the World Health Organization South-East Asian region) and has numerous repercussions over the consumer's health. This article reviews studies performed for SLT cessation using behavioral interventions, worldwide till 2017. METHODS: A systematic review by PICO (Problem, intervention, comparison, outcome) of behavioral intervention-based SLT cessation studies with minimum 6 months' follow-up, reporting outcomes in terms of risk ratios (RRs) and 95% confidence interval (CI), published between 1992 and 2017 was performed. This was followed by a meta-analysis of the outcomes of these studies by deriving the pooled estimates by the random effects model, for those on adults and youth, categorized according to the type of country where the study was performed, that is, in terms of developed or developing. Publication bias among the included studies was assessed by the Begg's test. RESULTS: Nineteen eligible studies comprising 24 498 participants, from all over the world were included. Behavioral interventions showed overall efficacy in SLT cessation in adults (RR = 1.63, 95% CI = 1.32 to 1.94) both in the developed (RR = 1.39, 95% CI = 1.16 to 1.63) and developing (RR = 2.79, 95% CI = 2.32 to 3.25) countries. However, these interventions did not prove effective for SLT cessation among youth overall (RR = 1.07, 95% CI = 0.73 to 1.41), either in the developed (RR = 1.39, 95% CI = 0.58 to 2.21) or in the developing (RR = 0.87, 95% CI = 0.68 to 1.07) countries. Publication bias was noted in all the studies among adults (p = .22) and youth (p = .05). CONCLUSION: Behavioral interventions as a single modality are effective in SLT cessation, both in the developed and developing countries. Health care providers should be sensitized to provide the same. IMPLICATIONS: A recent literature survey by Cochrane reviewed studies on interventions for SLT, including behavioral interventions, which included only those from the developed countries. The current analysis provides a broader, global update on the same by including studies performed both in the developed and developing countries (specifically the South-East Asian region-the high burden countries of SLT products).

Dual Burden of Smoked and Smokeless Tobacco Use in India, 2009-2017: A Repeated Cross-Sectional Analysis Based on Global Adult Tobacco Survey.

INTRODUCTION: The dual use of smoked and smokeless tobacco (SLT) poses a serious challenge to tobacco control efforts. This article examines the trends and patterns of this usage in India during the period 2009-2010 and 2016-2017. METHODS: Data from two rounds of nationally representative cross-sectional Global Adult Tobacco Survey (GATS) conducted in 2009-2010 and 2016-2017 have been used. Dual use was assessed based on current smokers and SLT users in both rounds. RESULTS: Findings reveal that dual use in India has dropped from 5.3% during 2009-2010 to 3.4% during 2016-2017, a decline of nearly 10 million dual users. However, some states have added nearly 4.6 million new dual users during this period. While dual use continues to remain high in rural areas, there has been a manifold increase in urban areas. Findings revealed that intention to quit tobacco was lower among dual tobacco users as compared to single users with considerable difference between urban and rural areas. CONCLUSION: Easy availability and affordability of SLT products compared to smoking products and restrictions on smoking in public places may have pushed current smokers and dual users to take to or intensify their SLT consumption. Measures relating to awareness, pricing, taxation, and enforcement of tobacco control laws should focus on all forms of tobacco, especially targeting high dual burden in rural and urban settings. IMPLICATIONS: Dual form of tobacco users represent 12% of all tobacco users in the country. The study reveals that intention to quit tobacco among dual users is significantly lower than that among single tobacco product users. This requires improving public awareness about the morbidity and mortality that arises from the use of all forms of tobacco products. Efforts to restrict the availability of tobacco products should focus on licensing the sale of all tobacco products. Reduction in dual tobacco use will not only result in multiplied health benefits but also help in achieving the Non-Communicable Diseases targets under the United Nations Sustainable Development Goals.

Chemistry, metabolism and pharmacology of carcinogenic alkaloids present in areca nut and factors affecting their concentration.

Areca Nut (AN), the seed of tropical palm tree Areca catechu, is a widely chewed natural product with estimated 600 million users across the world. Various AN products, thriving in the market, portray 'Areca nut' or 'Supari' as mouth freshener and safe alternative to smokeless tobacco. Unfortunately, AN is identified as a Group 1 human carcinogen by International Agency for Research on Cancer (IARC). Wide variation in the level of alkaloids, broadly ranging from 2 to 10 mg/gm dry weight, is observed in diverse variety of AN sold worldwide. For the first time, various factors influencing the formation of carcinogenic alkaloids in AN at various stages, including during the growth, processing, and storage of the nut, are discussed. Current review illustrates the mechanism of cancer induction by areca alkaloids in humans and also compiles dose-dependent pharmacology and toxicology data of arecoline, the most potent carcinogenic alkaloid in AN. Careful monitoring of the arecoline content in AN can potentially be used as a tool in product surveillance studies to identify the variations in characteristics of various AN sample sold worldwide. The article will help to generate public awareness and sensitize the government bodies to initiate campaigns against AN use and addiction.

Reappraisal of cytology-histology correlation in cervical cytology based on the recent American Society of Cytopathology guidelines (2017) at a cancer research centre.

OBJECTIVE: To assess the impact of recently published American Society of Cytopathology (ASC) guidelines (2017) on the conduct of cervical cytology-histology correlation (CHC). METHODS: A retrospective review was conducted for cervical biopsies with their corresponding conventional cervical smears over a 7.5-year period (January 2011-June 2018). As per the ASC guidelines, a discrepancy assessment grid was prepared. Major cytology-histology discordance was defined as a diagnosis of high-grade squamous intraepithelial lesion (HSIL) or CIN2+ in one of the tests with negative result in the other. Smears and biopsies of all discordant cases were reviewed for reasons of overcall and undercall. RESULTS: Of the 341 cervical biopsies with corresponding Papanicolaou smear, cytology-histology agreement was noted in 249 (73%) cases. Major discordance was observed in 22 cases (6.4%)-16 undercalls and six overcalls on cytology-while minor discrepancies were noted in 70 cases. Atypical metaplasia and repair changes were the main reasons for overcall while small HSIL cells in atrophic smear and scant HSIL cells were important causes of undercall on cytology review. Using the ASC guidelines, we could improvise upon the existing CHC methodology for categorisation of cyto-histological pairs of cases with a cytological diagnosis of atypical glandular cells. CONCLUSION: The present study demonstrates, for the first time, that the recent ASC guidelines facilitate cervical CHC, especially for categorisation of cases with atypical glandular cells on cytology. Uniform application of these guidelines would standardise the conduct of cervical CHC internationally and provide scope for inter-laboratory comparison of data as well as enhance self-learning and peer learning.

ANDB: Development of a Database Based on a Global Survey of Literature on Areca Nut and Associated Health Effects.

Areca nut (AN), commonly known as "Supari" in India is an addictive substance and widely consumed with or without tobacco as a part of customs in many South East Asian countries. Owing to the adverse health effects of AN, public awareness and stringent government policies to prohibit AN production and regulation of products containing AN should be addressed without further delay. Lack of a research database, motivated us to develop a comprehensive online portal on global survey of published articles with reference to AN. The Areca nut database (ANDB) is a manually curated database which provides the information on global literature according to the publication year, author, population, harmful effects, and associated disease. The present study is an attempt to deliver the relevant information which would be helpful to researchers in prioritizing the research areas with respect to AN and associated health effects. The portal has been developed in MySQL and the interface has been designed using core PhP and CSS, HTML. ANDB is an online resource available to provide global literature of AN in a user-friendly manner. It can be accessed freely on http://arecanut.icmr.org.in/. To the best of our knowledge, ANDB is the first portal delivering inclusive scientific literature related to AN and its health effects. This evidence-based scientific information would be useful for policy makers to make guidelines for increasing awareness and implementing the laws for regulated use of this potentially carcinogenic substance, thereby controlling the burden of many dreaded diseases primarily oral submucous fibrosis, cardiovascular disease, and cancers.

An Overview on Betel Quid and Areca Nut Practice and Control in Selected Asian and South East Asian Countries.

Background: Areca nut (AN) and betel quid (BQ) chewing are ancient practices followed by an extensive proportion of the world's population. These practices are endemic in larger parts of South and Southeast Asia and selected Western Pacific countries. The prevalence of these habits varies across regions, age, gender, cultural practice, and socioeconomic status groups. Considerable variations exist between countries with respect to prevention/intervention programs, and policy guidelines of BQ usage. Objectives: (1) To provide an overview of the BQ chewing prevalence, practices, preventive interventions and policies in selected Asian and Western Pacific countries. (2) To explore the different terminologies associated with BQ use. Method: A narrative review of the current literature related to BQ, AN, and oral cancer was conducted by searching PUBMED, CINAHL, and GOOGLE databases. Results: The literature review revealed that the prevalence of BQ was found to be highest in Papua New Guinea, followed by Bangladesh, India, Pakistan, Myanmar and Sri Lanka. While, Cambodia, Malaysia, Indonesia and Taiwan had comparatively lower prevalence. Smokeless tobacco, BQ with tobacco, BQ without tobacco, AN were some of the terminologies used for BQ in various studies. Conclusions: The prevalence, and the interventional policies related to BQ and AN chewing habits varies widely among the selected countries. With the increasing awareness and association of BQ with oral cancer, there is a need to have better awareness, prevention and interventional strategies in place. We also found considerable variation in the use of terminologies associated with BQ.