North American Journal of Medical Sciences

: 2015  |  Volume : 7  |  Issue : 8  |  Page : 377--378

Myanmar: An endemic country for oral cancer

Aung Zaw Win 
 Notre Dame de Namur University, Belmont, California, USA

Correspondence Address:
Aung Zaw Win
Notre Dame de Namur University, Belmont, California

How to cite this article:
Win AZ. Myanmar: An endemic country for oral cancer.North Am J Med Sci 2015;7:377-378

How to cite this URL:
Win AZ. Myanmar: An endemic country for oral cancer. North Am J Med Sci [serial online] 2015 [cited 2022 May 23 ];7:377-378
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Dear Editor,

Betel nut (paan, Areca nut) chewing existed in Myanmar (Burma) since ancient times and it was done by both the kings and princes in the Burmese court and also by the ordinary people. The Burmese kings used golden containers studded with jewels to put the ingredients for betel quid (betel nut, betel leaf, caustic lime, and tobacco), whereas the common people used a lacquerware box. According to historical annals, court ladies offered paan to heroes returning from battles as a sign of respect and affection. It is also a Burmese custom to offer visitors and guests pickled tea leaves, paan, and hot green tea in Myanmar households. These act as stimulants and have effects similar to that of drinking coffee.

The Burmese love the betel nut so much that tens of thousands of acres are dedicated to its cultivation. [1] Consequently, the number of betel nut stalls is also growing in towns and cities across Burma. [1] In Myanmar, the practice of chewing paan is increasing among both sexes and it is more popular among rural people than urban dwellers. [1] It tends to stain the lip and the teeth red but this does not signal bad aesthetics in Burmese culture. It is addictive and the Burmese believe that it can aid in digestion, and prevent halitosis and flatulence. After chewing, the end product, i.e., red betel juice has to be spit out. It creates a stain and this has become a concern for sanitation in modern times. Today, in Myanmar, there is a ban on spitting betel juice in public places. This is a big issue in the United States. Burmese immigrants were banned from a laundromat in Fort Wayne, Indiana for spitting betel juice inside the store. [2] Many of the Burmese immigrants are refugees and political asylees and have come from refugee camps along the Thailand-Burma border. They have low levels of education and have difficulty with the acculturation process in America.

Various compounds present in the nut, most importantly arecoline, are carcinogenic and contribute to histologic changes in the oral mucosa. People who chew betel nut are 10 times more likely to have oral cancer than those who do not. [1] About 90% of males with oral cancer in Myanmar had histories of habitual betel nut chewing. [3] Chewing paan causes oral submucous fibrosis (OSMF), a precancerous lesion that lies on the causal pathway to oral cancer. [4] Areca nut causes fibroblastic proliferation and an increased collagen formation. [5] In Myanmar, the tongue is commonly affected followed by the palate, and diseases like lichen planus, oral leukoplakia, and erythroplakia can be observed, in addition to submucous fibrosis. [3],[6]

Even though it has been proved that chewing betel nut causes oral cancer, there are very few education or intervention programs in Myanmar. Monks, men, women, and even kids as young as 10-year-olds chew betel nuts in Myanmar. Myanmar has the highest prevalence of betel nut chewing in the region - about 51.4% of adult males chew paan daily. [7] Compared to this, 32.9% of adult males in India, 31.2% in Nepal, 26.4% in Bangladesh, 24.9% in Sri Lanka, 2.8% in Philippines, 1.3% in Thailand, 0.9% in China, 0.7% in Cambodia, 0.5% in Malaysia, and 0.3% in Vietnam chew betel nut. [8] Of the adult males who chew paan in Myanmar, 31% also smoke tobacco. [7] These two hazardous behaviors are commonly observed together. Betel nut chewing and smoking have a synergistic effect on oral cancer occurrence. In addition, among the 13-15-year-old students in Myanmar, 15.2% of boys and 2.0% of girls chew betel nut. [9] Thus, even in modern times, the trend of chewing betel nut is increasing in Myanmar. [10]

In Myanmar, oral cancer is the fourth most common cancer among males and sixth most common among females. [11] Oral cancer ranks second in cancer mortality among males. [12] In addition to oral squamous cell carcinoma, betel quid with or without tobacco causes cancer of the pharynx and cancer of the esophagus in humans. [13],[14] Slaked lime is corrosive and causes chronic inflammation, and peptic and duodenal ulcers. [15] There is a need to educate the Burmese in America and also in their native country. Oral cancer is costly to treat in a Third World country like Myanmar where the preventive services are limited.

Tobacco is one of the main ingredients in the betel quid. There are no laws in Myanmar that prohibit the sale of smokeless tobacco to minors or prohibit the sale of smokeless tobacco within 100 yards of schools. [1] Thus, Myanmar is still far from banning the practice of chewing betel nut. [16] Currently, in the media, there are awareness campaigns in the form of public service announcements. However, in the major cities, there is a ban on spitting red betel juice in the streets, mainly for sanitary reasons. Betel nut chewing eventually becomes very hazardous to health and is a habit that should be strongly discouraged.


1Kyaing NN, Sein T, Sein AA, Than Htike MM, Tun A, Shein NN. Smokeless tobacco use in Myanmar. Indian J Cancer 2012;49:347-51.
2Burmese Try to Adapt to America′s Bigger ′Village′. (Accessed February 11, 2015,
3Oo HN, Myint YY, Maung CN, Oo PS, Cheng J, Maruyama S, et al. Oral cancer in Myanmar: A preliminary survey based on hospital-based cancer registries. J Oral Pathol Med 2011;40:20-6.
4Merchant AT, Pitiphat W. Total, direct, and indirect effects of paan on oral cancer. Cancer Causes Control 2015; 26:487-91.
5Murti PR, Bhonsle RB, Gupta PC, Daftary DK, Pindborg JJ, Mehta FS. Etiology of oral submucous fibrosis with special reference to the role of areca nut chewing. J Oral Pathol Med 1995;24:145-52.
6Reichart PA, Way TH. Oral cancer and pre-cancer in Myanmar: A short review. J Oral Pathol Med 2006;35:193-6.
7Sinha DN, Gupta PC, Ray C, Singh PK. Prevalence of smokeless tobacco use among adults in WHO South-East Asia. Indian J Cancer 2012;49:342-6.
8Crude Smokeless Tobacco Prevalence in WHO Member States. (Accessed February 11, 2015, at
9Myanmar 2011 (Ages 13-15) Global Youth Tobacco Survey (GYTS) Fact Sheet. (Accessed February 11, 2015,
10Sein T, Swe T, Toe MM, Zaw KK, Sein TO. Challenges of smokeless tobacco use in Myanmar. Indian J Cancer 2014;51(Suppl 1):S3-7.
11Kimman M, Norman R, Jan S, Kingston D, Woodward M. The burden of cancer in member countries of the Association of Southeast Asian Nations (ASEAN). Asian Pac J Cancer Prev 2012;13:411-20.
12World Health Organization - Cancer Country Profiles, 2014 - Myanmar. (Accessed February 11, 2015, at
13IARC Monographs Programme Finds Betel-Quid and Areca-Nut Chewing Carcinogenic to Humans. (Accessed February 11, 2015,
14Sharma DC. Betel quid and areca nut are carcinogenic without tobacco. Lancet Oncol 2003;4:587.
15Blank M, Deshpande L, Balster RL. Availability and characteristics of betel products in the U.S. J Psychoactive Drugs 2008;40:309-13.
16Lawmakers Push for Betel Nut Awareness Campaign. (Accessed April 14, 2015,