Journal of Refugee & Global Health


Betel nut is estimated to be the fourth most common psychoactive substance used globally behind caffeine, alcohol, and nicotine with 600 million global users. Betel nut use has a strong association with oral cancer and many other systemic effects including oral submucosal fibrosis. Although North American use is rare, its enduring effects may surface long after use posing a diagnostic challenge to practitioners caring for an increasingly global diaspora. Herein, we present a patient with severe trismus due to advanced oral submucosal fibrosis who was unexpectedly found to be importing and using Betel nut for over thirty years after immigrating. The prevalence of use in North America is unknown due to a paucity of current epidemiologic data. Betel nut side effects include a strong association with oral squamous cell carcinoma, hepatocellular carcinoma, cirrhosis, and cardiovascular disease, among others. However, there remains widespread lack of attributable risk awareness and entrenched social norms that permit betel nut use in early childhood in endemic areas. Importantly, women often bear a higher proportion of betel nut-related disease not only due to limited means of healthcare access but also due to cultural norms that often discourage women from smoking tobacco and instead encourage betel nut use. Here, standard tobacco and cancer screening had the potential to overlook a silent but significant driver of poor health. This case demonstrates a need for awareness of betel nut availability and its effects in the North American context. Moreover, it underscores the judicious care warranted for migrant patients who may have a history of exposure to betel nut and other imported cultural habits of clinical importance; these considerations are relevant to the individualized provision of culturally informed, gender equitable care.


The author(s) received no specific funding for this work.



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