HUNAN, Central China — Chewing a betel nut like a piece of gum, it first tastes of maltose syrup oozing from a wooden twig. Then, suddenly, something strong strikes your tongue and thousands of strings tug on your throat. Your cheeks flush, your breath shortens, and you might feel a slight buzz.

It’s a sensation Tan knows all too well. For 10 years, he chewed betel nuts every day, even bringing weeks of supplies from his hometown of Huaihua to a job some 1,500 kilometers away in Tianjin, a city near Beijing. There, his cheek suddenly started swelling.

Tan had heard of the dangers — his wife had pleaded with him plenty of times to stop. “We fought about chewing betel nuts, but he wouldn’t listen to me,” she says, requesting their given names not be used out of privacy concerns. Now her husband spends his days in bed, recovering from a surgery that removed an egg-sized tumor from his left cheek. The hole it made in his face is covered by a piece of skin grafted from his thigh, held in place by dark crimson stitches. Two catheters run into his throat, one for air and one for food.

Tan is one of thousands of oral cancer patients in Hunan province, where the condition occurs at a rate about 30% higher than the national average. Doctors say there is a clear link with betel nut consumption, but their warnings are usually met with indifference — and sometimes intimidation.

Meanwhile, consumption is only on the rise. In the province, betel nuts are deeply ingrained into the cultural fabric. Where, elsewhere in China, two men meeting on the street might share a cigarette, in Hunan they’ll enjoy a betel nut. The fruits are offered at business meetings and, because they symbolize a successful marriage, at weddings. Anyone from school children to taxi drivers count on them to stay awake. Nearly four out of 10 Hunanese chew betel nuts, with four-fifths of those people chewing more than 10 grams a day. In the city of Xiangtan, the center of the betel nut processing industry, nearly 60% of residents chew betel nuts, a 2010 study found.

Jiang Canhua, a dental surgeon at Xiangya Hospital of Central South University, where Tan was treated, tells Sixth Tone that the number of oral cancer patients at his hospital has increased dramatically in the past decade. Though there is a lack of scientific research, Jiang is convinced that betel nuts are to blame. “Of 45 oral cancer patients in our hospital last year, 44 had a history of chewing betel nuts,” Jiang says. With 25 years of experience, he knows their symptoms well.

Arecoline, an addictive chemical similar to nicotine that is found only in betel nuts, is suspected to be a major contributing factor to oral cancer. The nuts are often seasoned with sweetener and lime, the latter of which has been identified as a carcinogen as well. In 2003, the International Agency for Research on Cancer, an affiliate of the World Health Organization, listed two betel nut products, one seasoned and one unseasoned, as Group I carcinogens, meaning there is sufficient evidence of them being carcinogenic to humans.

Unlike places such as Taiwan, the betel nuts chewed in Hunan are dried before consumption. This is by necessity, as the tropical fruit does not grow in the province and has to be transported from Hainan, an island province in China’s far south that grows over 95% of the country’s betel nuts. Hardened by the drying process, the nuts are even more damaging, scraping the inner cheeks when chewed, according to Jiang. Betel nut consumers often develop a symptom called oral submucous fibrosis, a sign of early stage cancer in which the skin inside the mouth stiffens. Once someone develops oral cancer, the death rate is high. Within five years, 40% of patients die. “Recurrence is common,” Jiang says. “And even if a patient is cured, there is a big chance that their appearance and ability to talk will clearly not recover to their former levels.”

Betel nut companies and their supporters question the link between chewing betel nuts and developing oral cancer, or point to the fact that the WHO report only covers fresh — not dried — betel nuts. “(The effect of) chewing betel nuts differs from person to person,” says Hu Xiaozhou, a deputy director at Xiangtan Stomatological Hospital, invoking a common defense. “Some people are fine, even if they chew three bags of betel nuts a day.” Jiang, the doctor, disagrees, saying there is a clear link when looking at larger groups rather than individuals. But he admits hard evidence is lacking. There is no funding for systematic studies in Hunan, and the situation is complicated by the fact that most betel nut chewers are smokers, too.

The industry enjoys political support. By 2017, there were over 30 betel nut companies in Xiangtan who in total employed nearly 300,000 people. Most of Xiangtan’s betel nut companies are located in the city’s Tianyi Development Zone, where, in 2016, they paid nearly 100 million yuan (then $15.2 million) in taxes, or about 10% of the zone’s total. The Xiangtan government set a target last year for the industry’s sales to grow from 30 billion to 50 billion yuan in five years and announced favorable land and tax policies. “For the local government, the GDP goes up, and employment goes up as well,” says Jiang. The industry is so lucrative, local media have reported, criminal gangs have been involved with shady attempts to capture market share. Jian Xinchun, a colleague of Jiang’s and a longtime anti-betel nut advocate, has received death threats for speaking out.

The companies also claim to have history on their side. Some of their advertisements say arecoline is good for people’s health, pointing to its long history of use in traditional Chinese medicine. A report by the local government-affiliated Center of Disease Control came to a similar conclusion after experiments on mice. But Jiang says this is misleading. “Betel nuts are used in different ways in traditional medicine,” he says, explaining that arecoline intake from drinking betel nut water is much lower than from chewing the nuts.

Nevertheless, historical narratives are hard to overcome. A widely known story in Xiangtan about how betel nuts became popular goes back nearly 400 years, to the civil war during the transition from the Ming to the Qing dynasty. The dead filled the streets and plague spread fast. No one dared to collect the bodies except for one monk, who miraculously never got ill. His secret, he later told people, was chewing betel nuts. Resisting miasma is still among the many supposed betel nut benefits that Xiangtan people believe in. A medical book from the 17th century that is still quoted today describes the fruit’s advantages as: “When you are hungry, it can make you feel full; when you are full, it can make you feel hungry; when you are awake, it can make you sleepy; but when you are sleepy, it can make you awake.”

Everyone in Xiangtan grew up with betel nuts. Zhao Fake — a 70-something retired construction worker, who his friends call “the betel nut king” — says he has been chewing for more than six decades. “There were betel nut stands (in Xiangtan) even before Liberation in 1949,” he says, referring to the Communist Party’s civil war victory. He recalls how vendors would quarter betel nuts with a fodder chopper and sell them at 3 cents apiece, the same price for a portion of rice at the time. As a young boy from a poor family, Zhao could only afford to buy leftover slices. Until now, he chews daily, meeting up with former colleagues across the road from some of the oldest betel nut shops in the city.

Even Hunan’s most famous son, revolutionary leader Mao Zedong, liked betel nuts. A state-owned news website recalls an anecdote from 1952 when a cousin visiting Beijing brought Mao several bags of Xiangtan specialties: “When Mao Zedong laid eyes on the betel nuts he became especially cheerful. He grabbed one and began chewing, but his personal physician tried to dissuade him. Mao Zedong said laughing: ‘I’ve been chewing these for decades; I never needed a medical inspection. It’s no problem, no problem!’ His Hunanese dialect made everyone laugh.”

In the early 1980s, following economic reforms, Xiangtan became the center of Hunan’s betel nut industry. Now, decades of growth later, local companies have begun courting the national market. With modern production methods and plastic wrapping guaranteeing at least 60 days of shelf life, packaged betel nuts are for sale throughout the country. Companies buy prime time commercials on Hunan TV, a station popular nationwide for its reality shows. In 2016, a Xiangtan business even paid for courtside ads at an NBA game played in Memphis, USA. The province’s total sales of betel nut products grew from tens of million of yuan in the 1990s to over 30 billion yuan in 2017.

But though the industry grew, regulation lagged. For years, a tug of war between the local and central authorities has played out over whether betel nuts can be labeled “food,” making it impossible to introduce updated regulations.

Six years ago, the case of Tang Lian looked like it might finally give betel nut critics the pull needed to advocate better oversight. Back then, she and her husband Zhu Ze ran a small grocery store in Changsha, Hunan’s provincial capital, and lived a simple and happy life with their two children. Then Zhu, who had been chewing betel nuts for over a decade, contracted tongue cancer. After several months, unable to bear the pain, he took his own life. Wanting to know what caused the suffering, Tang told media she planned to sue Old Xiangtan and Wuzizui, two betel nut companies located in Xiangtan. “If the product’s additives are problematic, they have to stop producing; if it is not the additives, they should warn citizens that chewing too many betel nuts may cost them their lives,” she says.

Tang’s quest was widely covered by the local press, which was sympathetic to her cause. But in the end, the industry managed to escape the uproar mostly unscathed. As Tang tells it, people who initially promised to help — journalists, lawyers — at some point stopped calling. A local newspaper, Sanxiang Daily Express, first appealed for justice and even offered to provide Tang with a lawyer, but then changed its tune, denying that betel nuts themselves cause cancer. “Illegal use of additives is to blame for causing cancer,” it quoted a doctor as saying. Zeng Xin, the lawyer whom Sanxiang Daily Express had found to help Tang, tells Sixth Tone that the case went into mediation.

But Tang denies this ever happened. Without legal knowledge or enough money, she never filed the lawsuit, and the companies never compensated her. After her husband’s death, she took all betel nut products off her shelves. Eventually, the business ground to a halt without her husband. “Now I am taking odd jobs to support my two children,” she says. Initially, she didn’t want to discuss the case with Sixth Tone and even lied about who she was, not wanting to bring up the bad memories of her fruitless pursuit of justice.

Zeng, the lawyer, is a member of a provincial consultative political body and appealed for industry regulations from 2004 to be revised to ensure the safe use of additives and mandate health warnings. New rules were promised for late 2013 that would include mandatory “excessive eating of betel nuts will harm your health” labeling, according to a local newspaper. But expert groups vetoed the revision over concerns for the safety of betel nuts and the fact that the regulations categorized them as “food.” The 2013 regulations were never approved, Hunan’s Health Department tells Sixth Tone. The 2004 version, which was listed under “food standards” despite the central government instructions to the contrary, was never invalidated. In 2016, the provincial government removed the regulation from the category. 

Neither of the companies Tang wanted to sue responded to Sixth Tone’s requests for comment. Zeng eventually won an award for Tang’s case and was praised for “using the law to promote the healthy development of Hunan’s betel nut industry.”

The industry is aware that its products aren’t all good news. When Sixth Tone visited Hunan in March, once-ubiquitous betel nut ads were nowhere to be seen. The Hunan Province Betel-Nut Food Industry Association (HNBA) had issued a notice to ban all commercials ahead of World Consumer Rights Day on March 15 — a stressful day for companies in China, who fear media exposure of their wrongdoing. Around the same time, Hunan TV took a reality show sponsored by a betel nut company offline. The HNBA refused Sixth Tone’s multiple interview requests.

Nevertheless, local betel nut companies have been pushing for more favorable policies. In both 2018 and 2019, Chen Xiao, chief director of HNBA member company Bingzhilang and representative of the Hunan People’s Congress, the provincial parliament, proposed that the government list betel nuts as a “Hunan local delicacy,” a tag that would bring both legitimacy and marketability. Once more defying central government pushback, the province said last year it is “evaluating the safety of betel nuts as food” in preparation for new regional safety standards, which have yet to come out.

In many ways, the struggle against the betel nut industry is reminiscent of the battle surrounding cigarettes in the USA half a century ago. Jiang, the doctor, says he hopes the government won’t smother public conversation on the topic: “Then we can discuss how to guide people to avoid chewing betel nuts.” But in a policy document, the Xiangtan government seems to call for the opposite, warning against negative reporting that could harm the industry.

The result, for now, is a new generation growing up and seeing betel nut-chewing as part of daily life. During a break at a Xiangtan middle school, it doesn’t take long for seventh grader Yaxi to list the people she knows who have developed a habit: her father, her high school teacher, and someone she knows from primary school. It’s no rarity for children to start young. “When I feel sleepy during class, I’ll chew a betel nut afterward,” says Zhe, who is a few years older. “It really packs a mean punch!”

Additional reporting: Liu Chang; editor: Kevin Schoenmakers.

(Header image: A worker sorts betel nuts at a processing factory in Wanning, Hainan province, April 30, 2019. Yuan Chen/VCG)