Sir, it came to my attention whilst browsing in a local supermarket that pan masala is readily available for sale. Its sale is unrestricted by law in England and Wales, and there are no health warnings associated on the packaging to alert users to the dangers of chewing such a product.

The main constituent, areca nut or sopari, contains a powerful stimulant arecoline, the most widely-used worldwide.1 The pan on sale was in a ready-mixed format, consisting of areca nut, fennel, watermelon seeds, menthol, saccharin and glucose, with artificial colours (E102 and E142). It can also be mixed with slaked lime and wrapped in a betel leaf (known as a betel quid), with or without tobacco for chewing.

My concerns regarding pan stem from the large body of evidence linking it with submucous fibrosis, a premalignant lesion, and oral squamous cell carcinoma.2 The former has led to difficulties in intubation for general anaesthesia.3 Loss of periodontal attachment4 and obesity5 have links with the product. Other serious health problems include cardiovascular disease, diabetes mellitus and asthma.2 Unfortunately the arecoline produces dependence and addiction in its users.

A study of Bangladeshi adolescents found that few were aware of the association between pan chewing and oral cancer.6 Other workers found that pan chewing is commonly used by children living in Tower Hamlets, London.7

An Evidence-Based Dentistry article concluded that there is strong evidence associating areca nut (especially in the form of pan masala) and oral submucous fibrosis.8 I would agree with Professor Porter who provided commentary for this paper that public health promotion strategies should be implemented. I would also suggest that the availability of this potentially harmful agent should be restricted in a similar way to alcohol and tobacco. This is an area where targeted public education together with legislation could help to protect our patients' health.