CCA urges signing into law bill requiring warning labels on betel nut packaging

The Commonwealth Cancer Association is voicing strong support for a new bill that would require health warning labels on all betel nut products sold or imported into the CNMI, calling it a critical step in addressing rising oral cancer cases.

In an interview with Marianas Press, CCA executive director Lynn Tenorio described House Bill 24-20 as "a very important piece for public health," emphasizing that the data shows warning labels are effective in discouraging harmful behaviors like chewing betel nut.

"It's about giving people an informed choice," said Tenorio. "The label actually helps them reconsider. Do I want to pick up this bag again?"

Tenorio said the legislation has been years in the making, initiated under former CCA board chair Bo Palacios, and guided through the Legislature by Rep. Blas Jonathan Attao. The measure was unanimously passed by both chambers of the Legislature and is now awaiting Gov. Arnold I. Palacios' signature.

Under the bill, labels must be prominently displayed on each package and container of betel nut, warning consumers of the health risks associated with arecoline, a carcinogenic compound found in betel nut. Two different warning labels will rotate every six months to prevent desensitization among buyers.

To support the rollout, CCA has committed to printing and providing the warning labels for the first two years, free of charge, to the Department of Commerce for distribution to licensed sellers.

"We did not want the cost to be a barrier for this legislation," said Tenorio. "We'll look for donors and do our best to raise the funds because the public health benefit is so much greater than the immediate cost."

The warning labels will be updated every six months, ensuring recurring exposure to the health message. "It changes every six months so buyers are reminded. We want it to keep having an impact," Tenorio added.

Tenorio also provided data illustrating the growing concern. Over a recent three-year period, she said CNMI Medicaid paid approximately $14 million for the treatment of just 48 oral cancer patients in the CNMI.

"That's significant," she said. "And that's just Medicaid's cost—it doesn't include the pain and suffering of the individuals or their families."

According to CCA's internal monitoring, the number of oral cancer cases in the CNMI continues to rise. The organization sees labeling as a proactive move that could help reverse this troubling trend.

E.M. Bai, who has chewed betel nut for the past 20 years and began adding tobacco around 15 years ago, weighed the pros and cons of the legislation.

First, he said he understand both the cultural significance and the personal habit tied to its use, but recognizes the growing concern over its health impacts, especially with increased awareness about oral cancers and other related conditions.

When it comes to House Bill 24-20, which would require warning labels on betel nut products sold or imported in the CNMI, Bai sees both benefits and challenges.

"A health warning label helps inform new or occasional users about the risks, especially those who may not fully understand the long-term effects. It also supports efforts to reduce preventable illnesses, like oral cancer, by educating consumers at the point of purchase."

He also sees consumer empowerment through the bill because with transparent information, individuals can make more informed choices about their health.

Add to that, Bai said it's consistent with other regulated substances.

"Tobacco and alcohol already require health warnings, so applying a similar approach to betel nut aligns with broader public health policies."

He then discussed in length the problems of adding a warning label on betel nut packaging.

First, cultural sensitivity as Bai said betel nut use is deeply rooted in many Pacific cultures, including the CNMI, and labeling could be seen by some as stigmatizing or disrespectful to tradition.

He also sights perceived government overreach in its codification as some may feel that this is an unnecessary regulation that infringes on personal freedom or consumer choice.

There could also be some impact on small businesses as retailers who sell betel nut may face logistical or cost-related challenges in complying with new labeling requirements after CCA's two-year period of shouldering the cost of labels.

Bai said the bill may also result in limited behavior change, arguing that "for long-time users like myself, a warning label is unlikely to change existing habits—especially if they've already been chewing for years."

In the end, he believes the intent behind the bill is more to promote awareness, not to entirely ban betel but chewing.

"While I continue to chew, I understand and respect the importance of educating the public—especially the younger generation—so they can make conscious decisions with full knowledge of the risks involved."

Former lawmaker Luis John Castro, meanwhile, supports the bill slapping warning labels on betel but packaging.

"I believe it's a good bill. I mean cigarettes, tobacco, and vaping products already display warning labels so why not betel nut and lime," he said.

Trench Tech Promotions’ Justis “Cuki” Alvarez agrees with Castro, saying, "I feel that betel nut alone, mixed with pepper leaf (pupulu) and lime (åfuk) isn't as deadly as when you mix it with cigarette tobacco. Warning signs are all over cigarettes and alcohol, so why not betel nut too?"

Under HB 24-20, all betel nut products sold or imported in the CNMI must have clear and conspicuous warning labels.

Labels must address the risks of arecoline and follow similar regulatory standards as tobacco warnings under federal law and retailers who fail to comply may not receive or renew their betel nut sales licenses.

The bill also said retailers must track monthly betel nut sales and submit reports to the Department of Commerce.

The department then may share sales data with public health agencies to monitor compliance and measure impact.

As already mentioned, CCA will provide the labels for the first two years, relieving retailers of the financial burden.

Tenorio said she hopes the labeling campaign will do for betel nut what tobacco labeling has done for smoking awareness.

"It's not a war we can't win," she said. "But we have to start with information and visibility. This bill gives us both."

If HB 24-20 is signed into law, implementation could begin within months.