Dear Editor, The increasing use of smokeless tobacco has taken an alarming scenario worldwide, especially in Pakistan1. A 2018 literature review based on evidence found that smokeless tobacco use is highly prevalent in Southeast Asia, with India and Pakistan alone having an estimated 100 million consumers2. Particularly common among the lower socioeconomic class due to their affordability and widespread availability, smokeless tobacco products are deeply rooted in Pakistani culture and associated with several social and religious customs. As a part of their daily routine, >35% of the population in Karachi, Pakistan, consume chewable betel, areca, and tobacco products3. One of the main risk factors for oral cancer in Pakistan is smokeless tobacco use (tobacco consumed without burning). Smokeless tobacco is widely used in Pakistan, particularly in the form of snus, snuff, chewable tobacco—gutkha and paan, or betel quid (a mixture of areca nut, tobacco, slaked lime, and other ingredients wrapped in a betel leaf)4. Oral cancer is a significant health issue that affects a large number of people globally. According to the International Agency for Research on Cancer GLOBOCON database, it is the 16th most common type of cancer worldwide5. Oral cancer is a prevalent form of cancer in Pakistan, particularly among men, where it is the most diagnosed cancer. Among women, it is the second most common type of cancer6. Given the high prevalence of smokeless tobacco use in Pakistan and its association with oral cancer, there is a clear need for public health interventions to address this issue, which our current study aims to point out to the Pakistani population and the world at large. Smokeless tobacco contains over 25 compounds with cancer-causing properties, with tobacco-specific nitrosamines being the most dangerous7. These carcinogens can damage the DNA in oral cells leading to the development of oral cancer3. A cohort study performed in India found that regardless of the age at which they began using tobacco, women who consume chewing tobacco with a frequency of 10 or more times a day are at a 9.2 times greater risk of developing oral cancer than nontobacco users8. Although there is strong evidence of the carcinogenic potential of smokeless tobacco, it is still widely used as a cigarette smoking alternative mainly because of the common myth that smokeless tobacco is relatively innocuous. However, the question arises is it a “safer alternative”? Smokeless tobacco products contain a highly addictive substance called nicotine7, which is not only absorbed in larger quantities but also lingers in the bloodstream for a long duration than nicotine obtained through smoking9. Moreover, studies have shown that tobacco chewing has similar adverse effects on lipid profiles and increases the risk of cardiovascular disease almost equally to tobacco smoking10. In 2022, a comprehensive literature review revealed that smokeless tobacco products contain microbes that heighten the probability of developing cancer and opportunistic infections, placing them on par with the dangers associated with tobacco smoking9. Despite the known risks and hazards, the problem remains highly overlooked. Studies show that Pakistan has not fully implemented the WHO Framework Convention on Tobacco Control, it signed in 200511. Research has revealed that the existing Framework Convention on Tobacco Control smokeless tobacco control policies in 4 South Asian countries, namely Bangladesh, India, Nepal, and Pakistan, fall short due to either poor implementation or inadequacy. The main obstacles are inadequate regulation and control over the sales and licensing of these products, low tax rates, and a lack of support for individuals who want to quit using smokeless tobacco12. The Global Adult Tobacco Survey conducted in various countries, including India and Pakistan, reported that health care professionals provided more tobacco cessation counseling to smokers than smokeless tobacco users13. Similarly, most tobacco cessation and control programs target smoking, giving little or no attention to the increasing smokeless tobacco use14. Moreover, there is a lack of proper tobacco cessation training among health care students and professionals, hampering the progress toward a tobacco-free society13. Given the high prevalence of smokeless tobacco use in Pakistan and its association with oral cancer, there is a clear need for public health interventions to address this issue. Efforts should be made to raise awareness of the risks associated with smokeless tobacco use, particularly among at-risk people, such as older adults, the lower socioeconomic class, less literate people, and males, especially those with more exposure to SLT markets15. In addition to mandating documentation of smokeless tobacco users in the hospital record, health care providers in Pakistan should get trained to screen for oral cancer and provide appropriate counseling and treatment to these patients. Finally, policymakers in Pakistan should consider implementing regulations to control the use of smokeless tobacco, such as increasing taxes on tobacco products and restricting advertisement and promotion on Radio and Television stations, posters, placards, including social media platforms. Research has shown that Quitline and telephone support has proven effective in quitting tobacco16. The development of a National Quitline and smokeless tobacco control policy is the need of the hour. We then urge the Pakistani government to adopt this Quitline and telephone support. Finally, we urge the Pakistani government to conduct a nationwide analysis of the situation of smokeless tobacco consumption in the country and take bold steps in the proper implementation of our outlined recommendations above to address this problem before it becomes too late. Ethics approval None. Sources of funding None. Author contributions H.Q.A. and M.O.O.: conceptualization; C.M.V.S.: funding acquisition; H.Q.A.: investigation; H.Q.A. and M.O.O.: project administration; H.Q.A.: resources; C.M.V.S.: software; M.O.O.: supervision; H.Q.A.: validation, M.O.O.: visualization, H.Q.A.: writing – original draft: M.O.O.: writing– review and editing; All authors: final approval of manuscript for publication. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) Name of the registry: not applicable. Unique identifying number or registration ID: not applicable. Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable. Guarantor Haleema Qayyum Abbasi. Availability of data and material None. Consent for publication None. Provenance and peer review None.